Monitoring the prevalence of severe intellectual disability in children across Europe: feasibility of a common database

Assessing harmonized intelligence measures in a multinational study

Studies examining the neurocognitive and circuit-based etiology of psychiatric illness are moving toward inclusive, global designs. A potential confounding effect of these associations is general intelligence; however, an internationally validated, harmonized intelligence quotient (IQ) measure is not available. We describe the procedures used to measure IQ across a five-site, multinational study and demonstrate the harmonized measure's cross-site validity. Culturally appropriate intelligence measures were selected: four short-form Wechsler intelligence tests (Brazil, Netherlands, South Africa, United States) and the Binet Kamat (India). Analyses included IQ scores from 255 healthy participants (age 18-50; 42% male). Regression analyses tested between-site differences in IQ scores, as well as expected associations with sociodemographic factors (sex, socioeconomic status, education) to assess validity. Harmonization (e.g., a priori selection of tests) yielded the compatibility of IQ measures. Higher IQ was associated with higher socioeconomic status, suggesting good convergent validity. No association was found between sex and IQ at any site, suggesting good discriminant validity. Associations between higher IQ and higher years of education were found at all sites except the United States. Harmonized IQ scores provide a measure of IQ with evidence of good validity that can be used in neurocognitive and circuit-based studies to control for intelligence across global sites.

Trends in the prevalence of intellectual disability among children in Taiwan

BACKGROUND

Intellectual disability (ID) is a major developmental disability. However, data on changes in the prevalence over time at the national level are limited.

METHOD

Using data from the national disability registry, we conducted an ecological study to evaluate the time trends of ID among children in Taiwan. We calculated the prevalence of ID by age, sex and severity, from 2000 to 2011, and assessed the time trends.

RESULTS

During the study period, the overall prevalence of ID in children aged 3-17 years increased from 3.60 to 5.91 per 1000 (β = 0.22, P < 0.001, r2  = 0.97). The prevalence of mild ID (MID, intelligence quotient: 50-69) increased from 1.30 to 3.60 per 1000 (β = 0.21, P < 0.001, r2  = 0.98). However, the prevalence of severe ID (SID, intelligence quotient: <50) was relatively constant, between 2.22 and 2.38 per 1000 (β = 0.01, P = 0.076, r2  = 0.96). Boys had a higher prevalence than girls, and the average boy-to-girl prevalence ratio was 1.42 for MID and 1.31 for SID. The boy-to-girl prevalence ratios of MID and SID decreased over time (β = -0.01, P < 0.001, r2  = 0.99 for MID; β = -0.01, P < 0.001, r2  = 1.00 for SID).

CONCLUSION

The prevalence of ID in Taiwanese children increased from 2000 to 2011 and was largely attributable to increases in MID. Boys had a higher prevalence of ID and were more likely to have MID.

The contribution of epidemiology to the understanding of neurodevelopmental disabilities

Epidemiological approaches have played an important role in creating better understanding of developmental disabilities by delineating their frequency in populations and changes in their frequency over time, by identifying etiological factors, and by documenting pathways to prevention. Both cerebral palsy (CP) and mild intellectual disability are declining in frequency in high-income countries. The diagnosis of autism spectrum disorder has increased in recent decades, but much of this increase is a result of changing approaches to ascertainment and recording. Epidemiological studies have found that most CP is not of birth-asphyxial origin, that most febrile seizures do not pose a major risk for epilepsy, and that folic acid deficiency may contribute to developmental disabilities apart from its effect on neural tube defects. Epidemiological research has shown that an important fraction of neural tube defects and virtually all cases of Reye syndrome are preventable, and recent trials have shown ways to prevent CP. Early psychoeducational interventions in children at risk for mild intellectual disability are an effective and valuable societal investment. Very large population-based studies starting in pregnancy have been launched in Norway, Denmark, and Japan in recent years and these and other population studies promise to continue the epidemiological contribution to a better understanding of developmental disabilities.

Natural History and Developmental Trajectories of Individuals With Disease-Causing Variants in STXBP1

BACKGROUND AND OBJECTIVES

Pathogenic variants in STXBP1 are among the major genetic causes of neurodevelopmental disorders. Despite the increasing number of individuals diagnosed without a history of epilepsy, little is known about the natural history and developmental trajectories in this subgroup and endpoints for future therapeutic studies are limited to seizure control.

METHODS

We performed a cross-sectional retrospective study using standardized questionnaires for clinicians and caregivers of individuals with STXBP1-related disorders capturing medical histories, genetic findings, and developmental outcomes. Motor and language function were assessed using Gross Motor Function Classification System (GMFCS) scores and a speech impairment score and were compared within and across clinically defined subgroups.

RESULTS

We collected data of 71 individuals with STXBP1-related disorders, including 44 previously unreported individuals. Median age at inclusion was 5.3 years (interquartile range 3.5-9.3) with the oldest individual aged 43.8 years. Epilepsy was absent in 18/71 (25%) of individuals. The range of developmental outcomes was broad, including 2 individuals presenting with close to age-appropriate motor development. Twenty-nine of 61 individuals (48%) were able to walk unassisted, and 24/69 (35%) were able to speak single words. Individuals without epilepsy presented with a similar onset and spectrum of phenotypic features but had lower GMFCS scores (median 3 vs 4, p < 0.01) than individuals with epilepsy. Individuals with epileptic spasms were less likely to walk unassisted than individuals with other seizure types (6% vs 58%, p < 0.01). Individuals with early epilepsy onset had higher speech impairment scores (p = 0.02) than individuals with later epilepsy onset.

DISCUSSION

We expand the spectrum of STXBP1-related disorders and provide clinical features and developmental trajectories in individuals with and without a history of epilepsy. Individuals with epilepsy, in particular epileptic spasms, and neonatal or early-onset presented with less favorable motor and language functional outcomes compared with individuals without epilepsy. These findings identify children at risk for severe disease and can serve as comparator for future interventional studies in STXBP1-related disorders.

Heart rate monitoring to detect acute pain in non-verbal patients: a study protocol for a randomized controlled clinical trial

BACKGROUND

Autism entails reduced communicative abilities. Approximately 30% of individuals with autism have intellectual disability (ID). Some people with autism and ID are virtually non-communicative and unable to notify their caregivers when they are in pain. In a pilot study, we showed that heart rate (HR) monitoring may identify painful situations in this patient group, as HR increases in acutely painful situations.

OBJECTIVES

This study aims to generate knowledge to reduce the number of painful episodes in non-communicative patients' everyday lives. We will 1) assess the effectiveness of HR as a tool for identifying potentially painful care procedures, 2) test the effect of HR-informed changes in potentially painful care procedures on biomarkers of pain, and 3) assess how six weeks of communication through HR affects the quality of communication between patient and caregiver.

METHODS

We will recruit 38 non-communicative patients with autism and ID residing in care homes.

ASSESSMENTS

HR is measured continuously to identify acutely painful situations. HR variability and pain-related cytokines (MCP-1, IL-1RA, IL-8, TGFβ1, and IL-17) are collected as measures of long-term pain. Caregivers will be asked to what degree they observe pain in their patients and how well they believe they understand their patient's expressions of emotion and pain. Pre-intervention: HR is measured 8 h/day over 2 weeks to identify potentially painful situations across four settings: physiotherapy, cast use, lifting, and personal hygiene.

INTERVENTION

Changes in procedures for identified painful situations are in the form of changes in 1) physiotherapy techniques, 2) preparations for putting on casts, 3) lifting techniques or 4) personal hygiene procedures.

DESIGN

Nineteen patients will start intervention in week 3 while 19 patients will continue data collection for another 2 weeks before procedure changes are introduced. This is done to distinguish between specific effects of changes in procedures and non-specific effects, such as caregivers increased attention.

DISCUSSION

This study will advance the field of wearable physiological sensor use in patient care.

TRIAL REGISTRATION

Registered prospectively at ClinicalTrials.gov (NCT05738278).

Predictors of access to healthcare professionals for people with intellectual disability in Ireland

The Irish National Intellectual Disability Database is updated annually and in 2017 contained records for nearly 22,000 persons aged 15 years and over. Information was extracted on the contacts each person had with one of eight health professionals in the years 2007, 2012 and 2017. Over these years, there was an increase in the number of people in contact with any professional or with four and more professionals. Nevertheless, the people less likely to have contact were those with milder forms of intellectual disability, persons living with family carers or independently and those linked to smaller provider agencies. By contrast, the odds of people with more severe disability in residential settings were up to eight times greater for having contact with four or more different professionals. As demand for healthcare grows due to increased longevity and service models shift to the community, redeployment of existing professional resources will be needed along with a review of the skill mix.

Glycogen Synthase Kinase-3 Inhibitors: Preclinical and Clinical Focus on CNS-A Decade Onward

The protein kinase, GSK-3, participates in diverse biological processes and is now recognized a promising drug discovery target in treating multiple pathological conditions. Over the last decade, a range of newly developed GSK-3 inhibitors of diverse chemotypes and inhibition modes has been developed. Even more conspicuous is the dramatic increase in the indications that were tested from mood and behavior disorders, autism and cognitive disabilities, to neurodegeneration, brain injury and pain. Indeed, clinical and pre-clinical studies were largely expanded uncovering new mechanisms and novel insights into the contribution of GSK-3 to neurodegeneration and central nerve system (CNS)-related disorders. In this review we summarize new developments in the field and describe the use of GSK-3 inhibitors in the variety of CNS disorders. This remarkable volume of information being generated undoubtedly reflects the great interest, as well as the intense hope, in developing potent and safe GSK-3 inhibitors in clinical practice.

Risk factors for intellectual disability in children with spastic cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a non-progressive disorder of posture and movement caused by prenatal or perinatal lesions of the brain. Children with CP are also at increased risk of other disabilities, for example, intellectual disability. Previous studies suggest the risk of intellectual disability varies in complex ways according to the type of motor impairment and perinatal factors such as gestational age.

OBJECTIVE

To determine the patterns of risk of intellectual disability in children with spastic CP.

DESIGN

Cross-sectional, population-based study using the Northern Ireland Cerebral Palsy Register.

PARTICIPANTS

Persons born in 1981-2008 with congenital bilateral or unilateral spastic CP (N=1452).

OUTCOME MEASURE

The outcome measure was severe intellectual disability (IQ <50), as reported by clinicians known to the child. Data pertaining to CP subtype, sex, gestational age, birth weight and functional level were included in analyses.

RESULTS

Severe intellectual disability was significantly more prevalent in children with bilateral spastic CP (BSCP) compared with children with unilateral spastic CP (χ² (2)=162.60, p<0.001). Compared with very preterm infants with BSCP, the risk of intellectual disability increased in moderately preterm (OR=3.97, 95% CI 1.04 to 15.23) and at-term (OR=2.51, 95% CI 1.16 to 5.44) children with BSCP.

CONCLUSIONS

Children with BSCP are at increased risk of intellectual disability, with those born at term at the highest risk. The findings highlight the importance of early screening, particularly for children with BSCP born at term.

FUNCTIONAL CLASSIFICATION OF CHILDREN WITH CEREBRAL PALSY IN KRAPINA-ZAGORJE COUNTY

The aim was to study functional abilities and to create functional classification of children with cerebral palsy (CP) in Krapina-Zagorje County, based on the classification of gross and fine motor skills and associated impairments. Classification was performed according to the SCPE (Surveillance of Cerebral Palsy in Europe) criteria. We used standardized and complementary functional classification systems for cerebral palsy to create a functional profile. Research included 44 children with CP in the age range of 4 to 18 years. The results showed that the majority of children had bilateral spastic CP (63.6%), followed by unilateral spastic (22.7%) while the representation of dyskinetic CP was 9.09% and ataxic CP 4.55%. Based on the classification of gross and fine motor skills, 43.2% of children had the ability to walk, 11% of children could walk with assistive mobility devices, while 45.4% of children had a low functional level. The study also analyzed the associated impairments where higher classification score of motor impairment correlated with the severity of impairment. The results showed that children with dyskinetic CP and severe motor impairment could have mild cognitive impairment. We systematically present the neuropsychological and functional profile according to the CP type.

Increased heart rate functions as a signal of acute distress in non-communicating persons with intellectual disability

Intellectual disability (ID) affects approximately 1% of the population. Some patients with severe or profound ID are essentially non-communicating and therefore risk experiencing pain and distress without being able to notify their caregivers, which is a major health issue. This real-world proof of concept study aimed to see if heart rate (HR) monitoring could reveal whether non-communicating persons with ID experience acute pain or distress in their daily lives. We monitored HR in 14 non-communicating participants with ID in their daily environment to see if specific situations were associated with increased HR. We defined increased HR as being > 1 standard deviation above the daily mean and lasting > 5 s. In 11 out of 14 participants, increased HR indicated pain or distress in situations that were not previously suspected to be stressful, e.g. passive stretching of spastic limbs or being transported in patient lifts. Increased HR suggesting joy was detected in three participants (during car rides, movies). In some situations that were previously suspected to be stressful, absence of HR increase suggested absence of pain or distress. We conclude that HR monitoring may identify acute pain and distress in non-communicating persons with ID, allowing for improved health care for this patient group.

Community Living, Intellectual Disability and Extensive Support Needs: A Rights-Based Approach to Assessment and Intervention

People with intellectual disability (ID) and extensive support needs experience poorer quality of life than their peers whose disability is not as severe. Many of them live in residential settings that limit community participation and prevent them from exercising control over their lives. This work analyzes the extent to which professional practices are aimed at promoting the right to community living for people with ID and extensive support needs, as well as the rights that are particularly linked to it, such as the right to habilitation and rehabilitation and the right to privacy. A specific questionnaire was designed and administered to 729 adults with intellectual disability (M = 37.05; DT = 12.79) living in different settings (family home, residential facilities and group homes). Measurement and structural models were estimated using exploratory structural equation modeling. Results obtained reveal that people with extensive support needs receive less support in terms of guaranteeing their right to independent living and privacy, especially when they live in disability-related services. This study highlights the need to implement and monitor, using valid and reliable indicators, mesosystem strategies that guarantee the right to live and participate in the community, especially for individuals with ID and extensive support needs.

Genomically Aided Diagnosis of Severe Developmental Disorders

Our ability to make accurate and specific genetic diagnoses in individuals with severe developmental disorders has been transformed by data derived from genomic sequencing technologies. These data reveal both the patterns and rates of different mutational mechanisms and identify regions of the human genome with fewer mutations than would be expected. In outbred populations, the most common identifiable cause of severe developmental disorders is de novo mutation affecting the coding region in one of approximately 500 different genes, almost universally showing constraint. Simply combining the location of a de novo genomic event with its predicted consequence on the gene product gives significant diagnostic power. Our knowledge of the diversity of phenotypic consequences associated with comparable diagnostic genotypes at each locus is improving. Computationally useful phenotype data will improve diagnostic interpretation of ultrarare genetic variants and, in the long run, indicate which specific embryonic processes have been perturbed.

Cerebral palsy information system with an approach to information architecture: a systematic review

Background

Long-term complications and high costs of cerebral palsy (CP) as well as inconsistency in data related to this disease reveal the need for extensive planning to obtain accurate and complete data for the effective management of patients.

Objective

The present study reviews the information architecture of CP information system.

Method

The relevant articles published from early 1988 to 31 July 2018 were extracted through searching PubMed, Scopus, Cochran, Web of Science and Embase databases conducted independently by two researchers.

Results

A total of 39 articles on CP information system were reviewed. Hospitals, rehabilitation centres and outpatient clinics were found to be the main organisations in charge of generating CP data. Each CP database used several data sources, with hospitals serving as the most important sources of information and the main generators of data. The main CP datasets were categorised into four groups of demographic data, diagnosis, motor function and visual impairment. The majority of data standards were related to the use of the International Classification of Functioning, Disability and Health and the Gross Motor Function Classification System. Finally, accuracy, completeness and consistency were the criteria employed in data quality control.

Conclusion

Developing a robust CP information system requires deploying the principles of information architecture when developing the system, as these can improve data structure and content of CP system, as well as data quality and data sharing.

A case-study of policy change in residential service provision for adult persons with intellectual disability in Ireland

In Europe, many people with intellectual disabilities continue to live in congregated settings. In 2012, Ireland formally introduced a resettlement policy with people moving to live in more personalised arrangements. This longitudinal country case-study aimed to monitor the implementation of this policy and the intra-country variations that arose using the records maintained in the National Intellectual Disability Database. Details of over 4,000 people living in congregated settings were examined in 2007 and again in 2012 and 2017. In addition, people who moved from such settings from 2007 onwards were tracked and the number of new admissions to them was estimated over the 10-year period. Overall there was nearly a 30% drop in the numbers of people in congregated settings but the reductions varied markedly across the country and by 2017 the disparity was greater than in 2007. Also by 2017 persons aged over 55 years were eight times more likely to be accommodated in congregated settings. The case-study illustrates the value of a longitudinal dataset for monitoring policy implementation across a diversity of provider organisations and administrative areas.

The prevalence of intellectual disability: A comparison of national census and register records

BACKGROUND

International prevalence rates for intellectual disability vary widely with estimates often based on samples. In Ireland people with an intellectual disability are identified in the national census. Moreover, a national register of people receiving or requiring intellectual disability services is maintained and updated annually.

AIMS

The prevalence rates from the census were contrasted with those from the register along with variations in prevalence across the 26 counties of Ireland.

METHODS

2011 and 2016 Census of Population prevalence per 1000 for children (aged 5-19 years) and adults (20 years and over) stratified by the 26 countries were contrasted with similar prevalence in the national register. Publically available data from the 2011 census in Northern Ireland and Scotland were obtained.

RESULTS

The Irish census identified nearly twice as many children and adults than were on the national register. Prevalence rates also varied across the 26 counties; more so on the register than the census. The Irish census had lower prevalence rates than Northern Ireland but higher than Scotland.

CONCLUSIONS

Determining the prevalence of intellectual disability is challenging due to variations in terminology. A national register has advantages over reliance on census data for service planning.

Kinematic Analysis of Handwriting Movements in Individuals with Intellectual Disabilities with and without Obsessive Compulsive Symptoms

Theory/calculation: Movement disorders such as disturbances of coordination, clumsiness, and hand-related stereotypies are a frequent phenomenon in individuals with intellectual disabilities (ID). Obsessive-compulsive symptoms are also common in persons with ID. Our aim was to investigate hand motor dysfunction in persons with ID with and without OCD, using a digitizing tablet and the kinematic analysis of handwriting and drawing movements.

METHODS

We examinedthe hand motor performance of 23 individuals (12 males, 11 females, 42.6 ± 13.7 years old) with ID of heterogeneous aetiology. All subjects were required to write a sentence and draw circles under various conditions. Kinematic parameters were calculated to quantify hand motion.

RESULTS

Individuals with ID exhibit serious hand motor impairments suggestive of bradykinesia, irregularity, and micrographia. More than half of our ID patients (60.9%) displayed obsessive-compulsive symptoms of moderate severity (Y-BOCS total score: 16.6 ± 8.3). Interestingly, the ID patients with OCD displayed smaller amplitudes of hand motor movements than did patients with no obsessive-compulsive symptoms, while differences observed in the writing and drawing concentric circles trials were significant.

CONCLUSIONS

The results of this pilot study support the use of kinematic analyses of handwriting movements to evaluate motor abnormalities in patients with ID and comorbid mental illnesses.

Lithium Treatment Is Safe in Children With Intellectual Disability

Lithium is a widely used and effective treatment for individuals with psycho-neurological disorders, and it exhibits protective and regenerative properties in multiple brain injury animal models, but the clinical experience in young children is limited due to potential toxicity. As an interim analysis, this paper reports the safety/tolerability profiles of low-dose lithium treatment in children with intellectual disability (ID) and its possible beneficial effects. In a randomized, single-center clinical trial, 124 children with ID were given either oral lithium carbonate 6 mg/kg twice per day or the same dose of calcium carbonate as a placebo (n = 62/group) for 3 months. The safety of low-dose lithium treatment in children, and all the adverse events were monitored. The effects of low-dose lithium on cognition was evaluated by intelligence quotient (IQ), adaptive capacity was assessed by the Infant-Junior Middle School Students Social-Life Abilities Scale (IJMSSSLAS), and overall performance was evaluated according to the Clinical Global Impression-Improvement (CGI-I) scale. After 3 months of lithium treatment, 13/61 children (21.3%) presented with mild side effects, including 4 (6.6%) with gastrointestinal symptoms, 4 (6.6%) with neurological symptoms, 2 (3.3%) with polyuria, and 3 (4.9%) with other symptoms—one with hyperhidrosis, one with alopecia, and one with drooling. Four children in the lithium group had elevated blood thyroid stimulating hormone, which normalized spontaneously after lithium discontinuation. Both IQ and IJMSSSAS scores increased following 3 months of lithium treatment (F = 11.03, p = 0.002 and F = 7.80, p = 0.007, respectively), but such increases were not seen in the placebo group. CGI-I scores in the lithium group were 1.25 points lower (better) than in the placebo group (F = 82.66, p < 0.001) after 3 months of treatment. In summary, lithium treatment for 3 months had only mild and reversible side effects and had positive effects on cognition and overall performance in children with ID.

Clinical Trial Registration: Chinese Clinical Trial Registry, ChiCTR-IPR-15007518.

Low Apgar scores at both one and five minutes are associated with long-term neurological morbidity

AIM

This study evaluated the associations between low Apgar scores at one and five minutes and long-term neurological impairments.

METHODS

This study used population-based data on 399,815 singletons born in Finland in 2004-2010 and multivariable logistic regression to examine any associations between low (0-3) and intermediate (4-6) Apgar scores and cerebral palsy, epilepsy, intellectual disability and sensorineural defects by the age of four years.

RESULTS

The odd ratios (OR) and 95% confidence intervals (95% CI) showed that low Apgar scores were associated with cerebral palsy at one and five minutes (ORs 2.08, 95% CI 1.32-3.26 and 5.19, 95% CI 3.06-8.80), epilepsy (ORs 1.62, 95% CI 1.13-2.33 and 4.79, 95% CI 3.03-7.56), and intellectual disability (ORs 2.46, 95% CI 1.45-4.16 and 6.21, 95% CI 3.33-11.58). Only a low five-minute Apgar score was associated with sensorineural defects (OR 3.13, 95% CI 1.95-5.02). Neurological impairment risks were increased by low Apgar scores at both one and five minutes (OR 11.1, 95% CI 8.6-14.5), but 90.3% of children with persistent low Apgar scores had no impairment.

CONCLUSION

Low one-minute and five-minute Apgar scores were associated with long-term neurological morbidity, especially when both scores were low.

A Review of Global Literature on Using Administrative Data to Estimate Prevalence of Intellectual and Developmental Disabilities

As understanding of health deficits among people with intellectual and developmental disabilities (IDD) increases, concerns grow about how to develop comprehensive, sustainable surveillance systems to reliably monitor the health of this population over time. This study reviews literature from 12 countries in which retrospective administrative data have been used to estimate population-based prevalence of IDD, identifies promising practices in that literature, and discusses the feasibility of applying those promising practices to other countries. Administrative data sources can be used to identify the number of people with IDD (numerators) in the presence of population estimates from which people with IDD are drawn (denominators) for discrete geographic locations. Case ascertainment methods, age groupings, data years captured, and other methods vary, contributing to a wide variation in prevalence rates. Six methods are identified from five countries that appear to offer the greatest likelihood of expanded applications. Approaches in which administrative data collections are linked with other population-based data sources appear promising as a means of estimating the size and characteristics of populations living with IDD in defined geographic locations. They offer the potential for sustainability, timeliness, accuracy, and efficiency.

Prevalence of autism and attention-deficit-hyperactivity disorder in Down syndrome: a population-based study

AIM

To investigate the prevalence of autism spectrum disorder (ASD) and attention-deficit-hyperactivity disorder (ADHD) in a population-based group of children and adolescents with Down syndrome, and to relate the findings to level of intellectual disability and to medical conditions.

METHOD

From a population-based cohort of 60 children and adolescents with Down syndrome, 41 individuals (29 males, 12 females; mean age 11y, age range 5-17y) for whom parents gave consent for participation were clinically assessed with regard to ASD and ADHD. The main instruments used were the Autism Diagnostic Interview-Revised, Autism Diagnostic Observation Schedule, Swanson, Nolan, and Pelham-IV Rating Scale, and the Adaptive Behavior Assessment System-II.

RESULTS

High rates of ASD and ADHD were found: 17 (42%) and 14 (34%) of the 41 children met DSM criteria for ASD and ADHD respectively.

INTERPRETATION

Children with Down syndrome and coexisting neurodevelopmental/neuropsychiatric disorders in addition to intellectual disability and medical disorders constitute a severely disabled group. Based on the results, we suggest that screening is implemented for both ASD and ADHD, at the age of 3 to 5 years and early school years respectively, to make adequate interventions possible.

Pain in Intellectually Disabled Children: Towards Evidence-Based Pharmacotherapy?

This critical opinion article deals with the challenges of finding the most effective pharmacotherapeutic options for the management of pain in intellectually disabled children and provides recommendations for clinical practice and research. Intellectual disability can be caused by a wide variety of underlying diseases and may be associated with congenital anomalies such as cardiac defects, small-bowel obstructions or limb abnormalities as well as with comorbidities such as scoliosis, gastro-esophageal reflux disease, spasticity, and epilepsy. These conditions themselves or any necessary surgical interventions are sources of pain. Epilepsy often requires chronic pharmacological treatment with antiepileptic drugs. These antiepileptic drugs can potentially cause drug-drug interactions with analgesic drugs. It is unfortunate that children with intellectual disabilities often cannot communicate pain to caregivers. Although these children are at high risk of experiencing pain, researchers nevertheless often have to exclude them from trials on pain management because of ethical considerations. We therefore make a plea for prescribers, researchers, patient organizations, pharmaceutical companies, and policy makers to study evidence-based, safe and effective pharmacotherapy in these children through properly designed studies. In the meantime, parents and clinicians must resort to validated pain assessment tools such as the revised FLACC scale.

[Schooling and care of mild intellectual disability children]

Studies on mild intellectual disability (MID) are scarce. The aim of this study was to describe the educational and medical care trajectories and their determinants in children with MID. The study population concerned children born in 1997 and resident in a French county (Isère) in 2008. MID was defined as an overall IQ score between 50 and 69. For the present study, this definition was adjusted by integrating the IQ confidence intervals so that the risk of IQ measurement relativity and possible score discrepancy could be taken into account. Of the 267 children included, 180 (67%) were identified through an institute that decides upon special education and allowances (MDPH) and 87 (33%) through the educational system. The parents of 181 children (68%) accepted to answer a telephone questionnaire, describing their child's educational and medical history. Children with MID frequently presented clinical signs and comorbidities. Educational trajectories were quite varied: a majority of the children (52.9%) were oriented toward sections with adapted general and professional education (SEGPA) after finishing primary school, a minority (41.3%) were oriented towards specialized schools, such as medical-educational institutions, and a small proportion of children (5.8%) stayed in ordinary school. Children followed the SEGPA orientation more frequently when a relative written language disorder was present, and autism-spectrum disorders or other clinical signs were absent. Concerning follow-up care and rehabilitation, children mostly took part in speech therapy (76.2%) and psychotherapy (55.8%). The French law dating from 2005, ensuring equal opportunity for people with disabilities, has borne fruit in the diversification of educational trajectories.