Trauma exposure and post‐traumatic stress disorder in people with intellectual disabilities: A Delphi expert rating

Stressful life events, post-traumatic stress disorder symptoms and mental health in individuals with intellectual disabilities: a scoping review

BACKGROUND

Stressful life events are events that do not fulfil the A criterion of PTSD in the DSM-5(TR) but are perceived as negative by the person. There is an ongoing debate about the usefulness of the A criterion as a gate criterion for PTSD, and especially regarding which events qualify as traumatic or stressful life events. This debate is particularly important for individuals with intellectual disabilities (ID) or borderline intellectual functioning (BIF), as they seem to be more likely to experience traumatic and stressful life events than their peers without ID-BIF and appear to be more susceptible to the disruptive effects of these events. As a result, people with ID-BIF are more likely to develop mental health and behavioural problems. There is insufficient knowledge about how the relationship between stressful life events and PTSD symptoms should be interpreted, how traumatic and stressful life events are defined and distinguished in people with ID, and whether the A criterion should be broadened for individuals with ID-BIF. The aim of this scoping review was to understand stressful life events and their relationship with PTSD symptoms, other mental health and/or behavioural problems in individuals with ID-BIF.

METHODS

The scoping review was conducted in accordance with the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).

RESULTS

Thirty-eight studies were included. Five studies focused on stressful life events and PTSD symptoms. The other studies examined associations between stressful life events and other mental health and/or behavioural problems. Most of the studies did not clearly differentiate between stressful and traumatic events according to the A criterion of PTSD in the DSM-IV (TR) or DSM-5(TR). Of the six studies in which stressful life events were specified and could be distinguished from traumatic events, one found a positive association between PTSD symptoms and stressful life events and five showed weak to strong positive associations with other mental health and/or behavioural problems.

CONCLUSIONS

PTSD symptoms following stressful life events in individuals with ID-BIF are underrepresented in the literature. The lack of a clear definition of stressful life events leads to a gap in the knowledge on whether and how stressful life events may lead to PTSD symptoms, other mental health and/or behavioural problems in individuals with ID-BIF. Therefore, no general conclusions or recommendations can be made regarding the appropriateness of the PTSD A criterion for individuals with ID-BIF. Further research is needed to establish the role of stressful life events in relation to PTSD symptoms and to inform the assessment and effective treatment in people with ID-BIF, as expert clinical experience studies suggest that broadening the PTSD A criterion should be considered for people with ID-BIF.

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.

Forensic psychiatric issues in intellectual disability

Forensic psychiatrists and neuropsychiatrists are likely to encounter individuals with intellectual disability as they are over-represented in the judicial system. These individuals may have the full range of mental illnesses and comorbid conditions, including physical infirmity, sensory deficits, language impairment, and maladaptive behaviors. They are frequently disadvantaged in the judicial system due to lack of comprehension, lack of accommodations, and stigmatization. Decision making capacity may need to be assessed for health care, sexual autonomy, marriage, financial management, making a will, and need for guardianship. The usual approach to conducting an evaluation needs adaptation to fit the unique characteristics and circumstances of the individual with intellectual disability. The forensic consultant can assist attorneys, defendants, and victims in recommending accommodations and the expert witness can provide education to juries.

Clinicians' experiences of learning to use eye movement desensitisation and reprocessing therapy with people with intellectual disabilities: A qualitative study

BACKGROUND

Eye Movement Desensitisation and Reprocessing therapy (EMDR) is a NICE recommended treatment for post-traumatic stress disorder within the general population. Ongoing research is now investigating the use of EMDR for individuals with intellectual disability. Alongside quantitative research efforts, it is beneficial to explore the qualitative experience of clinicians adopting EMDR in their practice. The current study interviewed newly trained EMDR therapists working in intellectual disability services.

METHOD

Participants (six Clinical Psychologists from an NHS learning disability service) had recently undertaken EMDR training as part of a wider randomised control trial (Trauma-AID). Interviews were qualitatively analysed using thematic analysis.

RESULTS

Three themes emerged; learning EMDR, conducting EMDR and external factors, with respect to clinicians' experiences.

CONCLUSIONS

Further research is needed to provide guidance and reassurance for clinicians currently using or hoping to use this therapy with people with intellectual disabilities.

Organisational impact on the use of restrictive measures: The perspective of Swedish front-line managers

BACKGROUND

Restrictive measures (RM) are prevalent in services for people with intellectual disabilities. This study investigates managerial awareness of RM and the nature of organisational supports required to reduce their use.

METHOD

A survey asked front-line managers and staff what (RM) were used, their purpose, impact and importance (10-item Likert scales) and what organisational changes were required (free text). Responses were analysed using descriptive methods and content analysis.

RESULTS

Managers reported a lower use of RM, compared with staff. According to managers, RM were mainly used to keep service users from harm, their use having a significant impact. Opportunities to change practices were limited by a lack of resources and organisational support.

CONCLUSION

Front-line managers seem to lack the capacity to address the use of RM due to organisational drift; limited manager time and opportunity to allocate resources; inadequate environments; and lack of skilled staff, knowledge and relevant professional input.

Gaining consensus on clinical quality outcomes for eating disorders: Framework for the development of an Australian national minimum dataset

OBJECTIVES

Eating disorders (EDs) are complex psychiatric illnesses requiring multidisciplinary care across both mental and medical healthcare settings. Currently, no nationally comprehensive, consistent, agreed on or mandated data set or data collection strategy exists for EDs in Australia: thus, little is known about the outcomes of care nor treatment pathways taken by individuals with EDs. InsideOut Institute was contracted by the Australian Government Department of Health to develop a minimum dataset (MDS) for the illness group with consideration given to data capture mechanisms and the scoping of a national registry.

DESIGN

A four-step modified Delphi methodology was used, including national consultations followed by three rounds of quantitative feedback by an expert panel.

SETTING

Due to social distancing protocols throughout the global SARS-CoV-2 pandemic, the study was conducted online using video conferencing (Zoom and Microsoft Teams) (Step 1), email communication and the REDCap secure web-based survey platform (Steps 2-4).

PARTICIPANTS

14 data management organisations, 5 state and territory government departments of health, 2 Aboriginal and Torres Strait Islander advising organisations and 28 stakeholders representing public and private health sectors across Australia participated in consultations. 123 ED experts (including lived experience) participated in the first quantitative round of the Delphi survey. Retention was high, with 80% of experts continuing to the second round and 73% to the third.

MAIN OUTCOME MEASURES

Items and categories endorsed by the expert panel (defined a priori as >85% rating an item or category 'very important' or 'imperative').

RESULTS

High consensus across dataset items and categories led to the stratification of an identified MDS. Medical status and quality of life were rated the most important outcomes to collect in an MDS. Other items meeting high levels of consensus included anxiety disorders, depression and suicidality; type of treatment being received; body mass index and recent weight change.

CONCLUSIONS

Understanding presentation to and outcomes from ED treatment is vital to drive improvements in healthcare delivery. A nationally agreed MDS has been defined to facilitate this understanding and support improvements.

Internet Risk Perception: Development and Validation of a Scale for Adults

Despite the importance of Internet risk perception, no instrument currently exists that measures this awareness in the Spanish population. The goal of this study was to provide information on studies of the validity and reliability of the Internet Risk Perception (IRP) Scale for adult Spanish citizens. We began with a literature review and validation using a mixed panel with 20 participants. We analyzed the degree to which the subjects agreed or disagreed with the criteria evaluated, including contributions for improving the instrument, and performed a pilot test with 517 adults aged 18 to 77. Construct reliability and validity were analyzed using various statistical analyses. The results from the confirmatory factor analysis showed a sufficient accuracy of the data with parameters that indicated an excellent fit for all items. The Spanish version of the scale for adults is a reliable and valid instrument for use in studies that investigate Internet risk perception in people over 18 years of age.

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.

Potentially traumatic experiences and behavioural symptoms in adults with autism and intellectual disability referred for psychiatric assessment

BACKGROUND

Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) more frequently experience potentially traumatic events (PTEs), and may be more vulnerable to trauma-related symptoms. However, it is unclear how such symptoms are captured on tools used for behavioural and psychiatric assessment in this population.

AIMS

To explore whether and how PTEs are associated with symptom reports in adults with ASD and ID.

METHODS AND PROCEDURES

Associations and group differences for death of a close relative and serious disease/injury in a close relative/caregiver/friend were explored in a clinical sample of 171 adults with ASD and ID referred for psychiatric assessment. Symptoms were measured using Aberrant Behavior Checklist (ABC) and Psychopathology in Autism Checklist (PAC).

OUTCOMES AND RESULTS

Disease/injury was associated with higher scores on ABC irritability, ABC hyperactivity and self-injurious behaviour. Death was associated with lower scores on ABC lethargy and ABC stereotypic behaviour. Some associations reached significance only when controlling for ASD, ID, or verbal language skills, but the identified associations were not robust. No associations were found for PAC.

CONCLUSIONS AND IMPLICATIONS

There is a risk of under-appreciating the impact of PTEs in this population unless ASD, ID and verbal language skills are taken into account.

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.