Psychiatric symptoms in adults with learning disability and challenging behaviour

Diagnosis and pharmacological management of attention deficit hyperactivity disorder in adults with and without intellectual disability: cohort study using electronic health records

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is increasingly diagnosed in adults. People with intellectual disability have higher rates of ADHD yet there is little evidence on the presentation and pharmacological treatment of ADHD in this population or how this differs from the general population.

METHODS

Retrospective cohort study using data from electronic health records. Adults with intellectual disability newly diagnosed with ADHD between 2007 and 2022 were matched to adults with ADHD without intellectual disability and their clinical features and treatments were compared.

RESULTS

A total of 159 adults with ADHD and intellectual disability and 648 adults with ADHD without intellectual disability formed the dataset. Adults with intellectual disability had higher rates of psychiatric co-morbidity and spent more time under mental health services than those without intellectual disability. They were more likely to have recorded agitation, aggression, hostility, and mood instability, and less likely to have poor concentration recorded in the 12 months prior to the diagnosis of ADHD. Following diagnosis, people with intellectual disability were significantly less likely to be prescribed any medication for ADHD than controls without intellectual disability (adjusted odds ratio 0.60, 95% confidence interval 0.38-0.91), and were less likely to be prescribed stimulants (27.7% v 46.0%, p < 0.001).

CONCLUSIONS

The presence of behaviors that challenge in adults with intellectual disability may indicate co-occurring ADHD. Further work to define the safety and efficacy of medication for ADHD in adults with intellectual disability is needed to understand differences in prescription rates and to avoid inequities in care outcomes.

Profound Autism: An Imperative Diagnosis

Profound autism refers to a subset of individuals with autism spectrum disorder who have an intellectual disability with an intelligence quotient less than 50 and minimal-to-no language and require 24-hour supervision and assistance with activities of daily living. The general pediatrician will invariably work with autistic children across the spectrum and will likely encounter youth with profound autism. Awareness of profound autism as a real entity describing autistic children with concomitant intellectual disability and language impairment who require 24-hour care is the first step in developing a solid pediatric home for these youth.

Appropriateness of psychopharmacological therapies to psychiatric diagnoses in persons with autism spectrum disorder with or without intellectual disabilities: a cross-sectional analytic study

BACKGROUND

Observational studies highlighted high rates of psychotropic medication in persons with autistic spectrum disorder (ASD) with or without intellectual disability, which seems to be associated with the management of problem behaviors more than co-occurrent psychiatric disorders. The purpose of the study is to investigate psychopharmacology use and diagnoses of co-occurrent psychiatric disorder (PD) in persons with ASD attending a public mental health service in Emilia Romagna, Italy.

METHODS

The present study is a multicenter, cross-sectional study.

RESULTS

275 persons out of 486 (56.5%) resulted to receive at least one psychotropic drug, compared to 74 persons (15.2%) that were diagnosed with a PD. 63.6% were on poly-pharmacotherapy (2-10 compounds), with 37.8% receiving 3 or more medications. Antipsychotics were the most frequently prescribed class of psychotropic drugs (89%), followed by antiepileptics/mood stabilizers/lithium (42.1%) and anxiolytics (BDZ) (38.5%). Most common psychiatric disorders were psychotic disorders (29.7%), followed by anxiety disorders (17.5%), bipolar disorders (12.2%), and depressive disorders (9.4%).

CONCLUSIONS

Our findings support earlier research showing that many individuals with ASD receive pharmacotherapy without being diagnosed with a co-occurring psychiatric disorder, indicating that the main reasons for prescription and the type of compound frequently have little to no link with specific psychopathology.

Consensus recommendations on mental health issues in Phelan-McDermid syndrome

Phelan-McDermid syndrome is a rare genetic condition caused by a deletion encompassing the 22q13.3 region or a pathogenic variant of the gene SHANK3. The clinical presentation is variable, but main characteristics include global developmental delay/intellectual disability (ID), marked speech impairment or delay, along with other features like hypotonia and somatic or psychiatric comorbidities. This publication delineates mental health, developmental and behavioural themes across the lifetime of individuals with PMS as informed by parents/caregivers, experts, and other key professionals involved in PMS care. We put forward several recommendations based on the available literature concerning mental health and behaviour in PMS. Additionally, this article aims to improve our awareness of the importance of considering developmental level of the individual with PMS when assessing mental health and behavioural issues. Understanding how the discrepancy between developmental level and chronological age may impact concerning behaviours offers insight into the meaning of those behaviours and informs care for individuals with PMS, enabling clinicians to address unmet (mental health) care needs and improve quality of life.

La discapacidad de especial dificultad. Perspectivas y líneas de actuación

Al tratarse la discapacidad y el empleo en los estudios académicos, normalmente se hace de una forma conjunta, sin tener en cuenta la diversidad que existe dentro de este ámbito. La realidad es que, según el grado y la tipología de discapacidad, la incorporación al mercado laboral resulta más o menos sencilla. De hecho, la legislación española ha definido lo que denominamos discapacidad de “especial dificultad” con la finalidad de diferenciar unos grados y tipos determinados. Este artículo pretende incidir en las características de dicha categoría, mostrando aquellos aspectos que la diferencian del resto. Se proponen asimismo unas estratégicas líneas de acción a seguir por parte de la administración pública. Con la proposición de estas líneas de acción se pretende recibir una respuesta específica de apoyo a estas personas, cuya incorporación al mercado laboral no es tan solo un propósito loable y de responsabilidad social, sino que a su vez genera un impacto positivo en la economía, donde el empleo protegido va cada vez ganando mayor importancia.

Smartphone-based behaviour analysis for challenging behaviour in intellectual and developmental disabilities and autism spectrum disorder - Study protocol for the ProVIA trial

Background

Challenging behaviour (CB) comprises various forms of aggressive and problematic behaviours frequently occurring in children with intellectual and developmental disability (IDD) or autism spectrum disorder (ASD). CB often arises from impaired communication or problem solving skills. It is often met with coercive measure due to a lack of alternative strategies on the part of the caregiver, while it also impacts on the caregivers due to the exposure to physical harm and high levels of stress. Within the ProVIA project we developed a smartphone-based tool for caregivers of children with IDD and/or ASD to prevent and modify CB. The ProVIA app systematically helps caregivers to identify specific causes of CB and provides individualised practical guidance to prevent CB and consecutive coercive measures, thus aiming to improve the health and well-being of the children and caregivers.

Methods

In this uncontrolled open trial we will enrol N = 25 caregivers of children aged 3-11 years with a diagnosis of IDD and/or ASD. Participants will use the ProVIA-Kids app for 8 weeks. During the intervention phase, participants will conduct behaviour analyses after each instance of CB. The app will summarise the identified putative causes for the CB in each situation, and provide recommendations regarding the handling and prevention of CB. Furthermore, the app will aggregate data from all available behaviour analyses and identify the most relevant (i.e., most frequently reported) risk factors. Measurement points are at baseline (T0), after the intervention (T1) and 12 weeks after the end of the intervention (follow-up; T2). The primary outcome is the absolute change in parental stress (EBI total scale) between T0 and T1. Further aspects of interest are changes in CB severity and frequency, caregiver mood, satisfaction with the parenting role (EFB-K total scale) and experienced parenting competence (FKE total scale). Pre-post comparisons will be analysed with paired sample t-tests.

Discussion

ProVIA is pioneering structured behaviour analysis via smartphone, assessing predefined causes of CB and providing feedback and recommendations. If this approach proves successful, the ProVIA-Kids app will be a valuable tool for caregivers to prevent CB and improve their own as well as the children's quality of life.

Trial registration

The study is registered at https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_IDDRKS00029039 (registered May 31, 2022).

Is health a priority? Examining health-related support needs in adults with intellectual disability through a self-determination framework

BACKGROUND

People with intellectual disabilities experience inequities in healthcare. Those are maintained by individual limitations as well as environmental factors. In this context, health needs are less likely to be expressed, identified and met.

METHOD

We led a survey in 832 adults with intellectual disabilities to identify if health was set as a priority and if so, what were their major health-related support needs (in terms of physical, social and psychological health).

RESULTS

67.1% of participants reported at least one need. Most frequently, two or more types of needs were reported with gender and living facility having an effect on whether participants would report these needs, but these did not affect which type of needs were reported.

CONCLUSIONS

Health-related support needs are highly prevalent and diversified in people with intellectual disabilities. This study emphasizes the importance to consider health as a global concept as well as the relationships between health and self-determination.

Comprehensive Assessment of Triggers for Behaviours of Concern Scale (CATS): Initial Development

Challenging behaviour displayed by people with intellectual disabilities (ID) can be difficult to manage if caregivers do not understand the reasons for the behaviour. Identifying the contextual variables/triggers for the behaviour is likely to help undertake a functional analysis leading to a person-centred positive behaviour support plan. Currently, a limited number of checklists are available for trigger assessment and none were developed using an interview with the family caregivers. This article describes the development and contents of the comprehensive assessment of triggers for behaviours of concern scale (CATS). CATS was developed in two stages. Stage 1 used a ‘bottom-up’ approach, in which caregivers of adults with ID who show aggressive behaviour were interviewed to identify the triggers for aggression. In stage two, using a ‘top-down’ approach, a comprehensive literature review was conducted to gather items from existing trigger checklists. Trigger items from both stages were combined and the duplicates were removed. The final list in CATS consists of 333 contextual triggers categorised under five main domains and 12 subdomains. CATS can be used by caregivers to identify triggers or antecedents of challenging behaviour. Further work is needed to test its psychometric properties, utility, and acceptability.

Psychometric properties of the Psychopathology in Autism Checklist (PAC)

Psychiatric disorders in individuals with co-occurring autism spectrum disorders (ASD) and intellectual disability (ID) are common, but diagnosis presents many challenges. The Psychopathology in Autism checklist (PAC) is among the very few instruments specifically developed for this group of individuals. The psychometric properties of the PAC (i.e. criterion validity, specificity, sensitivity and predictive values) were explored by comparing scores with assessments on the Aberrant Behavior Checklist (ABC) and examining how well assessment by the PAC at referral predicts final clinical diagnoses. Results indicated a significant correlation with the ABC, further supporting the validity of the PAC. Sensitivity and Specificity for specific diagnoses were variable, although positive predictive value for "any diagnosis' was relatively high. The study confirms the potential value of the PAC as a screening checklist but highlights the need for clinical diagnosis to be based on a multimodal, multidisciplinary assessment.

Underdiagnosis of psychiatric disorders in people with intellectual disabilities: Differences between psychiatric disorders and challenging behaviour

BACKGROUND AND PURPOSE

The purpose of this study was to assess the level of mental disorders and challenging behaviour in individuals with intellectual disability (ID) supported by specialized services, but without a prior psychiatric diagnosis, and to compare the levels of different disorders depending on the severity of ID.

METHODS

This is a cross-sectional study (N = 142) of population with ID. Inclusion criteria were the following: adult patients with ID and with no previous psychiatric diagnosis prior to this survey. The Wechsler Adults Intelligence Scale-II, the Psychiatric Assessment Schedule for Adults with Developmental Disability checklist and clinical interview, the Diagnostic Assessment for the Severely Handicapped scale and the Inventory for Client and Agency Planning were the assessment tools.

RESULTS

A previously undiagnosed mental disorder was found in 29.6% of the sample. The most prevalent mental disorders were major depressive and anxiety disorders. An association between psychiatric comorbidity and challenging behaviour was found only for mild/moderate ID, especially for affective disorders.

CONCLUSIONS

The presence of a psychiatric as well as a medical comorbidity is associated with severe ID, unlike challenging behaviour. Clinical limitations of the study have been discussed.

Psychiatric symptoms, challenging behaviour and utilization of psychiatric services among adults with intellectual disabilities in Turkey

BACKGROUND

The aim of this study was to investigate the prevalence of and the factors associated with psychiatric symptoms (PS) and challenging behaviour (CB) in adults with intellectual disabilities, and the utilization of psychiatric services in Turkey.

METHOD

Psychiatric Assessment Schedule for Adults with Developmental Disorders Checklist-Revised was used for PS and a structured form for other variables in 771 participants.

RESULTS

Of the participants, 50.1% had PS and 36.4% presented with CB. Multivariate analysis revealed that a higher level of needs, better verbal ability, residential living, incontinence and CB, and lifetime suicidal ideation/attempt were independently associated with PS. For CB, it emerged as male carer, PS, lifetime suicidal attempt/ideation, lower level of verbal ability and autism spectrum disorder. Barriers were experienced by 64.7% of participants within the previous year.

CONCLUSIONS

Psychiatric symptoms and CB seem to be problems for a significant proportion of adults with intellectual disabilities in Turkey, and there are certain barriers to psychiatric services.

Triggers of Aggressive Behaviors in Intellectually Disabled Adults and Their Association with Autism, Medical Conditions, Psychiatric Disorders, Age and Sex: A Large-Scale Study

Aggressive behaviors in those with intellectual disability (ID) and autism (ASD) have been linked to a variety of factors including ID level, age, sex, psychiatric disorders, and medical conditions but these factors have not been studied, in large samples, in terms of how they affect the stimuli that trigger aggression. In this survey of 2243 adults, four triggers of aggression associated with frustration, discomfort, change in the physical/social environment, and defensive reactions were analyzed for their relation to ID level, ASD, age, sex, number of psychiatric diagnoses, sleeping problems, seizures, visual impairment, ear infections and gastrointestinal problems. All four triggers were associated with increasing number of psychiatric disorders, with frustration, discomfort, and change intolerance commonly linked to sleeping problems and ASD. Implications for assessment and intervention are discussed.

Standardizing the assessment of emotional development in adults with intellectual and developmental disability

OBJECTIVE

The Scale of Emotional Development-Short (SED-S) is an instrument to assess the level of emotional development (ED) in people with intellectual and developmental disability. Index cases are developed as a didactic tool to standardize the application of the scale.

METHOD

In a stepwise process, a European working group from six countries developed five index cases, one for each level of ED. All cases were first scored by 20 raters using the SED-S and then rephrased to reduce inter-rater variations (SD > 0.5).

RESULTS

All five index cases yielded overall ratings that matched the intended level of ED. Across the range of ED, Regulating Affect needed rephrasing most to ensure a distinct description within each level of ED.

CONCLUSIONS

The tri-lingual, cross-cultural evolution of five index cases contributes to a standardized application of the SED-S and can serve as training material to improve the inter-rater reliability of the SED-S across different cultures and languages.

Problem behaviours and Major Depressive Disorder in adults with intellectual disability and autism

The high prevalence of Problem Behaviours (PB) in persons with intellectual disability (ID) and Autism Spectrum Disorder (ASD) has been associated by some researchers to a proportionate frequency of Major Depressive Disorder (MDD), which have a different presentation in persons with ID and ASD than in the general population, mostly as behavioural changes. Nevertheless, evidence on this behavioural equivalency is still scarce. The present study aims at evaluating the rate of MDD in persons with ID and ASD presenting PB. Two groups of persons with mild-to-moderate ID and ASD, with and without PB underwent a complex clinical (Diagnostic Manual - Intellectual Disability) and instrumental (Reiss Screen for Maladaptive Behaviour; Mini Psychiatric Assessment Schedule for Adults with Developmental Disabilities). The prevalence of MDD was found to be significantly higher in the group with PB. The severity of depressive symptoms resulted to have a strong correlation with the scores of instrumental assessment of PB. Our findings support previous literature on a high association between PB and MDD in persons with ID and ASD. The level of the equivalency between specific MDD symptoms and different PB deserves further investigations.

Prevalence and associated factors of problem behaviours among older adults with intellectual disabilities in Ireland

A growing number of adults with intellectual disabilities (ID) are reaching old age, however, little is known about epidemiology of problem behaviours (PBs) in this population. The aim was to identify the prevalence and associated factors of PBs among older adults with ID in Ireland. Data was generated from Wave 2 of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA), a nationally representative sample of adults with ID aged ≥40. Data on PBs was available for 683 (98.3%) of individuals. Over half (53%; n = 362) reported displaying any PB (verbal aggression, physical aggression, destruction, self-injury, or "other" PB). Multivariate analyses indicated PBs were independently associated with moderate or severe/profound ID, living in a community group home or residential centre, experiencing a greater number of life events in the last year, taking psychotropic medication, and reporting a doctor's diagnosis of a psychiatric problem. A considerable number of older adults with ID in Ireland display PBs, which may hinder their opportunities to engage in community based activities and form meaningful social connections. High rates of psychotropic medication and doctor's diagnosis of psychiatric conditions and their associations with PBs were highlighted. Future research should examine mechanisms underlying these linkages.

Development of a cognitive behavioural therapy-based guided self-help intervention for adults with intellectual disability

BACKGROUND

Despite strong evidence for cognitive behaviour therapy (CBT) in treating mental health, its use, thus far, has been limited for people with intellectual disabilities. This study describes a CBT-based guided self-help (CBT-GSH) manual for individuals with intellectual disability, and focus groups explore the views of clinicians, therapists, support staff and managers.

MATERIAL AND METHODS

Using a qualitative methodology, an expert team adapted the manual. Focus groups provided feedback, followed by thematic content analysis for modifications.

RESULTS

Participants supported using the manual, with varying views about the delivery. Quality of relationships and competence of the administrator determined the best person to deliver the treatment. Heterogeneity in the intellectual disability population was a challenge to delivering manual-based interventions. Participants made suggestions about language and organization.

CONCLUSIONS

Amendments were made to the manual in line with expert feedback. An evaluation is warranted to test for feasibility, delivery, acceptability and efficacy.

Electroconvulsive therapy for self-injurious behaviour in autism spectrum disorders: recognizing catatonia is key

PURPOSE OF REVIEW

Self-injurious behaviour (SIB) is a devastating condition frequently encountered in autism spectrum disorders (ASDs) that can lead to dangerous tissue injury and profound psychosocial difficulty. An increasing number of reports over the past decade have demonstrated the swift and well tolerated resolution of intractable SIB with electroconvulsive therapy (ECT) when psychopharmacological and behavioural interventions are ineffective. The current article provides a review of the salient literature, including the conceptualization of repetitive self-injury along the catatonia spectrum, and further clarifies the critical distinction between ECT and contingent electric shock.

RECENT FINDINGS

We searched electronically for literature regarding ECT for self-injurious behaviour from 1982 to present, as the first known report was published in 1982. Eleven reports were identified that presented ECT in the resolution of self-injury in autistic or intellectually disabled patients, and another five reports discussed such in typically developing individuals. These reports and related literature present such self-injury along the spectrum of agitated catatonia, with subsequent implications for ECT.

SUMMARY

Intractable self-injury remains a significant challenge in ASDs, especially when patients do not respond adequately to behavioural and psychopharmacological interventions. ECT is well tolerated and efficacious treatment for catatonia, and can confer marked reduction in SIB along the agitated catatonia spectrum.

Interventions for challenging behaviour in intellectual disability

Challenging behaviour is common in intellectual disability but it is difficult to diagnose and manage. It can adversely affect the quality of life of the individual and cause the breakdown of community placements, resulting in hospital admission. This article discusses the aetiology of challenging behaviour (including the complex relationship with mental illness), diagnostic problems, the current evidence base in relation to psychosocial and pharmacological treatments, and service delivery.

LEARNING OBJECTIVES

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Epidemiology of mental health problems in adults with learning disability: an update

Epidemiological studies measuring prevalence rates and factors associated with mental health problems in adults with learning disability have produced very different and sometimes contradictory results, mainly because of methodological problems. Consequently, much of the epidemiology of mental health problems in this population is still unknown, although improved methodology and additional information are emerging. This article describes the methodological difficulties of studies, the reported prevalence rates in the context of these difficulties and what is currently known about the factors associated with mental health problems in this population.

Anxiety disorders in people with learning disabilities

People with learning disabilities are much more vulnerable to psychiatric illnesses, and will increasingly be accessing generic services. Treatment and management of psychiatric disorders is problematic, primarily because of difficulties in diagnosis, since classificatory systems are standardised on people with average intellectual functioning. This article provides an overview of the clinical implications of anxiety disorders within the context of learning disability.

A multicenter randomized controlled trial for bright light therapy in adults with intellectual disabilities and depression: Study protocol and obstacle management

Due to the limited cognitive and communicative abilities of adults with intellectual disabilities (ID), current treatment options for depression are often limited to lifestyle changes and pharmacological treatment. Bright light therapy (BLT) is an effective intervention for both seasonal and non-seasonal depression in the general population. BLT is an inexpensive, easy to carry out intervention with minimal side effects. However, knowledge on its anti-depressant effect in adults with ID is lacking. Obstacles in realizing a controlled intervention study in this particular study population may have contributed to this lack. To study the effect of BLT on depression in this population, it is necessary to successfully execute a multicenter randomized controlled trial (RCT). Therefore, the study protocol and the management of anticipated obstacles regarding this trial are presented.

Factors Influencing Clinical Correlates of Chronic Traumatic Encephalopathy (CTE): a Review

Chronic traumatic encephalopathy (CTE) is a neuropathologically defined disease reportedly linked to a history of repetitive brain trauma. As such, retired collision sport athletes are likely at heightened risk for developing CTE. Researchers have described distinct pathological features of CTE as well a wide range of clinical symptom presentations, recently termed traumatic encephalopathy syndrome (TES). These clinical symptoms are highly variable, non-specific to individuals described as having CTE pathology in case reports, and are often associated with many other factors. This review describes the cognitive, emotional, and behavioral changes associated with 1) developmental and demographic factors, 2) neurodevelopmental disorders, 3) normal aging, 4) adjusting to retirement, 5) drug and alcohol abuse, 6) surgeries and anesthesia, and 7) sleep difficulties, as well as the relationship between these factors and risk for developing dementia-related neurodegenerative disease. We discuss why some professional athletes may be particularly susceptible to many of these effects and the importance of choosing appropriate controls groups when designing research protocols. We conclude that these factors should be considered as modifiers predominantly of the clinical outcomes associated with repetitive brain trauma within a broader biopsychosocial framework when interpreting and attributing symptom development, though also note potential effects on neuropathological outcomes. Importantly, this could have significant treatment implications for improving quality of life.

Problem behaviours and symptom dimensions of psychiatric disorders in adults with intellectual disabilities: An exploratory and confirmatory factor analysis

BACKGROUND

The limited evidence on the relationship between problem behaviours and symptoms of psychiatric disorders experienced by adults with intellectual disabilities leads to conflict about diagnostic criteria and confused treatment. This study examined the relationship between problem behaviours and other psychopathology, and compared the predictive validity of dimensional and categorical models experienced by adults with intellectual disabilities.

METHODS

Exploratory and confirmatory factor analyses appropriate for non-continuous data were used to derive, and validate, symptom dimensions using two clinical datasets (n=457; n=274). Categorical diagnoses were derived using DC-LD. Severity and 5-year longitudinal outcome was measured using a battery of instruments.

RESULTS

Five factors/dimensions were identified and confirmed. Problem behaviours were included in an emotion dysregulation-problem behaviour dimension that was distinct from the depressive, anxiety, organic and psychosis dimensions. The dimensional model had better predictive validity than categorical diagnosis.

CONCLUSIONS

International classification systems should not include problem behaviours as behavioural equivalents in diagnostic criteria for depression or other psychiatric disorders. Investigating the relevance of emotional regulation to psychopathology may provide an important pathway for development of improved interventions.

WHAT THIS PAPER ADDS

There is uncertainty whether new onset problem behaviours or a change in longstanding problem behaviours should be considered as symptoms of depression or other types of psychiatric disorders in adults with intellectual disabilities. The validity of previous studies was limited by the use of pre-defined, categorical diagnoses or unreliable statistical methods. This study used robust statistical modelling to examine problem behaviours within a dimensional model of symptoms. We found that problem behaviours were included in an emotional dysregulation dimension and not in the dimension that included symptoms that are typical of depression. The dimensional model of symptoms had greater predictive validity than categorical diagnoses of psychiatric disorders. Our findings suggest that problem behaviours are a final common pathway for emotional distress in adults with intellectual disabilities so clinicians should not use a change in problem behaviours as a diagnostic criterion for depression, or other psychiatric disorders.

Effectiveness of cognitive behavioural therapy (CBT) programmes for anxiety or depression in adults with intellectual disabilities: A review of the literature

Relatively little is known about the application of cognitive behavioural therapy (CBT) to people with intellectual disabilities (ID). This review sought to synthesise available evidence on the effectiveness of CBT for anxiety or depression to assess the current level of evidence and make recommendations for future research. A comprehensive systematic literature search was conducted to identify qualitative and quantitative studies. Robust criteria were applied to select papers that were relevant to the review. Included papers were subject to quality appraisal. Eleven out of the 223 studies considered met our inclusion criteria and were included in the review in which CBT was used with participants with ID and anxiety (n=3), depression (n=4) or a mixed clinical presentation (n=4). There remains a paucity of evidence of effectiveness, however, the studies indicate that CBT is feasible and well-tolerated and may be effective in reducing symptoms of depression among adults with mild ID. Qualitative data reflect a positive perception of CBT amongst clients and carers. Further research is required to investigate the components of CBT, suitability for CBT, and requisite skills for CBT, which uses valid, sensitive and more holistic outcome measures.

The Diagnostic Guideline for Anxiety and Challenging Behaviour for Persons with Intellectual Disabilities: Preliminary Outcomes on Internalizing Problems, Challenging Behaviours, Quality of Life and Clients' Satisfaction

BACKGROUND

People with intellectual disabilities are vulnerable to develop psychopathology (in particular anxiety) and related challenging behaviour. A diagnostic guideline was developed to support professionals to better diagnose and thus treat psychopathology and related CB. This study examined preliminary outcomes from the application of this guideline.

METHOD

A comparative multiple case study with an experimental and a control condition.

RESULTS

The application of the guideline showed a trend of decreases of internalizing problems (P = 0.07) and anxiety/depressed problems (P = 0.09). We found no statistically significant decreases of externalizing problems and no increases in perceived quality of life as compared with care as usual. Clients were not more satisfied with the support they received for coping with their emotional and behaviour problems.

CONCLUSION

The application of the Diagnostic Guideline for Anxiety and Challenging Behaviour did not show statistically significant changes in externalizing problems and Quality of Life. Despite the small sample size of n = 59, we did find a trend in decreasing internalizing problems and anxiety/depressed problems. Further research into either or not confirming these trends is recommended.

BEAT-IT: Comparing a behavioural activation treatment for depression in adults with intellectual disabilities with an attention control: study protocol for a randomised controlled trial

BACKGROUND

Depression appears to be more enduring amongst people with intellectual disabilities, suggesting that it is a more chronic problem or more poorly managed in this population. This is not helped by a lack of evidence about the effectiveness of psychological therapies for people who have intellectual disabilities and depression. Behavioural activation, which aims to counteract depression by increasing individuals' level of meaningful activity and their exposure to positive reinforcers, has proven to be as effective as cognitive behavioural therapy in the general population. Given that this therapy makes fewer communicative demands and focuses on activity, it was thought that behavioural activation would be both accessible and apt for people with intellectual disabilities, who are often socially marginalised.

METHODS/DESIGN

This study is a multi-centre single-blind randomised controlled trial of behavioural activation versus a self-help attention control intervention for depression in adults with mild/moderate intellectual disabilities. The study has an internal pilot in one centre, to establish that recruitment can be built up and sustained at the required level, before being rolled out across the other sites. One hundred sixty-six participants will be randomly assigned to the behavioural activation or self-help interventions, which will be delivered to individuals with mild to moderate intellectual disabilities, accompanied by someone who provides them with regular support. Both interventions are manualised and will be delivered over a period of approximately 4 months. The primary outcome measure will be the Glasgow Depression Scale, a self-report measure which is completed at baseline and 4 and 12 months post-randomisation. Secondary outcomes include measures of participants' activity levels, proxy reports of depressive symptoms, and cost-effectiveness.

DISCUSSION

The study will provide evidence about the effectiveness of behavioural activation for depression, adapted for people who have mild/moderate intellectual disabilities, and will inform the delivery of psychological therapies to people with intellectual disabilities in practice.

TRIAL REGISTRATION

Date trial registered: Nov. 13, 2012; trial registration number: ISRCTN 09753005.

A feasibility study of behavioural activation for depressive symptoms in adults with intellectual disabilities

BACKGROUND

Important work has been carried out adapting cognitive behavioural therapy for people with intellectual disabilities. However, there is a lack of alternative psychological therapies available for people with intellectual disabilities and emotional difficulties. Behavioural activation for depression is less reliant on verbal communication and focuses on increasing purposeful activity and reducing avoidance.

METHOD

This feasibility study involved the development and piloting of an adapted manual of behavioural activation for people with intellectual disabilities. The intervention consisted of 10-12 sessions and a key adaptation was that the therapist worked with the clients alongside a significant other in their life, either a paid carer or family member. Baseline, post-intervention (3 months after entering the study) and 6-month quantitative follow-up data were obtained. Primary outcome data were gathered, concerning depressive symptoms, participants' levels of activity and general well-being.

RESULTS

Twenty-three adults with intellectual disabilities with symptoms of depression were recruited from specialist health services. In terms of acceptability, the behavioural activation intervention was well received and only two individuals dropped out, with a further two lost to follow-up. The main measures of depression appeared to be sensitive to change. Pre- to post-intervention data showed a significant reduction in self-report of depressive symptoms with a strong effect size (r = 0.78), that was maintained at follow-up (r = 0.86). Positive change was also obtained for informant reports of depressive symptoms from pre- to post-intervention, with a strong effect size (r = 0.7). Once again, this positive change was maintained at follow-up (r = 0.72).

CONCLUSIONS

The study suggested that behavioural activation may be a feasible and worthwhile approach to tackling depression in people with intellectual disabilities. However, a randomised controlled trial would be required to establish its effectiveness, with more sensitive measurement of change in activity.

Proxy and self-reported Quality of Life in adults with intellectual disabilities: Impact of psychiatric symptoms, problem behaviour, psychotropic medication and unmet needs

Proxies often underestimate the subjective Quality of Life (QoL) of adults with intellectual disability (ID). However, little is known about the reasons for these differences. Accordingly, the purpose of the present study is to, firstly, compare the self-reported QoL of adults with ID with proxy reports from staff of sheltered working and housing facilities, and, secondly, to identify possible differences of the impact of four potential predictor variables. Data of 102 adults with ID were collected as part of the MEMENTA study ('Mental health care provision for adults with ID and a mental disorder'). Results show that self-report QoL scores ranged from 72.6 to 86.8. Both proxies consistently reported lower QoL scores and agreement between self and proxy ratings was predominantly poor. Unmet needs and psychotropic medication were identified as the most important predictors of reduced self-rated QoL, whereas an increase of psychiatric symptoms, problem behaviours, and psychotropic medication best predicted the reduced QoL proxy ratings. To conclude, proxies still have to strive for a more holistic approach in surrogate QoL assessments and according to adults with ID, service providers should focus on a reduction of unmet needs and psychotropic medication to further improve QoL.

Frequency of ICD-10 psychiatric diagnosis in children with intellectual disability in Lahore, Pakistan & Caregivers Perspective

Objective:

Association between Intellectual disability (ID) and psychiatric disorders in children & adolescents is well established but there is a paucity of published studies from Pakistan on this topic. The main aim of the study was to assess the frequency of ICD-10 psychiatric diagnosis in the hospital outpatient sample of children with ID in Lahore, Pakistan as well as to find out which challenging behaviors, caregivers find difficult to manage in this setup.

Methods:

Socio-demographic information was collected, Wechsler Intelligence Scale for Children-Revised & ICD-10 diagnostic criteria was used to assess children (age range 6 – 16 years) with suspected ID along with identification of behaviors found to be difficult to manage by caregivers.

Results:

150 children were assessed with mean age of 10.7 years (males 70 %). Majority (72%) had mild ID while 18.7% and 9.3% had moderate and severe ID respectively. Thirty percent of children met the criteria for any psychiatric diagnosis, the most common being Oppositional Defiant Disorder (14%) and Hyperkinetic Disorders (10%). Verbal and physical aggression, school difficulties, socialization problems, inappropriate behaviors (e.g. disinhibition), sleep & feeding difficulties were the significant areas identified by the caregivers as a cause of major concern.

Conclusions:

Significantly high prevalence of ICD-10 psychiatric diagnosis in children with ID was found in Lahore, Pakistan. Support services for these children should be responsive not only to the needs of the child, but also to the needs of the family.

Acute behavioral crises in psychiatric inpatients with autism spectrum disorder (ASD): recognition of concomitant medical or non-ASD psychiatric conditions predicts enhanced improvement

During adolescence, some individuals with autism spectrum disorder (ASD) engage in severe challenging behaviors, such as aggression, self-injury, disruption, agitation and tantrums. We aimed to assess risk factors associated with very acute behavioral crises in adolescents with ASD admitted to a dedicated neurobehavioral unit. We included retrospectively in 2008 and 2009 29 adolescents and young adults with ASD hospitalized for severe challenging behaviors and proposed a guideline (Perisse et al., 2010) that we applied prospectively for 29 patients recruited for the same indications between 2010 and 2012. In total, 58 patients were admitted (n=70 hospitalizations, mean age=15.66 (±4.07) years, 76% male). We systematically collected data describing socio-demographic characteristics, clinical variables (severity, presence of language, cognitive level), comorbid organic conditions, etiologic diagnosis of the episode, and treatments. We explored predictors of Global Assessment Functioning Scale (GAFS) score and duration of hospitalization at discharge. All but 2 patients exhibited severe autistic symptoms and intellectual disability (ID), and two-thirds had no functional verbal language. During the inpatient stay (mean=84.3 (±94.9) days), patients doubled on average their GAFS scores (mean=17.66 (±9.05) at admission vs. mean=31.4 (±9.48) at discharge). Most common etiologies for acute behavioral crises were organic causes [n=20 (28%), including epilepsy: n=10 (14%) and painful medical conditions: n=10 (14%)], environmental causes [n=17 (25%) including lack of treatment: n=11 (16%) and adjustment disorder: n=6 (9%)], and non-ASD psychiatric condition [n=33 (48%) including catatonia: n=5 (7%), major depressive episode: n=6 (9%), bipolar disorder: n=4 (6%), schizophrenia: n=6 (9%), other/unknown diagnosis: n=12 (17%)]. We found no influence of age, gender, socio-economic status, migration, level of ID, or history of seizure on improvement of GAFS score at discharge. Severity of autism at admission was the only negative predictor (p<.001). Painful medical conditions (p=.04), non-ASD psychiatric diagnoses (p=.001), prior usage of specialized ASD care programs (p=.004), functional language (p=.007), as well as a higher number of challenging behaviors upon admission (p=.001) were associated with higher GAFS scores at discharge. Clinical severity at admission, based on the number of challenging behaviors (r=.35, p=.003) and GAFS score (r=-.32, p=.008) was correlated with a longer inpatient stay. Longer hospitalization was however correlated (r=.27, p=.03) with higher GAFS score at discharge even after adjustment for confounding factors. Challenging behaviors among adolescents with ASD may stem from diverse risk factors, including environmental problems, comorbid acute psychiatric conditions, or somatic illness such as epilepsy or acute pain. The management of these behavioral challenges requires a unified, multidisciplinary approach.

Impact of exposure to potentially traumatic events on individuals with intellectual disability

This study explored the prevalence of posttraumatic symptomatology (PTS) and functional problems among Israeli individuals with intellectual disability (ID) who live in supported residential care settings and who have been exposed to political violence. The sample included 196 residents exposed to chronic missile attacks and 91 residents with ID who were not exposed. Results showed PTS and functional problems to be higher in the exposed group compared to the nonexposed one, although still low compared to the general exposed population. Exposure was found to be related to PTS and functioning problems suggested individuals with ID are reactive to political violence, though the underlying mechanisms are not clear. Implications for research, caretakers, and policy are discussed.

Mindfulness-based cognitive therapy for adults with intellectual disabilities: an evaluation of the effectiveness of mindfulness in reducing symptoms of depression and anxiety

BACKGROUND

Mindfulness-based interventions have been shown to be effective in the treatment of a range of health and psychological disorders in adults and young people without intellectual disabilities (ID). Clinical studies are emerging reporting on the efficacy of mindfulness-based interventions as a stand-alone treatment for common clinical disorders in adults with ID.

METHOD

This paper aims to evaluate the efficacy of an innovative structured mindfulness-based cognitive therapy (MBCT) group programme adapted for adults with ID with a diagnosis of either recurrent depression, anxiety or both clinical conditions and a history of deliberate self-harm behaviour. Two groups ran consecutively consisting of a total of fifteen participants and seven carers. All participants were recorded as having either a borderline, mild, or moderate ID. The group programme ran over a period of 9 weeks with a follow-up session at 6 weeks post group intervention. Outcome measures included the Hospital Anxiety and Depression Scale and two sub-scales from the Self-Compassion Scale administered at baseline, post therapy and at 6-week follow-up.

RESULTS

The evaluation showed that participants reported an improvement in their experience of depression, anxiety, self-compassion and compassion for others. The most significant impact was in the reduced levels of anxiety reported. Improvements across all outcomes were maintained at 6-week follow-up.

CONCLUSION

The results of the evaluation suggest that people with intellectual disabilities benefit from a structured MBCT group intervention and the results are maintained at 6-week follow-up.

RETRACTED: Prevalence of co-occurring disorders in a sample of adults with mild and moderate intellectual disabilities who reside in a residential treatment setting

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor in Chief, after review by an independent panel of experts, due to evidence of a compromised peer review process and the failure of one author to disclose significant conflicts of interest. An independent peer-review process is a cornerstone of scientific integrity that allows for research to be scrutinized before publication to ensure that conclusions are anchored in sound methodology and objective interpretation of the results. Equally important is that the readership of research is fully informed about any potential competing interests that may have influenced the research process. This article is being retracted because it did not include a declaration of a conflict of interest of one author in relation to diagnostic tools which the paper endorses. The same author was also the Editor in Chief of the journal at the time of publication and evidence indicates that the paper was accepted without any independent peer review by external reviewers. The article is therefore retracted in accordance with the ethical guidelines of Elsevier: https://www.elsevier.com/about/policies/publishing-ethics and the Committee on Publication Ethics (COPE) https://publicationethics.org/files/retraction-guidelines.pdf.

The association between self-injurious behaviors and autism spectrum disorders

A key area of concern in children with autism spectrum disorders (ASDs) are self-injurious behaviors (SIBs). These are behaviors that an individual engages in that may cause physical harm, such as head banging, or self-biting. SIBs are more common in children with ASD than those who are typically developing or have other neurodevelopmental disabilities. Therefore, it is important that clinicians who work with children with ASD have a solid understanding of SIB. The purpose of this paper is to review the research on the epidemiology of SIB in children with ASD, factors that predict the presence of SIB in this population, and the empirically supported behavioral treatments available.

Psychological therapies for people with intellectual disabilities: comments on a matrix of evidence for interventions in challenging behaviour

BACKGROUND

Psychological therapies with a proven efficacy in the general population are being adapted for use with people who have intellectual disabilities in community settings.

METHODS

A systematic review of peer-reviewed literature published between 1980 and 2010 was carried out, to identify the evidence base for effective psychological interventions in challenging behaviour. Relevant databases were searched using applied key terms. Evidence was graded, according to the quality of the research. A best-evidence Matrix was produced to improve guidance for service providers and practitioners in the range, volume and quality of psychological interventions.

RESULTS

There is a limited amount of efficacy research that meets the most stringent standards of empirical evidence.

CONCLUSIONS

It is important to broaden the evidence base and consider the context of psychological interventions, alongside the values underpinning care and treatment.

The relationship between challenging behaviour and anxiety in adults with intellectual disabilities: a literature review

BACKGROUND

Anxiety and challenging behaviour (CB) often occur simultaneously in people with intellectual disabilities (ID). Understanding the associations between anxiety and CB may contribute to more accurate diagnoses and management of both anxiety and CB in this population.

AIMS

To examine the relationship between anxiety and CB.

METHODS

A literature review covering the period from January 2000 to January 2012.

RESULTS

Seven studies about the relationship between psychiatric disorders, including anxiety, and CB were identified. These studies confirm the relationship between anxiety and CB in people with ID, although the precise nature of this relationship remains unclear.

CONCLUSIONS

The study points toward the existence of a moderate association between anxiety and CB. Further research is needed to clarify the complex nature of the association between anxiety and CB.

Prevalence and risk markers of behavior problems among adults with intellectual disabilities: a total population study in Örebro County, Sweden

The aim of the present study was to investigate the prevalence of behavior problems among people with administratively defined intellectual disability (ID) and identify possible risk markers for behavior problems using the Behavior Problems Inventory (BPI). Sixty-two percent of the ID population (n=915) had a behavior problem (self-injurious, stereotyped, or aggressive/destructive behavior) and 18.7% had a behavior problem identified as challenging behavior, resulting in a prevalence of 80.3 per 100,000 in the base population. The most pronounced risk markers for behavior problems were severity of ID, autism, night sleep disturbances, sensory hypersensitivity, communication dysfunction, social deficits, psychiatry involvement, and psychotropic medication. About 50% of people with behavior problems were on psychotropic drugs. Protective markers were Down's syndrome and, to some extent, cerebral palsy. The results were largely consistent with those reported in previous studies. Findings not previously reported were that prevalence of aggressive/destructive behavior peaked among those ≥70 years. Highlighting groups within a population at particular risk has implications for management and treatment of individuals with behavior problems.

Clients with intellectual disabilities on psychiatric units: care coordination for positive outcomes

The transition from residential facilities to and from the psychiatric hospital setting is difficult for individuals with intellectual disabilities (ID). In the U.S.A., specialized psychiatric units for individuals with ID are uncommon and this population is usually served in generalized services. Nevertheless, providers of mental health services in the U.S.A. receive little training in their specific needs. Best practices call for coordination of plans between psychiatric units and community agencies, multidisciplinary care plans, staff education and comprehensive discharge planning in order to improve outcomes of psychiatric hospitalization. An inner city psychiatric unit in a major academic medical centre and a community agency providing residential care for individuals with ID cooperated to provide a plan of care for a client with ID both for hospitalization and for discharge leading to improved outcomes.

Association of aggressive behaviours with psychiatric disorders, age, sex and degree of intellectual disability: a large-scale survey

BACKGROUND

The link between aggression and mental disorders has been the focus of diverse studies in persons with and without intellectual disabilities (ID). Because of discrepancies in the finding of studies in persons with ID to date, and because of differences in research design, instruments used and the population studied, more research is needed. The purpose of this study was to delineate any significant association between certain psychiatric disorders and specific domains of aggressive behaviours in a large sample of persons with ID controlling for sex, age, autism and degree of ID.

METHOD

Data from the present study were obtained from 47% of all persons with ID receiving services from New York State agencies, using the Institute for Basic Research - Modified Overt Aggression Scale (IBR-MOAS between 2006 and 2007). The IBR-MOAS was completed by the chief psychologists of 14 agencies based on information from the participants' files. Demographic information obtained included the psychiatric diagnosis made by the treating psychiatrist as well as information on age, sex and degree of ID. Data from 4069 participants were analysed.

RESULTS

Impulse control disorder and bipolar disorder were strongly associated with all five domains of aggressive behaviour in the IBR-MOAS. Psychotic disorder was highly associated with four domains except for physical aggression against self (PASLF), which was of borderline significance. Anxiety was most associated with PASLF and verbal aggression against self (VASLF); depression with VASLF; obsessive compulsive disorder with physical aggression against objects (PAOBJ); personality disorders with verbal aggression against others (VAOTH), VASLF and PASLF; and autism with physical aggression against others (PAOTH), PAOBJ and PASLF. Mild to moderate ID was associated with VAOTH and VASLF and severe to profound ID with PAOBJ and PASLF. Female sex was most associated with VASLF.

CONCLUSIONS

Impulse control, mood dysregulation and perceived threat appear to underlie most of the aggressive behaviours reported. Psychosis and depression appeared to have been over-diagnosed in persons with mild to moderate ID and under-diagnosed in persons with severe and profound ID. These findings replicate and extend findings from previous studies. The pattern of associations reported can be used as helpful indicators by professionals involved in the treatment of aggressive behaviours in persons with ID.

Massage as therapy for persons with intellectual disabilities: a review of the literature

Persons with intellectual disabilities record a higher incidence of challenging behaviours than the general population. Massage therapy has frequently been applied to such persons to induce relaxation. The aim of this review was to evaluate the effectiveness of massage therapy on relaxation and reduction of challenging behaviours. A literature search was conducted through various electronic databases; a total of 64 articles was generated but only seven met all inclusion criteria. These studies were evaluated in terms of (a) number of participants, (b) study setting, (c) methodology, (d) intervention pattern, (e) outcome measure of the intervention, and (f) major results. Evidence-based literature demonstrating the effectiveness of massage therapy in supporting clinical practice is extremely limited. Case study designs, large amounts of qualitative data and small sample sizes meant that the therapeutic effect of massage therapy could not be substantiated. Hence, future studies with randomized clinical trials or of experimental design are recommended.

Use of differential reinforcement to reduce behavior problems in adults with intellectual disabilities: a methodological review

The least-restrictive-alternative guideline for providing treatment emphasizes the use of non-aversive procedures to reduce maladaptive behaviors in individuals with intellectual disability (ID). Differential reinforcement (DR) is an excellent example of such a non-aversive, reinforcement based behavioral intervention. The purpose of this literature review was to summarize and provide a methodological analysis of studies, conducted between 1980 and 2009, using a DR contingency to reduce problem behaviors in adults with ID. A total of 31 studies were located that met the inclusion criteria. Of these, 15 reported DR to be an effective intervention when used independently. Of the remaining, 10 studies found DR to be useful as part of a treatment package, and six found a DR contingency used independently to be ineffective, and only observed treatment effects when an aversive component was added. Very few studies assessed the use of DR in older adults and in individuals with mild ID; these reflect areas of future research. A methodological analysis found that several studies did not report information on key methodological variables; for example, conducting a functional analysis and a stimulus preference assessment to guide choice of treatment and reinforcers, thinning very dense DR schedules, assessing collateral behaviors, generalization of behavior change across settings and implementers, and following up treatment outcomes over time. The overall positive findings about the effectiveness of DR are encouraging; however, more methodologically robust studies would serve to make such findings more conclusive and practically relevant for implementation in natural settings for adults with ID.