Mental health criminal defenses in persons with neuropsychiatric disorders

Persons with neuropsychiatric disorders present specific and unique challenges for forensic experts and defense attorneys in the criminal justice system. This article reviews two potential criminal defenses: legal insanity and the various legal standards or tests of criminal responsibility that are used in jurisdictions throughout the United States (i.e., the M'Naghten standard and the American Law Institute's Model Penal Code), and the partial legal defense of diminished capacity (lacking the mental state necessary to be found guilty of a specific intent crime). The process of evaluating criminal responsibility or diminished capacity is also presented with a specific emphasis on common issues that arise in evaluating defendants with Intellectual Developmental Disorder (Intellectual Disability), Parasomnias, Seizure Disorders, and Neurocognitive Disorders.

Predictors and moderators of the response of adults with intellectual disabilities and depression to behavioural activation and guided self-help therapies

BACKGROUND

No previous studies have reported predictors and moderators of outcome of psychological therapies for depression experienced by adults with intellectual disabilities (IDs). We investigated baseline variables as outcome predictors and moderators based on a randomised controlled trial where behavioural activation was compared with guided self-help.

METHODS

This study was an exploratory secondary data analysis of data collected during a randomised clinical trial. Participants (n = 161) were randomised to behavioural activation or guided self-help and followed up for 12 months. Pre-treatment variables were included if they have previously been shown to be associated with an increased risk of having depression in adults with IDs or have been reported as a potential predictor or moderator of outcome of treatment for depression with psychological therapies. The primary outcome measure, the Glasgow Depression Scale for Adults with Learning Disabilities (GDS-LD), was used as the dependant variable in mixed effects regression analyses testing for predictors and moderators of outcome, with baseline GDS-LD, treatment group, study centre and antidepressant use as fixed effects, and therapist as a random effect.

RESULTS

Higher baseline anxiety (mean difference in outcome associated with a 1 point increase in anxiety 0.164, 95% confidence interval [CI] 0.031, 0.297; P = 0.016), lower performance intelligence quotient (IQ) (mean difference in outcome associated with a 1 point increase in IQ 0.145, 95% CI 0.009, 0.280; P = 0.037) and hearing impairment (mean difference 3.449, 95% CI 0.466, 6.432; P = 0.024) were predictors of poorer outcomes, whilst greater severity of depressive symptoms at baseline (mean difference in outcome associated with 1 point increase in depression -0.160, 95% CI -0.806, -0.414; P < 0.001), higher expectation of change (mean difference in outcome associated with a 1 point increase in expectation of change -1.013, 95% CI -1.711, -0.314; p 0.005) and greater percentage of therapy sessions attended (mean difference in outcome with 1 point increase in percentage of sessions attended -0.058, 95% CI -0.099, -0.016; P = 0.007) were predictors of more positive outcomes for treatment after adjusting for randomised group allocation. The final model included severity of depressive and anxiety symptoms, lower WASI performance IQ subscale, hearing impairment, higher expectation of change and percentage of therapy sessions attended and explained 35.3% of the variance in the total GDS-LD score at 12 months (R2  = 0.353, F4, 128  = 17.24, P < 0.001). There is no evidence that baseline variables had a moderating effect on outcome for treatment with behavioural activation or guided self-help.

CONCLUSIONS

Our results suggest that baseline variables may be useful predictors of outcomes of psychological therapies for adults with IDs. Further research is required to examine the value of these potential predictors. However, our findings suggest that therapists consider how baseline variables may enable them to tailor their therapeutic approach when using psychological therapies to treat depression experienced by adults with IDs.

Keep My Teeth: An evaluation of multi-disciplinary training in mouth care for people with intellectual developmental disorders

AIM

To evaluate a modular didactic training intervention called Keep My Teeth designed by special care dentists, for a range of healthcare students to provide oral homecare for people with intellectual developmental disorders (PwIDD).

METHODS

To evaluate the intervention a one-group pre-test post-test pre-experimental research design was utilized. The intervention was delivered by virtual platforms or face-to-face, with a sub-sample of participants also receiving practical training. Healthcare students included Speech and Language Therapy (SLT), Registered Nurse Intellectual Disability (RNID), Dental Science (DS), Dental Nursing (DN), and Dental Hygiene (DH).

RESULTS

Sixty-three of the 147 trainees completed all surveys. A significant change in perspective on barriers was seen for most groups post-training, with an increase in confidence in delivering oral care to PwIDD across disciplines; 67% of DH/DN students who took part in the practical training felt that the didactic training was just as effective without the practical training, while 42% of the DS students felt that was true.

CONCLUSIONS

The training interventions provided seem to have increased the awareness of study participants in relation to barriers to care, and increased their self-efficacy towards, and intention to perform, oral homecare behaviors.

Oral sialic acid supplementation in NANS-CDG: Results of a single center, open-label, observational pilot study

NANS-CDG is a congenital disorder of glycosylation (CDG) caused by biallelic variants in NANS, encoding an essential enzyme in de novo sialic acid synthesis. It presents with intellectual developmental disorder (IDD), skeletal dysplasia, neurologic impairment, and gastrointestinal dysfunction. Some patients suffer progressive intellectual neurologic deterioration (PIND), emphasizing the need for a therapy. In a previous study, sialic acid supplementation in knockout nansa zebrafish partially rescued skeletal abnormalities. Here, we performed the first in-human pre- and postnatal sialic-acid study in NANS-CDG. In this open-label observational study, 5 patients with NANS-CDG (range 0-28 years) were treated with oral sialic acid for 15 months. The primary outcome was safety. Secondary outcomes were psychomotor/cognitive testing, height and weight, seizure control, bone health, gastrointestinal symptoms, and biochemical and hematological parameters. Sialic acid was well tolerated. In postnatally treated patients, there was no significant improvement. For the prenatally treated patient, psychomotor and neurologic development was better than two other genotypically identical patients (one treated postnatally, one untreated). The effect of sialic acid treatment may depend on the timing, with prenatal treatment potentially benefiting neurodevelopmental outcomes. Evidence is limited, however, and longer-term follow-up in a larger number of prenatally treated patients is required.

Clinical Heterogeneity and Different Phenotypes in Patients with SETD2 Variants: 18 New Patients and Review of the Literature

SETD2 belongs to the family of histone methyltransferase proteins and has been associated with three nosologically distinct entities with different clinical and molecular features: Luscan-Lumish syndrome (LLS), intellectual developmental disorder, autosomal dominant 70 (MRD70), and Rabin-Pappas syndrome (RAPAS). LLS [MIM #616831] is an overgrowth disorder with multisystem involvement including intellectual disability, speech delay, autism spectrum disorder (ASD), macrocephaly, tall stature, and motor delay. RAPAS [MIM #6201551] is a recently reported multisystemic disorder characterized by severely impaired global and intellectual development, hypotonia, feeding difficulties with failure to thrive, microcephaly, and dysmorphic facial features. Other neurologic findings may include seizures, hearing loss, ophthalmologic defects, and brain imaging abnormalities. There is variable involvement of other organ systems, including skeletal, genitourinary, cardiac, and potentially endocrine. Three patients who carried the missense variant p.Arg1740Gln in SETD2 were reported with a moderately impaired intellectual disability, speech difficulties, and behavioral abnormalities. More variable findings included hypotonia and dysmorphic features. Due to the differences with the two previous phenotypes, this association was then named intellectual developmental disorder, autosomal dominant 70 [MIM 620157]. These three disorders seem to be allelic and are caused either by loss-of-function, gain-of-function, or missense variants in the SETD2 gene. Here we describe 18 new patients with variants in SETD2, most of them with the LLS phenotype, and reviewed 33 additional patients with variants in SETD2 that have been previously reported in the scientific literature. This article offers an expansion of the number of reported individuals with LLS and highlights the clinical features and the similarities and differences among the three phenotypes associated with SETD2.

Multi-domain computerized cognitive training for children with intellectual developmental disorder: A randomized controlled trial

Purpose

To verify the effects of multi-domain computerized cognitive training on intellectual function and adaptive functioning in children with intellectual developmental disorder (IDD).

Methods

Children with IDD were randomized to a multi-domain computerized cognitive training (CCT) group (n = 30) and control group (n = 30). Both groups received a 5-week training program. Intellectual function was assessed by Chinese-Wechsler Young Children scale (C-WYCSI) and adaptive functioning was assessed by the Chinese Vineland Adaptive Behavior Rating Scale (VABS-C), which were used at baseline, post-training, and 3-month follow-up.

Results

There were significant differences for intellectual function and adaptive functioning between the two groups. The CCT group showed significant improvements in total full-scale intelligence quotient (FSIQ) score the Wechsler Intelligence Scale (F[60] = 31.97, p < 0.01) and its subdomain VIQ score (F[60] = 33.83, p < 0.01). For adaptive functioning, CCT had a better adaptive developmental quotient (ADQ) score (F[60] = 28.05, p < 0.01), and subdomain communication (F[60] = 10.86, p < 0.01) and socialization scores (F[60] = 4.35, p < 0.015). Moreover, there was a positive correlation between FSIQ changes and ADQ changes in the CCT group (r_s = 0.74, p < 0.01). A greater increase in VIQ score was associated with a greater increase in adaptive functioning (bootstrapping CI: [0.16, 3.30]) in the CCT group.

Conclusion

Multi-domain CCT improves the intellectual function and adaptive functioning of children with IDD.

The Effectiveness of Sensory Adaptive Dental Environments to Reduce Corresponding Negative Behaviours and Psychophysiology Responses in Children and Young People with Intellectual and Developmental Disabilities: A Protocol of a Systematic Review and Meta-Analysis

People with Intellectual and Developmental Disabilities (IDDs) are disproportionately vulnerable to poorer oral health due to their complex needs specifically sensory processing difficulties. This leads to increased maladaptive behaviours and psychophysiology responses of dental anxiety amplified by the overstimulating aspects of the dental environment. Although, there is a growing body of evidence to suggest that sensory adaptions are an effective strategy for individuals with IDDs in a wide range of settings, there is a lack of high-quality evidence detailing the effectiveness in a dental setting. The objective of this review is to assess the effectiveness of sensory adaptive dental environments (SADE) to reduce dental anxiety, corresponding negative behaviours and psychophysiology responses in children and young people with IDDs. The systematic review will include all Randomized Controlled Trials (RCTs) that investigate the effectiveness of SADE compared to control (no intervention), waitlist or usual care (regular dental environment) to reduce dental anxiety and the corresponding negative behaviours and psychophysiology responses in children and young people (upto the ages of 24 years) with IDDs. This review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases including MEDLINE (Ovid), The Cochrane Library, Embase, Google Scholar, Web of Science and OT Seeker will be searched using appropriate keywords. Additionally, citation searching will be conducted. Screening based on titles and abstracts will be done after de-duplication, followed by full-text reading for selection based on the inclusion criteria. Data extracted from the included studies will be tabulated and assessed for risk of bias. If applicable, a meta-analysis of the pooled data will be conducted. The review is registered with PROSPERO (CRD42022322083).

Prenatal diagnosis and molecular cytogenetic characterization of an inherited microdeletion of 18q12.3 encompassing SETBP1

The 18q12.3 region contains the SET binding protein 1 (SETBP1) gene. SETBP1 mutations or deletions are associated with Schinzel-Giedion syndrome or intellectual developmental disorder, autosomal dominant 29. We report the prenatal diagnosis and genetic counseling of a patient with a maternally inherited 18q12.3 microdeletion. In this family, the mother and son carried the same microdeletion. Chromosomal microdeletions and microduplications are difficult to detect using conventional cytogenetics, whereas the combination of prenatal ultrasound, karyotype analysis, chromosomal microarray analysis, and genetic counseling is helpful for the prenatal diagnosis of chromosomal microdeletions/microduplications.

Next-Generation Sequencing Reveals Novel Homozygous Missense Variant c.934T > C in POLR1C Gene Causing Leukodystrophy and Hypomyelinating Disease

Leukodystrophies are a diverse group of genetically established disorders categorized by unusual white matter changes on brain imaging. Hypomyelinating leukodystrophies (HLDs) are a group of neurodevelopmental disorders that affect myelin sheath development in the brain. These disorders are categorized as developmental delay, spasticity, hypotonia, and intellectual disabilities. We describe a patient with developmental delay, cerebellar ataxia, spasticity, hypotonia, and intellectual disability from a healthy family member. Whole exome sequencing (WES) was performed to identify causative variants, which were further analyzed by bioinformatic analysis. WES was performed, and Sanger sequencing-based segregation analysis confirmed the presence of the homozygous missense variants of NM_203290.3 c.934T > C p.Ser312Pro of RNA polymerase I and III subunit C (POLR1C) gene in this patient and heterozygous variant in the unaffected carrier father and mother, supporting the pathogenicity and inheritance pattern of this variant. Furthermore, the variant identified by WES was validated in healthy controls (n = 100) using Sanger sequencing analysis. Finally, our study explained the important use of WES in disease diagnosis and provided further evidence that the variant in the POLR1C gene may play an important role in the development of hypomyelinating leukodystrophy in Saudi families.

Satisfaction with life in Special Olympic athletes: the role of autonomy support and basic need fulfilment

Aims: Athletes in the general population report higher satisfaction of basic needs when coaches are providing an autonomy supportive sport climate (ASSC). Our study aims at investigating whether ASSC is associated with satisfaction with life in athletes with intellectual disabilities (ID) and whether this association is mediated by basic need satisfaction. Method: During the Special Olympics World Winter Games 2017, 168 athletes with ID (M = 33.86 years; SD = 10.47) completed questionnaires measuring ASSC, basic need satisfaction (autonomy, competence, and relatedness), and satisfaction with life. Multiple linear regression analyses and mediation analyses were performed. The mediation model was controlled for the potential impact of participating in team vs. individual sports. Additionally, gender effects were explored. Results: ASSC was significantly associated with satisfaction with life (β = .38, p < .001). This association was mediated by competence (indirect effect: ab₁ = .15; CI [.05; .32]) but not by autonomy or relatedness. No effects were found related to participating in team vs. individual sports or gender. Conclusions: Our study provides evidence that an ASSC is associated with athletes perceiving themselves as more competent and reporting more satisfaction with life.

The quandary of registered nurses untrained in adult intellectual disability nursing when caring for this diverse patient group in acute care settings: An integrated literature review

AIMS AND OBJECTIVES

To critically appraise relevant literature on the lived experiences of registered nurses caring for adults with intellectual disability in the acute care setting in Australia to determine current knowledge and gaps in the literature.

BACKGROUND

People with intellectual disability have the right to the highest attainable health care the same as everyone else. However, inequities still exist in the delivery of health care across the globe, including Australia that result in poorer health outcomes for this population group. Part of the problem is a lack of understanding of the complexities of ID care due to an absence of ID specific content in undergraduate curricula.

DESIGN

Integrative literature review.

METHODS

Electronic databases were searched for relevant empirical and theoretical literature. Additional articles were found by reviewing reference lists of selected articles resulting in ten articles for review. Selected articles were critically appraised using JBI critical appraisal tools. Data were analysed using comparative thematic analysis. PRISMA checklist completed the review.

RESULTS

Two main themes emerged from the data that informed the gap in knowledge: (a) Defining nursing practice; and (b) Confidence to practice.

CONCLUSIONS

There was limited qualitative research published on the topic. International studies revealed that a lack of understanding of the ID condition due to inadequate education left registered nurses feeling underprepared, unsupported and struggling to provide optimal care. No studies were located on the phenomenon within the Australian context. A study exploring the lived experiences of RNs in Australia is needed to offer a deeper understanding of the phenomenon that will help inform practice.

RELEVANCE TO PRACTICE

Including ID care in national undergraduate and postgraduate nursing curricula must become a nursing educational and professional priority to support nurses more fully in their practice to ensure patients with ID receive the highest attainable standard of nursing care.

Chromosomal Microarray Analysis in Turkish Patients with Unexplained Developmental Delay and Intellectual Developmental Disorders

INTRODUCTION

Aneuploids, copy number variations (CNVs), and single nucleotide variants in specific genes are the main genetic causes of developmental delay (DD) and intellectual disability disorder (IDD). These genetic changes can be detected using chromosome analysis, chromosomal microarray (CMA), and next-generation DNA sequencing techniques. Therefore; In this study, we aimed to investigate the importance of CMA in determining the genomic etiology of unexplained DD and IDD in 123 patients.

METHOD

For 123 patients, chromosome analysis, DNA fragment analysis and microarray were performed. Conventional G-band karyotype analysis from peripheral blood was performed as part of the initial screening tests. FMR1 gene CGG repeat number and methylation analysis were carried out to exclude fragile X syndrome.

RESULTS

CMA analysis was performed in 123 unexplained IDD/DD patients with normal karyotypes and fragile X screening, which were evaluated by conventional cytogenetics. Forty-four CNVs were detected in 39 (39/123=31.7%) patients. Twelve CNV variant of unknown significance (VUS) (9.75%) patients and 7 CNV benign (5.69%) patients were reported. In 6 patients, one or more pathogenic CNVs were determined. Therefore, the diagnostic efficiency of CMA was found to be 31.7% (39/123).

CONCLUSION

Today, genetic analysis is still not part of the routine in the evaluation of IDD patients who present to psychiatry clinics. A genetic diagnosis from CMA can eliminate genetic question marks and thus alter the clinical management of patients. Approximately one-third of the positive CMA findings are clinically intervenable. However, the emergence of CNVs as important risk factors for multiple disorders increases the need for individuals with comorbid neurodevelopmental conditions to be the priority where the CMA test is recommended.

Five-Year Trend in Issuing Disability Certificates from a General Hospital Psychiatric Unit in South India

BACKGROUND

Mental disability is a common condition but is considered as an invisible disability. The disability certificate in psychiatry remains underexplored. Some reasons are issues of confidentiality, stigma, lack of awareness in the public, and the hesitancy in the mental health professionals. We aim to provide a brief profile of patients with mental illness issued disability certificates from a psychiatric unit over a five-year period (2013-2017).

METHODS

Our retrospective study is based on the data available from the copies of the issued disability certificates from a psychiatric unit that functions in a multispecialty tertiary care teaching government hospital in Southern India. Patients undergoing treatment in psychiatry apply for a disability certificate to the medical superintendent of the hospital. Each applicant undergoes a detailed workup to ascertain the diagnosis, and the mental disability is assessed using Indian Disability Evaluation and Assessment Scale (IDEAS). Those with intellectual developmental disorder (IDD) are assessed by a clinical psychologist for quantifying intelligence quotient, based on which the disability certificate is issued. Data were extracted and analyzed using SPSS. Descriptive statistics were used.

RESULTS

Over five years, 258 disability certificates were issued. A total of 218 were for mental illness and 40 were for IDD. Schizophrenia was the commonest primary diagnosis. There was no gender predominance, nor the influence of gender on different domains of IDEAS except on work domain dysfunction due to mental illness. The validity period was not mentioned in 81% of the issued certificates for mental illness.

CONCLUSIONS

This descriptive study found a lower number of certificates issued from the psychiatric unit. Schizophrenia remains the main psychiatric diagnosis for which a disability certificate was issued. We did not assess the utilization pattern of the issued certificates.

Novel Missense Variant in Heterozygous State in the BRPF1 Gene Leading to Intellectual Developmental Disorder With Dysmorphic Facies and Ptosis

Intellectual developmental disorder with dysmorphic facies and ptosis is an autosomal dominant condition characterized by delayed psychomotor development, intellectual disability, delayed speech, and dysmorphic facial features, mostly ptosis. Heterozygous mutations in bromodomain and plant homeodomain (PHD) finger containing one (BRPF1) gene have been reported. In this study, whole exome sequencing (WES) was performed as a molecular diagnostic test. Bioinformatics of WES data and candidate gene prioritization identified a novel variant in heterozygous state in the exon 3 of BRPF1 gene (ENST383829: c.1054G > C and p.Val352Leu). Autosomal dominant inheritance in the family affected individuals and exclusion of non-pathogenicity in the ethnically matched healthy controls (n = 100) were performed by Sanger sequencing. To the best of our knowledge, this is the first evidence of BRPF1 variant in a Saudi family. Whole exome sequencing analysis has been proven as a valuable tool in the molecular diagnostics. Our findings further expand the role of WES in efficient disease diagnosis in Arab families and explained that the mutation in BRPF1 gene plays an important role for the development of IDDFP syndrome.

Leo Kanner and autism: a 75-year perspective

In 1943, Leo Kanner published the first systematic description of early infantile autism. He concluded that this was a neurodevelopmental disorder and that 'these children have come into the world with an innate inability to form the usual, biologically provided contact with people'. Moreover, his astute descriptions of parental behavior in his first publications were prescient and underlie later recognition of the importance of genetics. Our understanding has grown over the ensuing years with revisions in diagnostic classification, recognition of the broader autism phenotype in families, appreciation of the importance of developmental models, advances in genetic methodology, better understanding of the relationship to intellectual deficits, recognition of syndromic autism in neurogenetic sydromes, advances in neuroimaging, and advances in animal models, both mutant mouse models and transgenic non human primate models. Kanner recognized diagnostic heterogeneity and opined that the children had not read those diagnostic manuals and did not easily fall into clear cut categories. Such heterogeneity continues to confound our diagnostic efforts. Always an advocate for children, when reviewing the DSM III criteria in 1980, Kanner emphasized that no matter how well developed our criteria each child must be treated as a unique person.

CAPs-IDD: Characteristics of Assessment Instruments for Psychiatric Disorders in Persons with Intellectual Developmental Disorders

BACKGROUND

Assessment of psychiatric disorders in persons with an intellectual developmental disorder (IDD) can be performed with a variety of greatly differing instruments. This makes the choice of an instrument best suited for the intended purpose challenging. In this study, we developed a comprehensive set of characteristics for the evaluation and description of assessment instruments for psychiatric disorders in adult persons with IDD. This simplifies the search for an instrument as it makes an easy and direct comparison possible and hereby allows a more thorough and appropriate decision making when selecting assessment tools.

METHOD

A mixed-methods approach was used. First, a systematic literature search was conducted to identify existing tools for the description and evaluation of assessment instruments. Second, the content of these tools was combined and missing features and IDD-specific attributes were added. Finally, expert consultations were performed.

RESULTS

The Characteristics of Assessment Instruments for Psychiatric Disorders in Persons with Intellectual Developmental Disorders (CAPs-IDD) lists characteristics to evaluate and describe instruments for psychiatric disorders in persons with IDD. It comprises two sections: first, the conceptual and measurement model; second, the psychometric properties. Each section consists of various subsections and a detailed response format for coding instruments.

CONCLUSIONS

The use of the CAPs-IDD helps to identify and choose instruments that best suit the respective purpose. Filled with information, it could be made accessible via new technologies to researchers and practitioners and be updated when new information is available. Thus, it contributes to a more reliable and valid assessment of possible psychiatric disorders in persons with IDD.