Challenging behaviors should not be considered depressive equivalents in individuals with intellectual disabilities. II. A replication study

Previous research has proposed behavioral equivalents for depression, but evidence for behavioral equivalents has been contradictory. The relationship between a measure of depression and several proposed behavioral equivalents of depression was assessed in 693 adults living in a large residential setting. Most were adults with severe or profound intellectual disability. The frequency of language-based measures of depression was very low. A scale to assess depression was constructed based on an item analysis of a larger pool of items. Both item and factor analysis and correlations between scores on the depression scale and individual maladaptive behavior items showed little or no relationship between proposed behavioral equivalents and depression. No support was found for behavioral equivalents of depression. This replicated the findings of Tsiouris, Mann, Patti, and Sturmey (2003). Practitioners are cautioned against using maladaptive behaviors as evidence of depression in people with severe or profound intellectual disabilities.     

Diagnosis of depression in people with severe/profound intellectual disability

The Marston 30 Symptoms Checklist for detecting depression was used to determine whether or not the notion of ‘depressive equivalents’ can provide a few of the core characteristics necessary for the diagnosis of depressive disorders in people with severe/profound intellectual disability (ID). Diagnoses of major depression were made by a psychiatrist using the DSM‐III‐R criteria, combined with information from records, staff, team, parents, behaviour profiles, direct observations, mental status and follow‐up visits. Twenty‐two people with ID fulfilled the selection criteria from a larger sample of 150 patients who had been evaluated in 350 contact visits. Scores on the checklist for major depression for 15 subjects with severe/profound ID were similar to the core characteristics for diagnosis of major depression by DSM‐III‐R criteria. Evidence was found for the presence of depressive equivalents in the subjects, but these appeared to be secondary. The 15 participants with severe/profound ID were observed mostly during the depressive phase of bipolar I and bipolar II disorder, and major depression, recurrent type. Melancholic features were prominent in their presentation. Further studies of people with ID are needed to determine whether depressive equivalents are more prominent in cases of major depression with atypical features than in cases of major depression with melancholic features.     

Manifestations of depression in people with intellectual disability

The symptoms of 36 people with varying degrees of intellectual disability (ID) who had had an ICD-I0 depressive syndrome in the preceding year were compared with 46 non-depressed people with comparable degrees of ID. Throughout the spectrum of ID, symptoms of depressed affect and sleep disturbance were significantly different between the groups. While symptoms in people with mild ID were reflected in the standard diagnostic criteria, this was not the case in people with moderate and severe ID. With increasing disability there was a move towards ‘behavioural depressive equivalents’ such as aggression, screaming and self-injurious behaviour. Diagnostic criteria for depression among people with severe ID, should place more emphasis on behavioural ‘depressive equivalents’.     

Mental disorders and problematic behaviours in people with intellectual disability: future directions for research

In recent years there has been a nriajor growth of interest in the field of mental health and intellectual disability. This article outlines some of the issues that will be important to address in the coming years. The issues discussed include: the interaction of biological and environmental factors in the aetiology of behavioural and psychiatric disorders; diagnosis and classification; epidemiology; dementia; recognition of mental illness in the community; treatment; service provision; and training.     

Persistence of challenging behaviours in adults with intellectual disability over a period of 11 years

Background Challenging behaviours in people with an intellectual disability (ID) often develop early and tend to persist throughout life. This study presents data on the chronicity of challenging behaviours in adults with ID over a period of 11 years, and explores the characteristics of people with persistent serious behaviour problems. Method Support staff provided data on 58 adults living in a long‐term residential facility using an interview survey schedule assessing challenging behaviours in 1992 and 2003. Results Participants presenting with serious physical attacks, self‐injury and frequent stereotypy were the most likely to persist in these behaviours over time. These behaviours were characterised by high persistence percentages and associations over time. However, the earlier presence of serious challenging behaviours did not significantly affect the likelihood of serious challenging behaviours in 2003. Individuals with persisting behaviour problems differed from those who did not present serious behaviour problems on the basis of their younger age, increased mobility, and decreased sociability and daily living skills in 1992. Conclusions Estimates of persistence for challenging behaviours are affected by the statistics chosen to represent stability. The apparent persistence of serious challenging behaviours highlights the need to identify the factors related to maintenance of these behaviours over time. The participant characteristics and adaptive behaviours identified in the present study were not consistently related to the persistence of challenging behaviours. Therefore, other factors, including environmental characteristics, are likely to be related to challenging behaviour persistence.     

Staff attributions about challenging behaviours of people with intellectual disabilities and transactional stress process: a qualitative study

Background   Staff explanations about challenging behaviours of people with intellectual disabilities are purported to play a significant role in the way they respond to them. Despite attempts made in research to understand the mechanisms of causality, a lack of association between attributions, emotions and behaviours is reported. This study investigates these relationships within a broader framework including attributions in the transactional stress model of Lazarus and Folkman.
Method   A qualitative design has been selected; semi-structured interview format was used in order to investigate implication of attributions in stress regarding Weiner's model of helping behaviour. A case study method has been adopted to allow consideration of ecological data, a case study representing a special encounter with a challenging behaviour. Categorical analysis was conducted.
Results   The results suggest three main issues. First, it appears that Weiner's model is too restrictive in order to explain the complexity of contextualised encounters. Second, a need to differentiate types of attributions within a temporal perspective is highlighted. Finally, consideration of the coping role of attributions is suggested.
Conclusions   A need to extent the research concerning attribution is suggested. The insertion of research into ecological contexts and the introduction of coping concept regarding staff attributions of challenging behaviours would allow a broader view of the role of attributions.     

Maladaptive behaviours and symptoms of dementia in adults with Down's syndrome compared with adults with intellectual disability of other aetiologies

Dementia commonly occurs in elderly people with intellectual disability, especially those with Down's syndrome. The non-cognitive symptoms of dementia can be of greater significance to individuals and carers than the cognitive changes caused by this condition. It is not known whether there are differences between people with Down's syndrome and those with intellectual disability of other causes with regard to the prevalence of such symptoms. The present study was undertaken to draw a comparison between a group with Down's syndrome and dementia ( n = 19), and a group with intellectual disability of other causes and dementia ( n = 26). Maladaptive behaviours and psychiatric symptomatology were assessed in both groups. The group with Down's syndrome had a higher prevalence of low mood, restlessness/excessive overactivity, disturbed sleep, being excessively uncooperative and auditory hallucinations. Aggression occurred with greater frequency in those subjects with intellectual disability of other causes. These findings are of epidemiological importance in terms of service planning and understanding psychiatric presentation.     

Effects of symptoms of co-morbid psychopathology on challenging behaviours among infants and toddlers with Autistic Disorder and PDD-NOS as assessed with the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT)

Purpose: To examine whether level of symptoms of co-morbid psychopathology exacerbated challenging behaviours in young children with autism spectrum disorders (ASD).

Method: Using the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT)–Part 2 which measures co-morbid symptoms and the BISCUIT- Part 3 which examines challenging behaviours, 362 infants and toddlers with ASD were evaluated.

Results: Findings showed that participants scoring high on symptoms of Avoidance and Tantrum/Conduct problems had greater rates of aggressive/destructive behaviours, self-injurious behaviours (SIB) and stereotypies compared to those with low scores. Participants with high levels of Inattention/Impulsivity or Eat/Sleep concerns, compared to those with low levels, demonstrated greater aggressive/destructive behaviour and stereotypies. For symptoms of Anxiety/Repetitive Behaviours, participants with high scores displayed greater levels of stereotypies.

Conclusions: Symptoms of co-morbid psychopathology are present at a very early age for children with ASD and elevated levels of these symptoms may exacerbate challenging behaviours.     

The relationship between levels of mood, interest and pleasure and 'challenging behaviour' in adults with severe and profound intellectual disability

Background Research on affective disorders in adults with intellectual disability (ID) suggests that depression may not present a ‘classic picture’ in individuals with severe and profound ID, but may include challenging behaviours, which are referred to as ‘atypical symptoms’, such as self‐injury, aggression and irritability. The aim of the present study was to explore whether there is an association between constructs relating closely to the core symptoms of depression and challenging behaviours in adults with severe and profound ID. Method Mood and levels of interest and pleasure were measured in 53 adults with severe or pro‐found ID using the Mood, Interest and Pleasure Questionnaire (MIPQ). Results Two groups of adults were identified based on MIPQ scores: (1) a ‘low mood’ group (lowest score = 12); and (2) a comparison group (highest scoring = 12). The groups were clearly differentiated on the MIPQ (P < 0.0001), but were comparable on age, gender and medication use. The Challenging Behaviour Interview showed no difference between the two groups in self‐injury, aggression or disrupting the environment. A secondary analysis revealed that participants who showed challenging behaviour scored significantly lower on the MIPQ than those who did not show challenging behaviour. Conclusions Possible reasons for these results and considerations for future studies are discussed.     

Psychiatric symptoms and problem behaviours in people with intellectual disabilities

Background Previous studies have suggested different patterns of associations between psychiatric symptoms and problem behaviours in people with intellectual disabilities (ID). The aim of this study was to investigate which problem behaviours are associated with specific psychiatric symptoms and the relative strength of these specific associations. Method A cross sectional survey using the Psychiatric Assessment Schedule for Adults with Developmental Disabilities Checklist and the Disability Assessment Schedule was carried out in a sample of 214 adults with ID. Results Self‐injurious and, to a lesser extent, aggressive problem behaviours were most associated with affective type symptoms. Screaming and destructive behaviours tended to be more associated with autism‐related social impairment rather than conventional psychiatric symptoms. Conclusions This study gives further evidence of associations between psychiatric symptoms and specific problem behaviours in people with ID. It may be particularly useful to consider the diagnosis of affective disorders if a person with ID shows self‐injurious or aggressive behaviours.     

Supporting individuals with intellectual disability and challenging behaviour in integrated work settings: an overview and a model for service provision

An overview of supported employment and its historical context is examined, and supported employment for individuals with both intellectual disability and challenging behaviour is discussed. A proposed model for working with such individuals is briefly outlined. This model is based on previous work in the field, and is characterized by a multi-component approach which addresses the issues of both support and behavioural intervention.     

Staff strategies and explanations for intervening with challenging behaviours: a replication in a community sample

Carers' beliefs about challenging behaviours may partially determine their behavioural responses to them. The present study replicated previous work on the beliefs of institution staff and their explanations about interventions for challenging behaviours (Hastings 1996) with a sample of 56 community staff. Many immediate intervention strategies, and the staff motivation for these choices, were in conflict with behavioural approaches to challenging behaviour and would be considered counter-habilitative from this perspective. Staff were able to describe appropriate longer-term interventions. These basic findings confirmed those of previous research with institution staff. However, tentative comparisons suggested that community staff were more likely than institution staff (from previous research) to describe interventions involving the building of relationships with service users and the identification of the underlying causes of the behaviours.     

Service support to people in Wales with severe intellectual disability and the most severe challenging behaviours: processes, outcomes and costs

A survey of people with severe intellectual disability and the most severe challenging behaviour in Wales identified five adults living in family homes, 17 in new specialist community housing and 19 in traditional services. With the omission of two people from the latter group and with a restricted collection of data for people living in the family home, the present study explored service input, outcome and costs across the three setting types. Process and outcome indicators for the family home group, who received little service input, were better than those for the traditional service group, although less good than those for the community house group. The specialist community home model produced significant gains over the traditional services in virtually all areas. Across the residential data set as a whole, there was no association between staff:resident ratios and severity of disability or between costs and severity of disability. This was largely true of the service types separately. There was a relationship between costs and service quality. However, this association was underpinned by gross differences between community houses and traditional settings. Costs, processes and outcomes ceased to be related when the two residential types were considered separately. Although higher costs of new community services compared to traditional services may be set against improved outcomes, high costs within the former could not be related to benefit. Outcome indicators were generally related to each other, suggesting that high quality in one sense was matched by high quality in other senses. Outcome was significantly associated with the ability of residents. Outcome indicators also tended to be related to observed staff performance, which was independent of resident ability. Therefore, outcome may be considered as dually determined by differences in resident ability and in what staff did.     

Seizure disorders in people with intellectual disability: an analysis of differences in social functioning, adaptive functioning and maladaptive behaviours

The present study is an investigation into the effects of seizure disorders/epilepsy on psychopathology, social functioning, adaptive functioning and maladaptive behaviours using a sample of 353 people diagnosed with a seizure disorder, and either severe or profound intellectual disability. People with a diagnosis of seizure disorder were found to have significantly less social and adaptive skills when compared to developmentally disabled controls with no seizure disorder diagnosis. Additionally, patterns of maladaptive behaviours were identified for individuals with seizure disorders and found to be similar to those found in people without seizure activity. The implications of the present findings are discussed.     

A prospective analysis of life events, problem behaviours and depression in adults with intellectual disability

Background Life events have consistently been found to be associated with behaviour problems and depression among individuals with intellectual disability (ID). However, prior findings have typically been based on correlational or retrospective analyses of case files. The current study attempted to replicate prior findings from life events with concurrent data and extend them to the prospective prediction of behaviour problems and depression. The influence of impact ratings of life events was also explored. Methods Seventy‐four informants rated 104 adults with ID on measures of life events, behaviour problems and depressive symptoms. Life events were rated as having either a positive, negative or no impact on the life of the individual with ID. Measures were completed twice, at a 4‐month interval. Results Behaviour problems were both correlated with and predicted by frequency counts of life events and life events perceived as negative. However, the predictive ability depended on which measure of problem behaviour was selected. Positive life events were not associated with concurrent behaviour problems. Depressive symptoms were correlated with all life changes, but only predicted by frequency counts of life events and life events perceived as negative. Again, the predictive ability depended on which measure of depression was selected. Findings were corroborated with a group of individuals with clinical diagnoses of major depression. Conclusions Frequency counts of all life events and life events perceived as negative play a role in the development of behaviour problems and depressive symptoms among adults with ID. The results have implications for interventions for behaviour problems following a life event, and for reducing depressive symptoms for adults with mild ID.     

Post-traumatic stress disorder in young people with intellectual disability

Background Post-traumatic stress disorder (PTSD) is common and treatable. There is extensive research on people of average intelligence yet little on individuals with developmental disabilities. Methods We report two people with intellectual disability (ID) who experienced PTSD. The relevance of their developmental difficulties, social and communication profiles, attentional skills, and causes of these, to their presentations is discussed. Results Both individuals have fragile X syndrome and severe ID. One has Diagnostic and Statistical Manual – 4th Edition (DSM-IV) autistic disorder; the other DSM-IV attention deficit-hyperactivity disorder. They experienced developmental and psychological regressions, new challenging behaviours and exacerbations of existing ones coincident with emotional trauma. PTSD symptoms and phenomena were identifiable despite intellectual and communicatory impairments. Conclusion Presentation of PTSD is influenced by degree and cause of ID, social circumstances, social and communicatory skills, nature and timing of traumatic experience and subsequent management. The paucity of literature suggests it is missed frequently in individuals with ID who risk having problems misattributed to other causes with potential for inappropriate interventions.     

Predictors of depressive symptoms at hospital discharge in patients with major depressive disorder

Abstract

Objective. Often patients with major depressive disorder (MDD) leave the hospital with continued significant symptomatology. This study sought to evaluate demographic, clinical, and psychosocial predictors of the presence of clinically significant depressive symptoms, defined as a Modified Hamilton Rating Scale for Depression score of ≥ 14, immediately following hospitalization for MDD. Methods. The study enrolled 135 patients with MDD as part of a larger clinical trial investigating the efficacy of post-hospitalization pharmacologic and psychosocial treatments for depressed inpatients. Structured clinical interview and self-report data were available from 126 patients at hospital admission and discharge. Results. Despite the significant decreases in depressive symptoms over the course of hospitalization, 91 (72%) displayed clinically significant depressive symptoms at discharge. Multivariate logistic regression analysis revealed that female sex, earlier age of onset, and poorer social adjustment were unique predictors of symptom outcome. Conclusions. Results suggest that a large proportion of patients leave the hospital with continued significant symptomatology, and the presence of such symptoms following hospitalization for MDD is likely to be explained by a combination of factors.     

Identifying bipolar disorders in individuals with intellectual disability

Objective The aim of the present study was to characterize adults with intellectual disability (ID) and concomitant clinical diagnoses of bipolar disorder (BPD), and determine whether DSM‐IV criteria would distinguish individuals with BPD from patients with other psychiatric diagnoses. Methods A retrospective chart review was done of a convenience sample of adult patients seen over a 3‐year period in a specialty clinic for adults with ID and psychiatric disorders. The DSM‐IV criteria were used to differentiate individuals with clinical symptoms of BPD from groups of patients with other mood or thought disorders with behavioural symptoms which frequently overlap those of BPD. Behavioural symptoms were also catalogued and used to distinguish the diagnostic groups. Results Subjects with clinical symptoms of BPD had significantly more DSM‐IV mood‐related and non‐mood‐related symptoms, as well as functional impairments, compared to individuals with major depression, depression with psychosis or schizophrenia/psychosis NOS (not otherwise specified). Likewise, behavioural profiles of the BPD group of patients differed significantly from patients in the other three groups. Conclusions Bipolar disorder can be readily recognized and distinguished from other behavioural and psychiatric diagnoses in individuals with ID, and DSM‐IV criteria can be useful in the diagnosis of BPD.