Psychiatric disorders and behavior problems in people with intellectual disability

The relationship between behavior problems and psychiatric disorders in individuals with intellectual disability is still unresolved. The present study compares the prevalence and pattern of psychiatric disorders in individuals with intellectual disability who were assessed on the ABC to have moderate and severe behavior problems and a matched group of individuals without such problems. Both groups were living in community settings and had their intellectual disability varied from mild to profound degrees. The participants were screened for psychiatric disorders using four different instruments; the Reiss Screen, the Mini PAS-ADD, the DASH-II and the ADD. The group with moderate and severe behavior problems showed significantly more symptoms of psychiatric disorders than the group without such problems when items related to behavior disorders were omitted, and the majority of the participants with behavior problems had symptoms of the main psychiatric disorders. The participants with mild and moderate intellectual disability showed more symptoms of psychosis and depression than the participants with severe and profound intellectual disability. There were no direct associations between individual behavior problems and psychiatric disorders, but the group with mild/moderate intellectual disability showed a somewhat different pattern of associations than the group with severe/profound intellectual disability. Depression was associated with screaming and aggression in the participants with severe and profound intellectual disability, and with self-injury in the participants with mild and moderate intellectual disability. The finding that the majority of the participants with behavior problems showed symptoms of psychiatric disorders suggests that many behavior problems may be (unconventional) symptoms of psychiatric disorders or reflect a difficult life situation caused by a psychiatric disorders, or that a difficult life situation may contribute to both psychiatric disorders and behavior problems in individuals with intellectual disability.     

Behavioural and emotional problems in children with intellectual disability attending special schools in Cape Town, South Africa

A sample of 355 children with intellectual disability (ID) attending special schools in Cape Town, South Africa, were assessed on the Developmental Behavioural Checklist – Teacher Version (DBC‐T). A prevalence rate of 31% for psychopathology was found. Boys manifested more behaviour problems than girls, especially in relation to disruptive, self‐absorbed and antisocial behaviours. Children with severe and profound levels of ID showed more behavioural difficulties than those in the mild and moderate categories. Specific behaviour problems were self‐absorbed and autistic behaviours in children with profound ID, communication problems and anxiety in those with severe ID and antisocial behaviour in children with mild ID. Epilepsy, but not cerebral palsy was associated with higher total behaviour scores. Ambulant children were more disruptive and antisocial, while non‐ambulant children were more anxious. Non‐verbal children had higher scores on all of the subscales except for disruptive behaviour.     

Population prevalence of psychopathology in children and adolescents with intellectual disability: II epidemiological findings

This paper reports findings from an epidemiologically derived population in a multicentre study in NSW, Australia. The design of this study is described in the accompanying paper. Those with mild intellectual disability (ID) were likely to have been underascertained, but identification and participation rates for those with more severe ID were high. The study found that in the regions surveyed 40.7% of those with ID and aged between 4 and 18 could be classified as having severe emotional and behaviour disorder or as being psychiatrically disordered. The profoundly intellectually handicapped had lower levels of disturbance overall compared with those with mild, moderate and severe ID. The level of ID affected scores on a number of behavioural dimensions, with disruptive and antisocial behaviours more prominent in the mild ID group, and ‘self–absorbed’ and ‘autistic’ behaviours more prominent in those with severe ID. Age and sex did not affect prevalence, a finding that is in contrast to that found in general child psychopathology. The study found that fewer than 10% of children with intellectual disability and major psychiatric disorder had received specialist assistance.     

Competence and emotional/behavioural problems in 7-16-year-old Norwegian school children as reported by parents

Background: Previous studies from Nordic countries suggest that parent ratings of children's emotional and behavioural problems using the Child Behavior Checklist (CBCL) are among the lowest in the world. However, there has been no Norwegian population study with acceptable response rates to provide valid Norwegian reference data. Aims: Firstly, to compare CBCL Internalizing, Externalizing, Total Problems and Competence scores of Norwegian children and adolescents with those from 1) previous Norwegian studies, 2) other Nordic countries, and 3) international data. Secondly, to present Norwegian reference data in order to perform these comparisons. Thirdly, to investigate the effects of age, gender, socio-economic and urban/rural status on the CBCL. Methods: A stratified cluster sample of 2582 school children (1302 girls and 1280 boys) was identified from the general Norwegian population and their parents were asked to complete the CBCL. Results: The response rate was 65.5%. The mean Total Problems score for the whole sample was 14.2 (standard deviation, s = 14.1). Girls were rated as having greater Competence and fewer Total Problems than boys. Younger children had more Total Problems than adolescents. Parents with low education reported more child Total Problems and lower Competence than those with high education. All effect sizes were small, except for the effect of parental education on child Competence, which was moderate. Conclusions: Total Problems scores were lower than in other societies. The data from this study obtained from one county in central Norway provide an important reference for clinical practice and treatment outcome research.     

Psychiatric diagnoses in relation to severity of intellectual disability and challenging behaviors: a register study among older people

ABSTRACT

Objective: To investigate the possible association between severity of intellectual disability (ID) and presence of challenging behavior, respectively, on diagnoses of psychiatric disorders among older people with ID.

Methods: People with a diagnosis of ID in inpatient or specialist outpatient care in 2002–2012 were identified (n = 2147; 611 with mild ID, 285 with moderate ID, 255 with severe or profound ID, and 996 with other/unspecified ID). Moreover, using impairment of behavior as a proxy for challenging behavior, 627 people with, and 1514 without such behavior were identified.

Results: Severe/profound ID was associated with lower odds of diagnoses of psychotic, affective, and anxiety disorders than was mild/moderate ID. People with moderate ID had higher odds than those with mild ID of having diagnoses of affective disorders. Diagnoses of psychotic, affective, and anxiety disorders, and dementia were more common among people with challenging behavior than among those without.

Conclusions: People with severe/profound ID had lower odds of receiving psychiatric diagnoses than those with mild and moderate ID. Whether this is a result of differences in prevalence of disorders or diagnostic difficulties is unknown. Further, challenging behaviors were associated with diagnoses of psychiatric disorders. However, the nature of this association remains unclear.     

Deficits in reciprocal social behavior in male twins: evidence for a genetically independent domain of psychopathology

OBJECTIVE: Previous studies have demonstrated substantial genetic influences on many child psychiatric disorders, including autism. In this study the authors attempted to quantify the degree to which genetic influences on deficits in reciprocal social behavior (a defining feature of pervasive developmental disorders) are shared with genetic influences on other domains of behavior in children. METHOD: Child Behavior Checklists (CBCL) and Social Responsiveness Scales (SRS) were completed for an epidemiological sample of 219 pairs of male twins. The SRS (formerly known as the Social Reciprocity Scale) is a measure of social impairment that distinguishes children with autism spectrum disorders from those with other child psychiatric disorders. RESULTS: Regression analysis indicated that CBCL syndromes account for 43% of the variance in SRS scores. Bivariate analyses revealed that SRS scores are affected, in part, by phenotypic influences from the CBCL Social Problem syndrome. Forty-four percent of the causal influences on SRS scores, however, are independent from those on CBCL syndromes and are genetic in nature (90% confidence interval: 0.38-0.49). CONCLUSION: These results support the existence of a continuous distribution of deficits in reciprocal social behavior in the population, which are substantially genetically independent from other domains of child psychopathology.     

Latent class analysis of child behavior checklist anxiety/depression in children and adolescents

OBJECTIVE: Comorbidity of psychiatric problems such as anxiety and depression poses challenges to treatment and research. This study tested whether problem items from the Anxious/Depressed scale of the Child Behavior Checklist (CBCL) can be separated into distinct anxiety and depression classes or are continuously distributed throughout a population. METHOD: A CBCL was completed by a parent or guardian of each of 1,987 children and adolescents selected to represent nonreferred children in the United States, as well as by a parent or guardian of each of a demographically matched sample of 1,987 clinically referred children and adolescents. Problem items from the Anxious/Depressed scale of the CBCL were subjected to latent class analysis. RESULTS: Analyses revealed three levels of problem presentation in both samples. Children in the nonreferred sample were classified as having no problems, mild problems, or moderate anxiety/depression problems. Children and adolescents in the referred group were classified as having mild, moderate, or severe levels of problems. No pure anxiety or depression classes were found, only classes containing a mixture of both anxiety and depressive problems. Age, gender, and sample differences were found in class groupings, with nonreferred adolescent girls showing elevated levels of problems. CONCLUSIONS: Results suggest that the comorbid conditions of anxiety and depression, as assessed by the CBCL anxiety/depression problem items, can be thought of as part of the same continuum of problems. Implications for assessment and treatment utilization are discussed.     

Behaviour problems in children with dyslexia

The association between behaviour problems and dyslexia was assessed in a population sample of 10- to 12-year-old children. Twenty-five dyslexic children and a matched control group were recruited through a screening in primary schools in the city of Bergen, Norway. For the assessment of behaviour problems the Child Behavior Checklist (CBCL), Teacher Self Report (TRF), and Youth Self Report (YSR) were filled out by parents, teachers, and children, respectively. Information on health and developmental factors were obtained from parents on a separate questionnaire designed for the study. The dyslexic group had significantly more behaviour problems than the control group according to both the CBCL and the TRF. On the YSR there was no significant difference between the groups. Dyslexic children had higher CBCL and TRF scores on the Total Behaviour Problem scale, the Internalizing and Externalizing subdomains, and the Attention problem subscale. The groups differed in social background, prenatal risk factors, birth weight, preschool language problems, and IQ, but these variables showed no relationship to the level of behaviour problems in the present sample. We conclude that pre-adolescent dyslexic children show a wide range of behaviour problems that cannot be attributed to social or developmental background variables.     

Problems and competencies reported by parents of Vietnamese children in Hanoi.

OBJECTIVE: To determine the distribution of behavioral and emotional problems and competencies among a sample of Vietnamese children aged 4 through 18 years living in Hanoi. METHOD: A representative community sample of 1,526 children and adolescents was selected from 2 precincts in Hanoi. Problems and competencies were assessed with the Child Behavior Checklist (CBCL). RESULTS: Vietnamese children had lower mean raw scores than U.S. norms on the CBCL's Total, Externalizing, Internalizing, and Competence scales. Boys were reported to have more externalizing problems and girls more internalizing problems. Girls' levels of internalizing problems increased significantly with age. CONCLUSION: The lower levels of problems and competencies reported in Vietnamese children may represent differences in the prevalence of psychiatric disorders, in parental perceptions of what constitutes deviant behavior, or in parental comfort with reporting psychopathological behaviors. Further research is needed to clarify the relationship between the reported behavioral and emotional problems of Vietnamese children and the presence of psychiatric disorders. From a clinical perspective, the study's results suggest that levels of problems and competencies may vary significantly between different ethnic and cultural groups. Specific clinical cutoffs used to identify children requiring further psychiatric assessment need to be established separately for different ethnic groups.     

A study of behaviour profiles among intellectually disabled people in residential care in Hungary

The authors investigated the behavioural dimensions of 269 intellectually disabled (ID) people in residential care in specialized institutions in Tolna county (South-West Hungary) with the aim of screening the frequency and severity of the relevant behavioural symptoms associated with intellectual disability and depending on the level of intellectual impairment. Only 120 residents had an International Classification of Disease (ICD) diagnosis of “mental retardation (MR)” and a valid IQ grading either by means of the Hungarian standard version of the HAWIK or by the coloured Raven test. 4 IQ groups were created: borderline (B), mild (MID), moderate (MOD) and profound (PID) intellectual disability subgroups. The Hungarian pilot version of the Behaviour Problem Inventory (BPI) was used. Senventy-two percent of the residents displayed behavioural problems. All scale score means exhibited an enhancing tendency with IQ loss, as both frequency and severity increased linearly towards the more severe groups, but significantly only in the category of stereotyped behaviour. The authors focussed on problems of patient recruitment and discussed the measurement of behavioural and other psychiatric symptoms when researchers reported on the increased occurrence of behaviour and psychiatric symptoms in ID populations.     

Screening individuals with intellectual disability for psychiatric disorders: comparison of four measures

Convergences and divergences between four of the most commonly used checklists for psychiatric disorders (the Reiss Screen, The Mini PAS-ADD, the DASH-II, and the ADD) were examined. We screened 181 individuals with intellectual disability for psychiatric disorders with the four checklists and compared the results on the checklists. The concordance of the overall scores on the four checklists was high; but the agreement on specific psychiatric disorders was limited. The results indicate that the checklists are useful as general indicators of psychiatric disorders, but are of less value for specifying the nature of the disorders in individuals with intellectual disability.     

Epilepsy in school children with intellectual impairments in Sheffield: the size and nature of the problem and the implications for service provision

ABSTRACT. This study analyses the prevalence and nature of epilepsy in all children between the ages of 5 and 16 years of age in the City of Sheffield with mild, moderate or severe intellectual impairments. An overall figure of 18% was obtained with a range of 7% for those with mild to moderate intellectual impairments to 67% for those with severe intellectual impairments and a physical disability. The severity of the epilepsy similarly varied with the most severe being in those with severe intellectual impairments and physical disabilities.     

The Diagnosis of Depression in People with Severe Limitations in Intellectual Functioning

People with intellectual disability (ID) were once considered immune to developing psychopathology, including affective disorders such as depression. Now research has shown that people with ID do suffer from depression, and the focus is on understanding how to best diagnose and provide treatment. Research has come a long way in adapting the diagnostic process for people with mild/moderate deficits in intellectual functioning and communication abilities. However, there is a lack of research and clinical understanding regarding how to assess depression in people who lack communication skills and function with severe or profound deficits in intellectual functioning. This paper reviews the available literature on the occurrence of depression in people with ID, specifically those with more significant deficits, and discusses the difficulties that arise in trying to determine a diagnosis of depression for this population.     

Population prevalence of psychopathology in children and adolescents with intellectual disability: I rationale and methods

Our knowledge of the epidemiology of psychopathology in children and adolescents with intellectual disability (ID) is hampered by a number of factors. These include the relative scarcity of studies of children rather than adults, the study of non-epidemiological samples such as those in institutions or those attending psychiatric clinics, a lack of standardized methods of assessment of psychopathology, studies with numbers too small to provide adequate confidence intervals around identified prevalence rates, insufficient detail concerning symptoms or syndromes as well as disorder, and a lack of consistent data concerning the effects of basic demographic variables such as age, sex and IQ. Despite these limitations, it is clear that psychopathology is several times more prevalent in children and adolescents with ID than in those without this disability. This paper reviews findings from previous studies and describes the methodology of a new study using the Developmental Behaviour Checklist.     

Evidence for reciprocal interaction effects among adults with self-injury and their caregivers

Patterns of caregiver responses to client adaptive behavior were compared between adults with intellectual disabilities with and without self-injurious behavior. Participants with moderate to profound intellectual disability and self-injury (n=89) and age/IQ matched control participants (n=20) were selected from a large sample of adults living in a regional residential center. Approximately 45 minutes of direct observation data were collected for each participant during unstructured leisure time. Data were sequentially analyzed and Yule's Q scores derived and compared among groups. Results indicated that caregivers were more responsive to prosocial initiations and adaptive engagement among individuals with severe self-injurious behavior than to those with mild or no self-injurious behavior and that these responses were more likely to be in the form of a demand.     

The Stability of Axis I Diagnoses in Youth Across Multiple Psychiatric Hospitalizations

The literature has yet to reach a consensus as to the stability of severe psychiatric diagnoses in youth. Previous studies among youngsters tracked over set follow-up periods have reported diagnostic stability estimates that are similar to or slightly lower than those of adults. Less is known, however, about the stability of youth psychiatric diagnoses across multiple episodes of psychopathology, such as recurrent inpatient hospitalizations. The present study investigated diagnostic stability among inpatient youth with multiple hospitalizations through longitudinal and cross-sequential designs. Results indicate that diagnostic stability, as measured by positive concordance rates and the kappa coefficient, is highest for mood disorders, especially bipolar disorder. Externalizing disorders and schizophrenia displayed moderate to low stability, with oppositional-defiant disorder displaying the lowest stability. Substance use disorders were found to have moderate stability. Overall, across-episode diagnostic stability among hospitalized youngsters appears to be lower than that of adults. This finding appears to be due to lower stability among certain externalizing disorders and substance use disorders, whereas mood disorders display stability rates resembling those of adults. Potential explanations for and implications of these findings are discussed.     

The child behavior checklist broad-band scales predict subsequent psychopathology: A 5-year follow-up

OBJECTIVE: To evaluate the utility of the Child Behavior Check list (CBCL) for identifying children of parents with panic disorder or major depression at high-risk for future psychopathology. METHODS: Baseline Internalizing and Externalizing CBCL T-scores were used to predict subsequent depressive, anxiety, and disruptive behavior disorders at a 5-year follow-up in children of parents with panic disorder, major depression, or neither disorder. RESULTS: The Internalizing scale predicted subsequent agoraphobia, generalized anxiety disorder, separation anxiety disorder, and social phobia. In contrast, the Externalizing scale predicted subsequent disruptive behavior disorders and major depression. CONCLUSIONS: The convergence of these results with previous findings based on structured diagnostic interviews suggests that the CBCL broad-band scales can inexpensively and efficiently help identify children at high risk for future psychopathology within a population of children already at risk by virtue of parental psychopathology.     

The relationship between the severity of eating problems and intellectual developmental deficit level

Nutrition, essential in the daily living functions promoting life quality of persons with intellectual developmental deficits (IDD), is adversely affected by the highly prevalent eating problems in these persons. The current study explores the characteristics of eating problems in population of children with intellectual developmental disorders. We elaborate existing knowledge on the relationship of severity of eating/feeding disorders and intellectual handicap level in children who suffer from IDD. This study investigated differences in the kind of these disorders observed in children with IDD on three levels: mild, moderate, and severe/profound. Ninety-one children aged 4-9 participated in this study: 25 had mild IDD, 32 moderate IDD, and 34 severe/profound IDD. Feeding/eating functions were examined with the screening tool of eating problems (STEP) which was used as the main dependent measure (Matson & Kuhn, 2001). Results suggest that the prevalence of eating problems is higher than previously reported in the literature. Eating/feeding problems proved prevalent across all levels, in almost all of those with IDD, but certain categories of problems (i.e., skills and aspiration risk) are more prevalent among the group falling within the severe/profound range of intellectual disability.This finding makes a new important experimental contribution, suggesting that everyday functions such as eating/feeding be examined in all children with IDD and that clinical differences be considered in light of categorization according to IDD level. Results are discussed in light of the need to consider its implications for practice.     

Temporal changes in incidence and prevalence of intellectual disability between two birth cohorts in Northern Finland

We followed two separate, genetically homogeneous cohorts of children born in 1966 (n = 11,965) and 1985-1986 (n = 9,432) in Northern Finland to determine temporal changes in the incidence and prevalence of subcategories of intellectual disability within the same geographic area. The children were followed up to the age of 11.5 years. Similar study design, data ascertainment methods, and definition of intellectual disability were used. There was no change in the total incidence (12.62/1,000 in each) or in total prevalence (11.03/1,000 vs. 11.23/1,000) of intellectual disability. However, in the subcategories of intellectual disability, there was a shift from severe and moderate towards mild; whereas profound intellectual disability remained at the same level. The temporal changes followed generally similar patterns by gender.     

Evaluation of emotional and behavioral problems in language impaired children using the Child Behavior Checklist

Speech and language impaired children are at special risk for developing psychiatric disorders. Attention deficit, aggressive behaviour as well as overanxiety and excessive shyness have been reported in speech and language impaired children. The purpose of this study was to determine how the Child Behavior Checklist (CBCL) could be used as a screening instrument in language impaired children. In a sample of 83 language impaired children, emotional and behavioural problems were evaluated using the CBCL. Independent of this assessment, DSM-IV diagnoses were established for all children. Sixty-six of the 83 children had a psychiatric diagnosis. The use of the Total Behavior Problem score (TBP) as a global measure of behavioural disturbance showed that children with a psychiatric diagnosis had significantly higher scores on the TBP score than children without a psychiatric diagnosis. The specificity of the TBP was 88.2%, the sensitivity 75.8%, and the false classification rate 21.6%. The most frequently reported behavioural disturbances were problems on scale VI (“Attention Problems”-39 children) and on scale I (“Withdrawn”-32 children). A small group of children with a receptive language disorder and pronounced compulsive behavioural problems had elevated scores on scale V (“Thought Problems”). Accepted: 10 August 1998