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.     

The behavioural profile of psychiatric disorders in persons with intellectual disability

Background Problems associated with psychiatric diagnoses could be minimized by identifying behavioural clusters of specific psychiatric disorders. Methods Sixty persons with intellectual disability (ID) and behavioural problems, aged 12–55 years, were assessed with standardized Indian tools for intelligence and adaptive behaviour. Clinical diagnoses were conferred as per International Classification of Diseases – 10th Revision (ICD-10) criteria. Subsequently Reiss Screen for Maladaptive Behaviors (RSMB) and AAMD Adaptive Behavior Scale-Part II were administered independently. Results Aggression and rebellious behaviours were more common in affective disorders and personality disorders. Psychotic and paranoid features were significantly more in psychosis group. Those with behavioural problems had significantly low scores on the sub-scales of RSMB. Conclusion RSMB and AAMD Adaptive Behavior Scale-Part II will be useful to identify behavioural clusters, which will complement clinical psychiatric diagnoses in individuals with ID.     

Prevalence of psychiatric disorders in children and adolescents with and without intellectual disability

Background There have been very few population‐based studies of the prevalence of psychiatric disorders among children and adolescents with and without intellectual disability (ID). Methods Secondary analysis of the 1999 Office for National Statistics survey of the Mental Health of Children and Adolescents in Great Britain was performed. This survey collected information on a multistage, stratified, random sample of 10 438 children between 5 and 15 years of age across 475 postcode sectors in England, Scotland and Wales. Results The prevalence of any diagnosed ICD‐10 disorder, conduct disorder, anxiety disorder, hyperkinesis and pervasive developmental disorders were significantly greater among children with ID than among their non‐ID peers. There were no statistically significant differences between children with and without ID with regard to the prevalence of depressive disorders, eating disorders or psychosis. Factors associated with an increased risk of psychopathology among children and adolescents with ID included age, gender, social deprivation, family composition, number of potentially stressful life events, the mental health of the child's primary carer, family functioning and child management practices. Conclusions Children and adolescents with ID are at significantly increased risk of certain forms of psychiatric disorder. Careful consideration of the social and economic adversity facing such families will be necessary to ensure that support services are responsive to both the needs of child as well as the needs of the family in which they are living.     

Persons with intellectual disability receiving psychiatric treatment

Determinants of (1) referral to psychiatric services and (2) the amount of mental health care consumed were analysed in a population of individuals with intellectual disability, using data from a cumulative mental health case register in a defined geographical area. Associations between level of disability, gender, age and social environment on the one hand, and psychiatric referral and service consumption on the other were expressed as odds ratios (ORs). Being older (OR = 1.9; 95% Cl = 1.5–2.5), having milder intellectual disability (OR= 1.4; 95% Cl = 0.9–2.3) and living alone (OR = 5.8; 95% Cl = 2.8–1 1.9) predicted a higher probability of receiving psychiatric treatment. Living alone (OR = 15.3; 95% Cl = 1.7–136.1) was also associated with higher level of mental health service consumption.     

Executive functions in individuals with intellectual disability

The aim of the present study was to investigate executive functions in adults with intellectual disability, and compare them to a closely matched control group longitudinally for 5 years. In the Betula database, a group of adults with intellectual disability (ID, n = 46) was defined from measures of verbal and non-verbal IQ. A control group, with two people for every person with intellectual disability (n = 92), was chosen by matching on the following criterion in order of priority: IQ higher than 85, age, sex, sample, level of education, and years of education. Three types of tasks of executive functions were included on two occasions, with 5 years between testing sessions: The Tower of Hanoi, executively loaded dual task versions of word recall, and verbal fluency. Adults with ID showed significant impairments on verbal fluency and on the executively loaded dual task word recall task (at encoding but not at recall). There were no group differences on the Tower of Hanoi. No significant differences between the two test occasions were found. The results are interpreted in terms of individuals with ID having problems with speed of accessing lexical items and difficulties with working memory-related executive control at encoding, which includes shifting between tasks. There are, however, not necessarily problems with inhibition. The dual task results additionally imply that the adults with intellectual disability were more sensitive to strategy interruptions at encoding, but that dividing attention at recall did not have such detrimental effects.     

Reliability and validity of the SPAID-G checklist for detecting psychiatric disorders in adults with intellectual disability

SPAID (Psychiatric Instrument for the Intellectually Disabled Adult) is the first Italian tool-package for carrying out psychiatric diagnosis in adults with Intellectual Disabilities (ID). It includes the “G” form, for general diagnostic orientation, and specific checklists for all groups of syndromes stated by the available classification systems. SPAID was established to provide an easy and quick tool for daily practice of the personnel working with ID. The present study was aimed at evaluating psychometric and psychodiagnostic characteristics of the SPAID-G and at supplying new data on the prevalence rate of psychiatric disorders in a multicentric Italian sample of people with ID living in different settings. The SPAID-G was randomly applied to 304 participants with ID attending residential facilities or assessment services across Italy. A part of the sample was also consecutively assessed through the use of DASH, PDD-MRS and by the clinical application of the DSM-IV TR criteria. The correlation between SPAID-G scores and those provided by other evaluation tools was over 60%. Additionally, the internal consistency and inter-rater reliability resulted to be good. Psychopathological symptoms were detected in approximately 40% of the sample. Respectively, autistic spectrum disorders, impulse control disorders, mood disorders, and dramatic personality disorders were the diagnostic orientations providing the most prevalent over-threshold scores. SPAID-G seems to be a valid diagnostic tool, quick and easy to use in psychiatric disorders assessment within the Italian population with ID.     

Reliability and validity of the Mini PAS-ADD for assessing psychiatric disorders in adults with intellectual disability

The Mini PAS-ADD is an assessment schedule for psychiatric disorders in people with an intellectual disability. It is designed to provide a link between the mental health expertise of psychiatrists and psychologists, and the detailed knowledge of individual service users possessed by support staff. In broad terms, the aim of the Mini PAS-ADD is to enable non-psychiatrists accurately to recognize clinically significant psychiatric disorders in the people who they care for, so that they can make informed referral decisions, The instrument comprises 86 psychiatric symptoms and generates a series of subscores on: depression, anxiety and phobias, mania, obsessive-compulsive disorder, psychosis, unspecified disorder (including dementia), and pervasive developmental disorder (autism). The present paper reports the results of a study investigating internal consistency, inter-rater agreement and validity in relation to clinical opinion, using a sample of 68 people with intellectual disability who were in contact with psychiatric services. In terms of the instrument fulfilling its main intended function, i.e. accurate case recognition, the crucial question was whether the support workers, with their lesser knowledge of psychopathology, were also able to correctly identify cases identified by expert clinicians. The validity results in this respect (81% agreement on case recognition) were sufficiently good that it is to be anticipated that the Mini PAS-ADD should have a significant impact on the identification of psychiatric disorders in the community of people with intellectual disability.     

Reliability and validity of the PAS-ADD Checklist for detecting psychiatric disorders in adults with intellectual disability

The PAS-ADD Checklist is a screening instrument specifically designed to help staff recognize mental health problems in the people with intellectual disability for whom they care, and to make informed referral decisions. The instrument consists of a life-events checklist and 29 symptom items scored on a four-point scale. Scores are combined to provide three threshold scores. The crossing of any of these thresholds indicates the need for a fuller assessment. The items are worded in everyday language, making the Checklist suitable for use by individuals who do not have a background in psychopathology. The present paper presents the results of a number of studies evaluating the reliability and validity of the Checklist. Factor analysis of Checklists completed on a community sample of 201 individuals yielded eight factors, of which seven were readily interpretable in diagnostic terms. Internal consistency of the scales was generally acceptable. Inter-rarer reliability in respect to individual items gave a fairly low average Kappa of 0.42. However, agreement on case identification, the main purpose of the Checklist, was quite good, with 83% of the decision being in agreement. Validity in relation to clinical opinion was also satisfactory, case detection rising appropriately with the clinically judged severity of disorder. The PAS-ADD Checklist is published and distributed by the Hester Adrian Research Centre, Manchester, England, from where further information and order forms are available on request.     

Severe autosomal dominant nocturnal frontal lobe epilepsy associated with psychiatric disorders and intellectual disability

Autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE) is a relatively benign epilepsy syndrome with few comorbidities. Here we describe two families with unusually severe ADNFLE, with associated psychiatric, behavioral, and cognitive features. Detailed clinical data on 17 affected individuals were obtained, and genotyping of microsatellite markers, linkage analysis, and sequencing of candidate genes was performed. The severe ADNFLE phenotype in these families was often refractory to treatment, with status epilepticus occurring in 24% of subjects. Psychiatric or behavioral disorders occurred in 53%, with intellectual disability in 24%, and developmental regression in two individuals. No mutations were identified in alpha4, alpha2, or beta2 nAChR subunits. In one family there was evidence of linkage to a region of 15q24 without nAChR subunit genes. In conclusion, severe ADNFLE has significant medical, psychiatric, and intellectual morbidity. The molecular basis of severe ADNFLE is unknown but may involve non-nAChR-related mechanisms.     

Risk factors for psychiatric disturbance in children with intellectual disability

Background Children with intellectual disability (ID) have a higher risk for psychiatric disturbance than their peers with normal intelligence, but research data on risk factors are insufficient and partially conflicting. Method The subjects comprised 75 children with ID aged 6–13 years. Data were obtained from case files and the following four questionnaires completed by their parents or other carers: Developmental Behaviour Checklist, American Association of Mental Deficiency (AAMD) Adaptive Behavior Scale, a questionnaire on additional disabilities, and a questionnaire on family characteristics and child development. Results The risk of psychopathology was most significantly increased by moderate ID, limitations in adaptive behaviour, impaired language development, poor socialization, living with one biological parent, and low socio‐economic status of the family. Conclusions The risk of psychopathology in children with ID is increased by factors related to family characteristics and child development. Identifying these factors will help diagnose and possibly prevent psychiatric disorders in these children.     

Psychiatric disorders in children with intellectual disability

We investigated psychiatric disorders in intellectually disabled children; the prevalence rate and types of psychiatric disorders, and the association of psychiatric disorders with sex, residence type, level of disability, and epilepsy were examined. The population comprised 155 intellectually disabled children. Medical information was obtained from case files, which indicated that a psychiatric disorder had previously been diagnosed for 11% of patients. A careful re-examination of the case files revealed a psychiatric disorder for 33%. The criteria of a psychiatric ICD-10 diagnosis were fulfilled by 23%, and a further 10% had an unspecified mental disorder. The most common diagnoses were pervasive developmental disorders and hyperkinetic disorders. The former were less common among children with mild intellectual disability. In conclusion, about one-third of children with intellectual disability have a psychiatric disorder which needs to be taken into account in treatment.     

Eating disorders in adults with intellectual disability

There is an increasing focus on the nutrition of people with intellectual disability (ID), but less interest in the range of eating disorders (EDs) that they may exhibit and the bio‐psycho‐social impact of these conditions. Despite diagnostic and methodological difficulties, psychopathology and ED research studies suggest that 3–42% of institutionalized adults with ID and 1–19% of adults with ID in the community have diagnosable EDs. Weight surveys indicate that 2–35% of adults with ID are obese and 5–43% are significantly underweight, but the contribution of diagnosable EDs is unknown. Such data and case reports suggest that EDs are associated with considerable physical, behavioural, psychiatric and social comorbidity. Review papers have focused on the aetiology and treatment of pica, rumination, regurgitation, psychogenic vomiting and food faddiness/refusal. Emerging clinical issues are the development of appropriate diagnostic criteria, multimodal assessment and clinically effective treatment approaches. Key service issues include staff training to improve awareness, addressing comorbidity and access issues, and maintaining support for adults with ID and EDs, and their carers. Research should confirm the multifaceted aetiology and comorbidity of EDs. Then multicomponent assessment and treatment models for EDs can be developed and evaluated.     

A prospective case control study of psychiatric disorders in adults with epilepsy and intellectual disability

Purpose: No study to date has prospectively investigated the impact of epilepsy on psychiatric disorders among adults with an intellectual disability (ID). This study aimed to determine prospectively the influence of epilepsy on the development of psychiatric disorders in adults with ID. Method: Psychiatric symptoms were measured prospectively over a 1‐year period among 45 adults with ID and active epilepsy and 45 adults with ID without epilepsy, matched on level of ID. The 1‐year incidence rate (IR) of commonly occurring Axis 1 psychiatric disorders was compared with and without controlling for possible confounding factors. Total psychiatric symptom scores over the period were compared between the two groups using repeated‐measures analysis of covariance. Key Findings: Adults with epilepsy and ID had a more than seven times increased risk for developing psychiatric disorders, particularly depression and unspecified disorders of presumed organic origin, including dementia, over a 1‐year period compared to those with ID only. Comparison of the psychiatric scores showed the epilepsy group to have significantly higher unspecified disorder and depression symptom scores. Significance: The findings point to an increased risk of depression and unspecified disorders, including dementia, among adults with ID and epilepsy. Further exploration of the nature and treatment of these unspecified disorders may help the care of people with epilepsy and ID.     

Psychiatric disorders in children with intellectual disability

We investigated psychiatric disorders in intellectually disabled children; the prevalence rate and types of psychiatric disorders, and the association of psychiatric disorders with sex, residence type, level of disability, and epilepsy were examined. The population comprised 155 intellectually disabled children. Medical information was obtained from case files, which indicated that a psychiatric disorder had previously been diagnosed for 11% of patients. A careful re-examination of the case files revealed a psychiatric disorder for 33%. The criteria of a psychiatric ICD-10 diagnosis were fulfilled by 23%, and a further 10% had an unspecified mental disorder. The most common diagnoses were pervasive developmental disorders and hyperkinetic disorders. The former were less common among children with mild intellectual disability. In conclusion, about one-third of children with intellectual disability have a psychiatric disorder which needs to be taken into account in treatment.     

Characteristics of people with intellectual disability admitted for psychiatric inpatient treatment

The present prospective study describes the demographic, medical and psychosocial characteristics of 40 people with intellectual disability who were referred for psychiatric inpatient treatment in the special psychiatric unit of the Special Welfare District of South-west Finland. Three different control groups were used to study: (1) demographic variables (n = 122); (2) medical history (n = 39); and (3) psychosocial factors (n = 20). The symptoms leading to an admission to inpatient care and the connections of these clinical signs with the discharge diagnosis were evaluated. The typical inpatients were young males with mild intellectual disability, psychosis and a previous psychiatric diagnosis. They had lived in several places during their lives and their economic situation was poor. Affective and/or disruptive symptoms were the most common causes of an admission to inpatient care. The largest diagnostic group at discharge consisted of patients with psychotic disorders. The people with intellectual disability who were admitted for inpatient care formed a subgroup with certain psychiatric symptoms and social problems. Specialist psychiatric expertise is absolutely necessary for the treatment of this subgroup.     

Mood disorders in intellectual disability

PURPOSE OF REVIEW: This article examines reviews and research on the diagnosis and treatment of mood disorders in people with intellectual disability published from September 2004 to December 2005. RECENT FINDINGS: Patients with intellectual disability have limitations in verbal ability, and with increasing levels of disability may have an atypical clinical presentation. Thus, methods to diagnose mood disorders were a major research focus. Informant-rating scales and two self-report instruments provided data on thought patterns, aberrant behavior, appetite, and suicidality. Behavioral symptoms such as aggression were frequently associated with mood disorders. Pharmacotherapy and electroconvulsive therapy were found to be effective treatments. Mood disorders were frequently identified in people with intellectual disability, although suicide was still quite rare. SUMMARY: Patients with milder levels of disability can use self-report measures and can be diagnosed using standard criteria with little modification. For those with more severe disability, diagnosis is challenging and often requires the use of residual categories. Atypical clinical presentation, including maladaptive behaviors, lent support for 'behavioral equivalent' substitutes of standard criteria. Typical pharmacological agents were effective for depression and electroconvulsive therapy for treatment-resistant bipolar disorder.     

Diagnosis of dementia in individuals with intellectual disability*

The foremost impediment to progress in the understanding and treatment of dementia in adults with intellectual disability is the lack of standardized criteria and diagnostic procedures. Standardized criteria for the diagnosis of dementia in individuals with intellectual disability are proposed, and their application is discussed. In addition, procedures for determining v/hether or not     

A comparison study of adults with intellectual disability and psychiatric disorder with and without forensic involvement

The current study describes and compares profiles of patients in the same specialized hospital program for patients with intellectual disability with and without forensic involvement. A retrospective chart review of 78 individuals (39 forensic and 39 non-forensic) served between 2006 and 2008 was completed. The forensic sample was more likely to have a diagnosis of borderline to mild IQ and psychotic disorder was more common. Forensic patients were also more likely to have previously used drugs or alcohol. Forensic inpatients had significantly longer lengths of stay, and were more likely to change residence from admission to discharge than the non-forensic inpatients but the GAF scores did not differ between the two groups at admission or discharge. Although there are many similarities between the two groups, there are also some important differences that exist which should be considered in the design of inpatient and outpatient mental health and intellectual disability services.     

Choosing employment: factors that impact employment decisions for individuals with intellectual disability

Little is known about the factors that shape the employment-related decisions of individuals with intellectual and/or developmental disabilities. Findings from qualitative interviews with individuals, their family members, and employment-support professionals from four community rehabilitation providers throughout Massachusetts were reported. Recognizing the value of participatory action research, we also included a co-researcher with intellectual disability who participated in all facets of the research process. Findings revealed a collection of people and factors considered influential in employment-related decision-making. The family in the formative years, school-based staff and early employment experiences, the culture of the community rehabilitation providers, the job developer, and personal preferences all influenced participants' decisions. Through understanding these persuasive elements, we offer recommendations to those in the intellectual and developmental disabilities field to optimize employment choices and outcomes.