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.     

Clinical outcomes of a specialised inpatient unit for adults with mild to severe intellectual disability and mental illness

Background   Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with intellectual disability (ID) and mental health needs. Few studies have examined treatment outcomes of specialised inpatient units, and no studies have explored how the effects of intervention may differ for individuals at varying levels of cognitive ability. The present study examined clinical outcomes of inpatients with mild ID in contrast to inpatients with moderate to severe ID within the same service.
Method   Thirty-three patients (17 with mild ID and 16 with moderate to severe ID) discharged between 2006 and 2008 from a specialised inpatient unit in Canada for adults with ID and mental illness were studied. In addition to examining change in scores on clinical measures, outcomes with regard to length of stay, diagnostic change, residential change and re-admission to hospital were explored.
Results   Both groups demonstrated clinical improvement from admission to discharge. However, only patients with mild ID demonstrated improvements on the Global Assessment of Functioning.
Conclusions   This study is one of the first to consider outcomes of higher and lower functioning individuals with ID on a specialised inpatient unit. Results suggest that outcomes may be different for these groups, and some clinical measures may be more sensitive to changes in patients with more severe disabilities.     

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.     

Emotional and behavioural problems in adolescents with intellectual disability with and without chronic diseases

Background   Adolescents with intellectual disability (ID) (ID-adolescents) and adolescents with chronic diseases are both more likely to have emotional and behavioural problems. The aim of this study was to assess the association between chronic diseases in ID-adolescents and emotional and behavioural problems in a large school-based sample.
Methods   We obtained data on 1044 ID-adolescents, aged 12–18 years, attending secondary schools in the Netherlands. Parents of the adolescents completed the Dutch version of the Strengths and Difficulties Questionnaire and questions about chronic diseases in their child and about the background of the child.
Results   Prevalence rates of emotional and behavioural problems were generally high in ID-adolescents with chronic diseases (45%), compared with ID-adolescents without chronic diseases (17%). The likelihood of emotional and behavioural problems was high in ID-adolescents with two [odds ratios (OR) 4.47; 95% CI: 2.97–6.74] or more than two chronic diseases (OR 8.01; 95% CI: 5.18–12.39) and for ID-adolescents with mental chronic diseases (OR 4.56; 95% CI: 3.21–6.47). Also ID-adolescents with somatic chronic diseases had a high likelihood of emotional and behavioural problems (OR 1.99; 95% CI: 1.33–2.99), in particular in the combination of somatic and mental chronic diseases (OR 5.16; 95% CI: 3.46–7.71).
Conclusions   The current study showed that chronic diseases in ID-adolescents, in particular mental chronic diseases, largely increase the likelihood of emotional and behavioural problems. This should be taken in the provision and planning of care for ID-adolescents.     

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness

Background   There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services.
Method   A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies.
Results   People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services.
Conclusions   Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.     

General psychiatric services for adults with intellectual disability and mental illness

BACKGROUND: Adults with intellectual disability (ID) and mental illness may use general or specialist psychiatric services. This review aims to assess if there is evidence for a difference in outcome between them. METHODS: A literature review was conducted using a variety of electronic databases and hand-search strategies to identify all studies evaluating the outcome of people with ID and mental illness using general psychiatric services. RESULTS: There is no conclusive evidence to favour the use of general or specialist psychiatric services. People with ID stay less time on general psychiatric than specialist inpatient units. People with severe ID appear not to be well served in general services. Older studies of inpatient samples suggest a worse outcome for people with ID. Novel specialist services generally improve upon pre-existing general services. Assertive outreach in general services may preferentially benefit those with ID. Recent studies suggest similar lengths of stay in general psychiatric beds for people with and without ID. CONCLUSIONS: Although 27 studies were located, only two were randomized controlled trials. The evidence is poor quality therefore further evaluation of services employing a variety of designs need to be employed to give more robust evidence as to which services are preferred.     

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.     

Identification of personal factors that determine work outcome for adults with intellectual disability

Background Access to employment for people with intellectual disability (ID) has become a social priority. The aim of the present study is to try to determine which variables [sociodemographic variables, intelligence quotient (IQ), presence or absence of a psychiatric disorder, functioning, self‐determination, and behavioural problems] could most reliably account for access to remunerated employment of people with ID. Methods Two groups of people with ID participated in this study: (1) 69 workers in a sheltered‐employment programme; and (2) 110 clients of programmes in sheltered workshops. Both programmes were run by the Pardo‐Valcarce Foundation in Madrid (Spain). The following variables were assessed for every participant: IQ, functioning, behavioural problems, self‐determination and presence of psychiatric symptoms. A binary logistic regression analysis was carried out in order to identify the variables that best explained work outcome (sheltered workshop programme vs. sheltered employment programme). Results Although IQ showed no significant differences between the two groups of participants, the remaining variables did: behavioural problems, functioning, psychiatric symptoms and self‐determination significantly explained work outcome. As for sociodemographic variables, whereas gender did not show any significant relationship with the labour status of the participants, significant differences were found when considering variables such as age and pension benefits. Conclusions All the main variables considered, except IQ, turned out to be significant. Our findings should be considered encouraging, as they apparently show that both personal and social efforts can help individuals to overcome their low intellectual functioning in order to achieve access to employment. Such study highlights the importance of a prior psychopathological evaluation and efforts to enhance self‐determination in order to improve work inclusion for people with ID.     

Caregiving burden of families looking after persons with intellectual disability and behavioural or psychiatric problems

Background During the last decade, there has been a growing interest in outpatient support services for persons with intellectual disability (ID) and psychiatric and/or behavioural problems and their families. In this study, we explore the family burden that is associated with children or adults with ID and behavioural or psychiatric problems living at home. Method The research group consisted of 66 clients of In Casa, a project of outpatient treatment. Their average age is 18.97 years and their average IQ 55.37. The Reiss Screen for Maladaptive Behaviour (adults) or Reiss Scales for Children's Dual Diagnosis (children) and the Nijmegen Family Situation Questionnaire have been administered. Results About 62% of the children and 86% of the adults living at home and referred to In Casa have severe psychiatric or behavioural problems as measured by the Reiss scales. The dual diagnosis has a more negative impact on the family situation than the condition of ID only. Conclusion Parents consider the psychiatric or behavioural problems of their child to be an extra burden and feel it more difficult to raise and manage such a child. This impels them to change the situation and to call on the help of external services. Some methodological questions and the implications of the findings in terms of support needs are discussed.     

Queensland psychiatrists' attitudes and perceptions of adults with intellectual disability

Background Quality mental health care for adults with an intellectual disability (ID) depends upon the availability of appropriately trained and experienced psychiatrists. There have been few surveys of psychiatrists working with this population. Method This Australian study obtained psychiatrists’ attitudes to and perceptions of the mental health needs of adults with an ID. Training needs were also sought. The survey instrument used was a purposely designed, 28‐item self‐administered questionnaire featuring multiple‐choice and open‐ended questions. Results The majority of psychiatrists expressed concerns about treatment of this group, describing unmet needs. A total of 75% considered that antipsychotics were overused to control aggression, and 34% of psychiatrists were reluctant to treat adults with an ID. In total, 85% agreed that mental health in ID should be offered as a training option for psychiatric registrars, and that specialized mental health services would provide a high standard of care for this population. Conclusion Broad concerns are raised regarding pathways to mental health care for adults with an ID in Australia. An Australia‐wide training strategy needs to be developed. Partnerships between mental health, disability and community services that serve the mental health needs of this population, should actively seek to engage psychiatrists.     

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.     

Health, healthcare utilization and psychiatric disorder in people with intellectual disability in Taiwan

Objectives The aims of the present study were to examine health characteristics and healthcare utilization in relation to people with intellectual disability (ID) having psychiatric disorders in Taiwan. Methods A cross-sectional study was employed; study subjects were recruited from the National Disability Registration Database. Taiwan, stratified by administrative geographical area for the study. Statistical analysis of 1026 carers for people with ID was made to examine the health status and healthcare utilization of individuals with ID having psychiatric disorders. Results Approximately 12.1% of people with ID had psychiatric disorders. These individuals were more likely to be poorer in health condition and consuming more medical services (in the outpatient, inpatient and emergency care areas), than those individuals without psychiatric disorders. These individuals with psychiatric disorders were also taking medicines regularly at a far greater percentage than did those without psychiatric disorders. Conclusions Given the high prevalence of psychiatric disorders among individuals with ID, the healthcare system should take further steps to develop an appropriate health status monitoring system and community-based and easily accessible mental health services for them.