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Kildahl AN. Bias in assessment of co-occurring mental disorder in individuals with intellectual disabilities: Theoretical perspectives and implications for clinical practice. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2024; 28:393-414. [PMID: 36708367 PMCID: PMC11059834 DOI: 10.1177/17446295231154119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Influence from bias is unavoidable in clinical decision-making, and mental health assessment seems particularly vulnerable. Individuals with intellectual disabilities have increased risk of developing co-occurring mental disorder. Due to the inherent difficulties associated with intellectual disabilities, assessment of mental health in this population often relies on a different set of strategies, and it is unclear how these may affect risk of bias. In this theoretical paper, we apply recent conceptualisations of bias in clinical decision-making to the specific challenges and strategies in mental health assessment in intellectual disabilities. We suggest that clinical decision-making in these assessments is particularly vulnerable to bias, including sources of bias present in mental health assessment in the general population, as well as potential sources of bias which may be specific to assessments in this population. It follows that to manage potential bias, triangulating information from multi-informant, multi-method, interdisciplinary assessment strategies is likely to be necessary.
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Affiliation(s)
- Arvid Nikolai Kildahl
- Arvid Nikolai Kildahl, Regional Section Mental Health, Intellectual Disabilities/Autism, Oslo University Hospital, Verkensveien 19, Oslo, Asker 1385, Norway.
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Dell'Armo K, Tassé MJ. Diagnostic Overshadowing of Psychological Disorders in People With Intellectual Disability: A Systematic Review. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2024; 129:116-134. [PMID: 38411245 DOI: 10.1352/1944-7558-129.2.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 08/15/2024] [Indexed: 02/28/2024]
Abstract
Diagnostic overshadowing is a bias in which symptoms of a psychological disorder are falsely attributed to a known diagnosis of intellectual disability. This systematic review evaluated all research on diagnostic overshadowing conducted to date, including dissertations and peer-reviewed journal articles. In total, 25 studies were included in this review. Findings suggest diagnostic overshadowing may not be as ubiquitous as originally believed, with one third of included studies finding no overshadowing. The quality of the evidence was graded as "Low" using the LEGEND tool, with common issues including outdated studies, analogue methodologies, small sample sizes and convenience samples, and inappropriate conducting or reporting of statistical analyses. Implications for the field and recommendations for future research are discussed.
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Affiliation(s)
- Kristin Dell'Armo
- Kristin Dell'Armo, Nationwide Children's Hospital and The Ohio State University
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Becker-Haimes EM, Wislocki K, DiDonato S, Beidas RS, Jensen-Doss A. Youth Trauma Histories are Associated with Under-diagnosis and Under-treatment of Co-occurring Youth Psychiatric Symptoms. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:184-195. [PMID: 34038229 PMCID: PMC8617069 DOI: 10.1080/15374416.2021.1923020] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We examined whether in the presence of trauma exposure, non-traumatic stress-related symptoms are interpreted by mental health clinicians as less salient than the trauma exposure and are de-emphasized as a treatment target, consistent with a diagnostic overshadowing bias. METHODS Using an adapted version of a diagnostic overshadowing bias experimental paradigm, mental health clinicians (N = 266, M age = 34.4 years, 82% female) were randomly assigned to receive two of six clinical vignette variations. Vignette 1 described an adolescent with obsessive-compulsive disorder (OCD). Vignette 2 described a pre-adolescent with oppositional defiant disorder (ODD). Vignettes were identical except for whether the youth reported exposure to a potentially traumatic event (PTE; no PTE, sexual PTE, or physical PTE). Clinicians received one vignette with a PTE and one without, counterbalancing order. Clinicians rated the likelihood the youth met criteria for various diagnoses and the appropriateness of various treatments on 7-point scales. RESULTS Across both vignettes, clinicians rated the target diagnosis (OCD in Vignette 1, ODD in Vignette 2) as less likely for vignettes with a PTE than for the same vignettes without a PTE. Clinicians also rated evidence-based treatment modalities for target diagnoses as less appropriate in the presence of a PTE than when a PTE was present. CONCLUSIONS Consistent with possible bias, clinicians may under-recognize and under-treat non-traumatic stress-related mental health symptoms in youth with a co-occurring trauma history. Future work to validate this bias in real-world practice is indicated.
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Affiliation(s)
- Emily M. Becker-Haimes
- Department of Psychiatry, University of Pennsylvania
Perelman School of Medicine, Philadelphia, PA
- Hall Mercer Community Mental Health, University of
Pennsylvania Health System
| | - Katherine Wislocki
- Department of Psychiatry, University of Pennsylvania
Perelman School of Medicine, Philadelphia, PA
| | - Stephen DiDonato
- College of Nursing, Thomas Jefferson University,
Philadelphia, PA
| | - Rinad S. Beidas
- Department of Psychiatry, University of Pennsylvania
Perelman School of Medicine, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University
of Perelman School of Medicine, Philadelphia, PA
- Penn Implementation Science Center at the Leonard Davis
Institute of Health Economics (PISCE@LDI), University of Pennsylvania
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Manohar H, Subramanian K, Kandasamy P, Penchilaiya V, Arun A. Diagnostic Masking and Overshadowing in Intellectual Disability-How Structured Evaluation Helps. JOURNAL OF CHILD AND ADOLESCENT PSYCHIATRIC NURSING 2016; 29:171-176. [PMID: 27901303 DOI: 10.1111/jcap.12160] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 10/24/2016] [Accepted: 10/28/2016] [Indexed: 11/28/2022]
Abstract
PROBLEM Comorbid psychiatric diagnoses tend to be underdiagnosed in patients with intellectual disability. Diagnosing anxiety disorders in such patients can pose challenges, in particular with regard to obsessive and compulsive disorder (OCD). METHODS We present the case of an adolescent diagnosed with intellectual disability with poor expressive language skills who presented with nonspecific mood and behavioral symptoms, not improving with routine clinical evaluations and treatment. A structured assessment was done to decipher the psychopathology. FINDINGS The structured evaluation was able to diagnose OCD, and the treatment response was accentuated, bringing about a significant reduction in patient and caregiver distress. Psychosocial interventions through nurses played a significant role. CONCLUSIONS The case highlights the need for a systematic assessment of patients with intellectual disability to arrive at reliable diagnoses and to plan appropriate treatment strategies.
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Affiliation(s)
- Harshini Manohar
- Harshini Manohar, MBBS, is a Junior Resident, Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Karthick Subramanian
- Karthick Subramanian, MD, is a Senior Resident, Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Preeti Kandasamy
- Preeti Kandasamy, DM (Child & Adolescent Psychiatry), is an Assistant Professor, Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Venkatalakshmi Penchilaiya
- Venkatalakshmi Penchilaiya, MBBS, is a Junior Resident, Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Anandbabu Arun
- Anandbabu Arun, MD, is a Senior Resident, Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Robinson KS. Part of the Team; Art Therapy with Pre-School Children with Developmental Delays and Disabilities in a Children's Treatment Centre Setting. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/08322473.2009.11434781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Baumer N, Davidson EJ. Supporting a happy, healthy adolescence for young people with Down syndrome and other intellectual disabilities: recommendations for clinicians. Curr Opin Pediatr 2014; 26:428-34. [PMID: 25010137 DOI: 10.1097/mop.0000000000000122] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review clinical updates and current healthcare issues for adolescents with Down syndrome and intellectual disabilities, including behavioral, social, and emotional issues, health supervision recommendations, and recommendations for supporting the transition process. RECENT FINDINGS Several recent findings merit particular attention: low activity levels and implications for overweight and poor bone density; high prevalence of obstructive sleep apnea and its implications; prevalence of mental health and behavioral concerns; and need for appropriate transition services. SUMMARY In guiding adolescents with Down syndrome towards healthy productive adult lives, clinicians can make use of healthcare guidelines and should also take a broader, more interdisciplinary approach to ensure that social, educational, and vocational plans are in place to support physical and mental health and development during transition into adulthood. Many of these issues have broader applicability to any adolescent with an intellectual disability.
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Affiliation(s)
- Nicole Baumer
- Boston Children's Hospital, Down Syndrome Program, Developmental Medicine Center, Boston, Massachusetts, USA
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Brief report: an unusual manifestation of diagnostic overshadowing of pervasive developmental disorder--not otherwise specified: a five year longitudinal case study. J Autism Dev Disord 2014; 43:1491-4. [PMID: 23108987 DOI: 10.1007/s10803-012-1691-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Children with communication disorders present with a range of comorbid conditions. Occasionally one of the comorbid conditions manifests so strongly that the primary condition goes unnoticed by the clinician. This tendency to overlook comorbid health problems in the presence of a disability is referred to as diagnostic overshadowing. This is a five-year follow up case study of a 9-year-old female child. The child was initially diagnosed to have Separation anxiety disorder (SAD), but during the course of follow up she began to exhibit features of pervasive developmental disorder-not otherwise specified (PDD-NOS). This case report throws light on the severity of SAD which overshadowed PDD-NOS. Importance of follow-up and the need for a multidisciplinary team to be sensitive to the phenomenon of diagnostic overshadowing is discussed.
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Jackson HJ. Current Trends in the Treatment of Phobias in Autistic and Mentally Retarded Persons. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/13668258309016157] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Henry J. Jackson
- Melville Clinic, Mental Health Division, Health Commission of Victoria
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McIntyre LL. Parent training for young children with developmental disabilities: randomized controlled trial. ACTA ACUST UNITED AC 2008; 113:356-68. [PMID: 18702556 DOI: 10.1352/2008.113:356-368] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A randomized controlled trial was used to evaluate a parent training intervention for caregivers with preschool-age children with developmental disabilities. The 21 families in the experimental group received usual care plus the 12-week Incredible Years Parent Training Program with developmental delay modifications. Families in the control group (n = 23) received usual care, including early childhood education and related services. Results suggest that this parent training intervention was superior to usual care for young children with developmental delays or disabilities in reducing negative parent-child interactions and child behavior problems. Participants in the experimental group indicated high satisfaction with treatment. Additional research is necessary to document maintenance and generalization of treatment outcomes.
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Di Marco M, Iacono T. Mental Health Assessment and Intervention for People With Complex Communication Needs Associated With Developmental Disabilities. JOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES 2007. [DOI: 10.1111/j.1741-1130.2006.00096.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Mason J, Scior K. 'Diagnostic Overshadowing' Amongst Clinicians Working with People with Intellectual Disabilities in the UK. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2004. [DOI: 10.1111/j.1360-2322.2004.00184.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bailey NM, Andrews TM. Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) and the diagnosis of anxiety disorders: a review. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2003; 47 Suppl 1:50-61. [PMID: 14516374 DOI: 10.1046/j.1365-2788.47.s1.25.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND/METHODS During the development of Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities[DC-LD] a literature review of diagnostic issues in anxiety disorders in adults with intellectual disability (ID) was undertaken using electronic and hand searching of journals. RESULTS Relevant general concepts in the general population are reviewed briefly before those related specifically to adults with ID. The literature relating to the diagnosis of specific anxiety disorders is reviewed, although with the exception of obsessive compulsive disorder this consists mainly of case reports. Difficulties in the use of diagnostic systems developed for the general population for the diagnosis of anxiety disorders in adults with ID are frequently commented upon. CONCLUSIONS It is concluded that anxiety disorders are well recognized in adults with ID, although their prevalence is uncertain, and that the use of modified diagnostic criteria may aid further research in this area.
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Affiliation(s)
- N M Bailey
- Somerset Partnership NHS and Social Care Trust, South Somerset Community Team for Adults with Learning Disabilities, Yeovil, Somerset, UK.
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Balboni G, Battagliese G, Pedrabissi L. The psychopathology inventory for mentally retarded adults: factor structure and comparisons between subjects with or without dual diagnosis. RESEARCH IN DEVELOPMENTAL DISABILITIES 2000; 21:311-321. [PMID: 10983785 DOI: 10.1016/s0891-4222(00)00044-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Whether the Psychopathology Inventory for Mentally Retarded Adults (PIMRA) could detect specific psychopathological disorders was investigated in 652 subjects with different levels of mental retardation living in the community or in residential facilities. An exploratory factor analysis was carried out to check the scale organization of PIMRA. The Anxiety, Adjustment Disorder, Somatoform Disorder, and Soundness Scales were confirmed by 4 corresponding factors; the Psychosexual Disorder Scale was replaced by a factor specific to gender identity problems, and the Schizophrenia Scale by two factors concerning isolation and bizarre behaviors, respectively. The items of the Depression Scale were distributed over the three factors concerning anxiety, adjustment, and psychosomatic disorders, while the items of the Personality Disorder Scale were scattered over almost all the factors. Moreover, 55 subjects with anxiety disorders and 49 with depression were compared to 50 control subjects of the same age, intelligence level, and gender ratio but without dual diagnosis and obtained significantly higher factorial scores both on the overall scale and on the factors specifically related to their disorders. PIMRA has been found to show good construct validity. These results could be considered particularly valid as they were obtained from a large sample comprising different levels of mental retardation and thus showing all possible psychopathological behaviors.
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Affiliation(s)
- G Balboni
- Department of Devlopmental Psychology and Socialization, University of Padova, Italy.
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Moss S, Bouras N, Holt G. Mental health services for people with intellectual disability: a conceptual framework. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2000; 44 ( Pt 2):97-107. [PMID: 10898373 DOI: 10.1046/j.1365-2788.2000.00283.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The present paper discusses the application of the 'matrix model' to mental health services for people with intellectual disability. There is great variability between the service models in this area, which makes comparisons and conclusions difficult. The present model facilitates the breaking down of these complexities into understandable parts so that future directions for research, service planning and delivery can be logical, coherent and evidence-based.
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Affiliation(s)
- S Moss
- Estia Centre, York Clinic, Guy's Hospital, London, UK
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van Minnen A, Savelsberg PM, Hoogduin KA. A Dutch version of the Psychopathology Inventory for Mentally Retarded Adults (PIMRA). RESEARCH IN DEVELOPMENTAL DISABILITIES 1994; 15:269-278. [PMID: 7972966 DOI: 10.1016/0891-4222(94)90007-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Eighty-nine mildly mentally retarded adults were assessed using the Psychopathology Inventory for Mentally Retarded Adults (PIMRA). This study reports on the psychometric properties of the PIMRA in a Dutch population, the correlation between self-report and ratings-by-others forms, and the relationship of the PIMRA to both behavior problems and subject characteristics. It was revealed that internal consistency was good for both forms on total scores but modest for most of the subscales. Furthermore, interrater reliability was low to modest. Both forms of the PIMRA showed good criterion validity. The correlation between the two forms was modest. A strong relationship was found between PIMRA scores and behavior problems, as measured using the Reiss Screen of Maladaptive Behavior. Furthermore, the relationship between PIMRA scores and subject characteristics was weak.
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Affiliation(s)
- A van Minnen
- Department of Clinical Psychology, University of Nijmegen, The Netherlands
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Moss S, Patel P. The Prevalence of Mental Illness in People with Intellectual Disability Over 50 Years of Age, and the Diagnostic Importance of Information from Carers. ACTA ACUST UNITED AC 1993. [DOI: 10.1080/03033910.1993.10557918] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
The Tennessee Self-concept Scale was orally administered to 27 mothers with mental retardation and self-administered to 95 mothers whose children attended daycare in the areas in which the former mothers lived. Analyses showed that the mothers with mental retardation scored significantly lower on all subscales. Where 72% of the comparison group scored above a recommended cut-off indicative of a positive self-concept, only 33% of the mothers with mental retardation did. Comparisons of the 27 mothers with mental retardation (18 with positive versus 9 with negative self-concepts) on personal, child, family, and other background variables suggested different relationships for the two groups. Cross-validation of the present work and studies of the actual childcare of these latter two groups of mothers are needed.
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Affiliation(s)
- A J Tymchuk
- Department of Psychiatry, School of Medicine, University of California, Los Angeles 90024
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