Behavioural syndromes identified by cluster analysis in a sample of 100 severely and profoundly retarded adults

The diagnosis of eating disorders in adults with learning disabilities: Conceptualisation and implications for clinical practice

OBJECTIVE

The literature suggests that less attention has been afforded to eating disorders (EDs) in adults with learning disabilities (LDs) than in adults of normal intellect. This review aimed to examine the methods, prevalence and implications of an ED diagnosis in adults with LDs.

METHOD

Key texts, journals and online databases were searched for literature examining disordered eating in adults with LDs.

RESULTS

A review of the extant literature revealed that a range of dysfunctional eating behaviours have been classified as 'eating disorders' and highlighted a lack of clarity about the distinction between feeding and EDs. A small body of research suggests that some individuals with LDs show the emotional and cognitive characteristics of typical EDs.

DISCUSSION

The lack of consensus about conceptualisation, assessment, diagnosis and treatment of EDs in individuals with LDs needs to be addressed in order to aid awareness and enhance clinical approaches for this population.

[Neuromuscular dysfunction of the lower urinary tract dysfunction beyond spinal cord injury and multiple sclerosis. A challenge for urologists]

Neurogenic bladder subsequent to paraplegia serves as a paradigm when classifying the type of disorder analogous to the level of paralysis. In cases of multiple sclerosis micturition symptoms already present a manifold picture that changes in the clinical course. Rarer neurological disorders, on the other hand, such as infantile cerebral palsy, Parkinson's disease, multisystem atrophy, Alzheimer's disease, cerebrovascular disorders, Guillain-Barré syndrome, AIDS, herpes zoster, systemic lupus erythematosus, and herniated lumbar disc, often cause uncertainty with regard to necessary diagnostic tests and treatment.This review considers the available knowledge about voiding disorders and urinary incontinence associated with specific neurologic and neuromuscular diseases and provides recommendations for diagnostic work-up and pragmatic therapy.

Development of bladder control in mentally handicapped children

PURPOSE

To analyze the role of mental handicap as a possible source of lack of development of bladder control and to find out the chance of continence to advise future patients.

MATERIALS AND METHODS

The parents and relatives of 100 consecutive mentally handicapped patients were inquired by a personal interview. Questions included the age when they stopped using diapers, enuretic events, frequency, urgency and leakage episodes, urinary infections. Etiology of their mental problem was unknown in 34, perinatal anoxia in 17, Down syndrome in 15, phenylketonuria in 18 and others minors causes. The grade of mental deficiency were profound in 1, severe in 10, moderate in 39, mild in 33 and normal inferior value in 17. The age varied from 7 to 37 years old, with an average of 14 by the time of the interview, comprising 60 males and 40 females.

RESULTS

All profound and severe patients presented leakage episodes regardless of the age. The mild and normal inferior value acquired progressive urinary control with aging, and 33% still remain with urinary symptoms above 16 years old. Urinary infection was similar in males and females, around 29%. The most committed group presented less urinary infections. The etiology of the mental handicap was not correlated to the incidence of urinary leakage.

CONCLUSIONS

The lack of bladder control was correlated to the grade of mental handicap. In severe and profound groups, the expectancy of control is disappointing. In the less compromised groups, there is a delay in bladder training, with achievement of control in (2/3) after 16 years of age. Those in the normal inferior value have a chance of postponed urinary control, easily misdiagnosed by normal urological interviews.

Behavioural symptoms among people with severe and profound intellectual disabilities: a 26-year follow-up study

BACKGROUND

Very little is known about the natural history of challenging behaviour and psychiatric disorder in people with severe and profound degrees of intellectual disability.

AIMS

To clarify the natural history of challenging behaviour and psychiatric disorder in this population through a longterm prospective cohort study over a 26-year period.

METHOD

One hundred individuals with severe or profound intellectual disability were randomly selected in 1975. Their behaviour was recorded through carer and psychiatrist ratings using the Modified Manifest Abnormality Scale of the Clinical Interview Schedule. The presence and severity of psychiatric disorder were also recorded. The study was repeated in 1981/82 and 1992/93. We repeated the study again in 2001, supplementing the original observational data with the Checklist of Challenging Behaviour.

RESULTS

Behavioural symptomatology is remarkably persistent, particularly stereotypy, emotional abnormalities, eye avoidance and overactivity, although the severity of overall psychiatric disorder does show some abatement through time.

CONCLUSIONS

These findings influence the prospects of success in relocating adults with severe and profound degrees of intellectual disability back into the community.

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.

Epidemiology of self-injurious behaviour in adults with learning disabilities

BACKGROUND

There have been few epidemiological studies of the disabling and poorly understood disorder self-injurious behaviour among adults with learning disabilities.

METHOD

Interviews were undertaken with the carers of adults known to the Leicestershire Learning Disabilities Register (n = 2277). The Disability Assessment Schedule was used and information was also collected on demographic characteristics, developmental and physical status.

RESULTS

Self-injurious behaviour was present in 17.4% of the population. In 1.7% self-injurious behaviour occurred frequently and was severe. There was no gender difference between those with and without self-injurious behaviour. Both the chronological age and developmental quotient of individuals with self-injurious behaviour were lower than those of individuals without self-injurious behaviour. Autistic symptoms were more common among those with self-injurious behaviour. The association of self-injurious behaviour with a wide range of other maladaptive behaviours was highly significant. Logistic regression analysis retained age, developmental quotient, hearing status, immobility and number of autistic symptoms as explanatory variables for self-injurious behaviour.

CONCLUSIONS

Self-injurious behaviour is a prevalent and disabling disorder among adults with learning disabilities.

Self-injury and violence in people with severe learning disabilities

BACKGROUND

Psychiatry in severe and profound learning disability is essentially behavioural psychiatry. Some clinical and research observations of disorders of behaviour in this group are summarised in this study.

METHOD

After inspection of the literature, I postulated a clinical syndrome of violence and self-injury in the severely learning disabled. A check-list of behavioural symptoms was developed and used in a community survey.

RESULTS

Behaviour, assessed by the check-list, supported the existence of organic behaviour disorder, as did small-scale psychophysiological testing.

CONCLUSIONS

Self-injury is strongly associated with violence, and with severe and profound learning disability. Pathophysiology of violence and self-injury may include high levels of psychophysiological arousal demonstrated by unstable EEGs. Reduction of arousal by antipsychotic medication is associated with clinical improvement in violent and self-injurious behaviours.

Behaviour phenotype for Down's syndrome

BACKGROUND

For more than a century, the idea of particular personality/behavioural characteristics being associated with people with Down's syndrome has been explored, but with inconclusive results.

METHOD

The Disability Assessment Schedule was used to ascertain the behavioural profiles of 360 adults with Down's syndrome and 1829 adults with learning disabilities of other aetiologies, who were the whole identified population within a defined geographical area. Comparison was made between the two total groups and additionally for the subgroups aged < 35 years and aged > or = 35 years. Comparison was also made with regards to cluster analysis findings.

RESULTS

Despite an equal age and developmental quotient, the Down's syndrome group were less likely to demonstrate maladaptive behaviours. The behaviour characteristics of the adults with Down's syndrome remained constant in the younger and older age groups. Cluster analysis demonstrated adults with Down's syndrome to have an increased prevalence in cluster groupings with lower rates of maladaptive behaviours.

CONCLUSIONS

This study confirms there to be a behaviour phenotype among adults with Down's syndrome. The reasons for this (e.g. genetic/psychological/social) require further research. Such research may establish a better understanding of the aetiologies of maladaptive behaviours among people with learning disabilities in general.

Prevalence and cluster typology of maladaptive behaviors in a geographically defined population of adults with learning disabilities

BACKGROUND

Maladaptive behaviours are frequently present in individuals with learning disabilities; however, their prevalence varies between studies and the aetiology, classification and most appropriate management of such behaviors remain unclear. The aims of the study were twofold: firstly to determine the prevalence of maladaptive behaviours, and secondly to develop a classification typology.

METHOD

A population of 2202 adults with learning disabilities was surveyed to determine the prevalence of maladaptive behaviours. These were subjected on the basis of 13 behavioural characteristics to cluster analysis. The clusters were further examined in respect of secondary variables.

RESULTS

Over 60% of individuals demonstrated the presence of at least one maladaptive behaviour and in 40% this problem was of either severe degree or frequent occurrence. Men were more likely to demonstrate physical aggression, property destruction, tantrums and verbal abuse than women. Although some severe maladaptive behaviours diminished with age, many persisted through all age groups. Six behavioural clusters were devised which demonstrated face validity and which differed in respect of demographic and developmental variables, and the prevalence of maladaptive habits and autistic symptoms.

CONCLUSIONS

These findings demonstrate a high prevalence of maladaptive behaviours and 'objectionable habits' among people with learning disabilities. A classification of behavioural symptoms may be possible on the basis of symptom clusters.

Ring chromosome 22 and mood disorders

The case of a 21-year-old man with severe developmental disabilities, ring chromosome 22 and rapid-cycling bipolar illness is presented. This is the first reported occurrence of mood disorder in a person with ring chromosome 22. Previously published case reports describing behavioural problems associated with this chromosome disorder suggest that severe hyperactivity is typical and that affected individuals may have an excited mood state. These symptoms are consistent with atypical bipolar disorder and raise the possibility that ring chromosome 22 increases the risk for atypical bipolar disorder.

Behaviour symptoms among severely and profoundly mentally retarded patients. A 16-18 year follow-up study

BACKGROUND

Little is known about the natural history and evolution of behaviour symptoms and patterns in severely and profoundly mentally retarded adults. This paper reports a cohort study of 100 such adults.

METHOD

Abnormal behaviour symptoms and patterns have been followed, using a carer rating scale and the modified Manifest Abnormality Scale of Goldberg's Clinical Interview Schedule (1970) by the same two consultant psychiatrists in 1975, 1981 and 1992.

RESULTS

Emotional withdrawal, stereotypes and eye avoidance are particularly persistent. Carer ratings of noisiness and social withdrawal, and psychiatrist ratings of suspiciousness, overactivity and hostile irritability, are also persistent but to a lesser degree. Overall ratings of psychiatric disorder are persistent and act against successful community placement.

CONCLUSIONS

Abnormal behaviour patterns in severely and profoundly mentally retarded adults show only a modest degree of abatement over time. Care staff need a good understanding of clinical psychiatric and behaviour management techniques.

Issues in the taxonomy of psychopathology in mental retardation

Several factors appear to impede the development of a valid taxonomy of psychopathology in children and adolescents with mental retardation. These include (a) the lack of a widely accepted definition of psychopathology in mental retardation, (b) disagreement on the nature of the relationship between mental retardation and psychopathology, and (c) insufficient evidence for the reliability and validity of current DSM or ICD systems in this population. In this article, we offer a definition of psychopathology in children with mental retardation; review concepts of the relationship between psychopathology and mental retardation; argue that in moving toward a valid taxonomy factors to be considered should include data from multivariate studies, findings related to behavior phenotypes, and diagnostic considerations with stereotypic behavior and self-injury, organic brain syndromes and pervasive developmental disorders. Finally, we outline a research strategy that may serve as a useful framework for developing a valid taxonomy of psychopathology in this population.

The Developmental Behavior Checklist: the development and validation of an instrument to assess behavioral and emotional disturbance in children and adolescents with mental retardation

Describes the development and validation of the Developmental Behavior Checklist (DBC), a standardized instrument completed by lay informants to assess behavioral and emotional disturbance in children and adolescents with mental retardation (MR). Items describing common behavioral and emotional problems in this population were generated by extracting descriptions from 664 case files of children and adolescents with behavior disorders seen at a specialist developmental assessment service over 12 years. These items were reduced to a set of 96 items administered to a sample of 1,093 children and adolescents with mental retardation and then submitted to a principal components analysis. Six interpretable and partly validated subscales were obtained which explained 36% of the total variance and had satisfactory internal consistency. Interrater and test-retest agreement were satisfactory for both total scale score and for scores on each of the subscales. Good evidence of concurrent validity was provided by substantial positive correlations between total scores on the DBC completed by lay informants and the ratings of experienced psychiatrists based upon interviews and scores on two standardized instruments that must be completed by health professionals. The discriminative validity of the total score as assessed by area under the ROC curve was excellent (92%). Standardized norms for the DBC are derived from an epidemiological study of behavior problems in children and adolescents with mental retardation undertaken in two Australian States. Norms are available for the mild, moderate, severe, and profound MR groups and for the MR population as a whole.

Validity of the schizophrenia diagnosis of the psychopathology instrument for mentally retarded adults (PIMRA): a comparison of schizophrenic patients with and without mental retardation

The Psychopathology Instrument for Mentally Retarded Adults (PIMRA) was designed to assess psychiatric disorders among mildly and moderately mentally retarded persons. In a psychiatric population without mental retardation (n = 53), the PIMRA schizophrenia scale had an internal consistency coefficient alpha = 0.52. By removing one outlier item this increased to alpha = 0.61. By comparing the PIMRA schizophrenia diagnoses with DSM-III-R diagnoses in the psychiatric population, we found an external reliability corresponding to phi = 0.47 and an unweighted kappa = 0.43. Weighting of the mistakes resulted in a weighted kappa (w) = 0.74. A regression analysis of DSM-III-R diagnosis based on the PIMRA items was conducted. The regression equation was able to identify 75.5% of the DSM-III-R schizophrenic disorders in the psychiatric population. This equation correctly identified 75.5% of the PIMRA schizophrenias in a mentally retarded population. The intermethod reliability was phi = 0.49. We also compared the 38 psychiatric patients with DSM-III-R schizophrenic disorder with the 48 mentally retarded patients with PIMRA schizophrenic disorder. The mentally retarded patients had less delusions and more incoherence and flat affect. They also used less neuroleptic drugs.

Psychiatry and learning disability

My involvement with the psychiatry of learning disability began in 1968 when Professor Batchelor, then Professor of Psychiatry at the University of Dundee, suggested that mental illness in people with learning disability was a clinically interesting and under-researched topic which merited further investigation. At that time, mental illness was not usually considered even a part of the medical specialty of learning disability – or at least, not in Scotland. People in mental handicap hospitals who developed signs of mental illness were normally passed on to colleagues in general psychiatry who were considered to have the investigative and treatment expertise. If admission to in-patient care was considered necessary, it was usually to the local general psychiatry service.

The treatment of a chronic organic mental disorder with dextromethorphan in a man with severe mental retardation

Response to dextromethorphan (15 mg b.i.d.), an antitussive agent not usually considered to have psychotropic properties, was seen in a 25-year-old man with severe developmental disabilities, congenital rubella, and an organic mental disorder. Dextromethorphan affects CNS serotonergic systems, and this was the probable therapeutic mechanism. This and other published cases suggest the existence of a distinct organic mental syndrome in developmentally disabled persons which responds to drugs that increase indoleaminergic activity.

Clinical assessment of psychiatric symptoms in mentally retarded individuals

Mentally retarded Australians with emotional and behavioural disorders are seriously under-served by psychiatrists, despite such individuals being as prevalent as those with schizophrenia. These disorders have serious consequences for the individual, family and carers, and the community as a whole. In the psychiatric assessment of mentally retarded persons, a key principle is that while intellectual handicap increases vulnerability to psychiatric illness, it does not of itself cause psychopathology. A biopsychosocial framework provides a model whereby those factors which are contributing to psychopathology can be systematically elucidated. Biological factors include brain pathology associated with particular mental retardation syndromes, drug side-effects and epilepsy. Psychological factors include temperament, a history of abuse, and current life stresses. Social factors include distortions in family roles and hostel or workshop conflicts. Although clinical assessment can be challenging, and confident syndrome diagnosis is not always possible, a systematic approach to the analysis of symptoms will provide a guide to useful interventions.

The psychiatric symptoms, diagnoses and care needs of 100 mentally handicapped patients

One hundred randomly selected residents of a mental handicap hospital originating from Dundee were interviewed using a standardised assessment based on the modified Standardised Clinical Interview Schedule. Information on certain behavioural items and self-care skills was obtained from nursing staff and case records. An ICD-9 diagnosis could be made for 80 individuals, including diagnoses usually reserved for children. Thirty subjects were regarded as needing long-term psychiatric mental handicap hospital care. All but one of the remaining 70 subjects required a staffed residential placement and all but 15 some form of out-patient or short-term in-patient provision from specialist health services. The findings indicate a need for approximately 30 psychiatric mental handicap beds per 100,000 population.

Bladder function in the mentally retarded

A group of 21 mentally retarded patients with severe, long-standing urinary symptoms underwent urodynamical investigation. The most common abnormalities were detrusor areflexia and detrusor hyper-reflexia. Of 11 patients treated surgically, 10 derived marked benefit. Drugs were successful in reducing micturition problems in 3/6 patients. Severely retarded patients with spastic quadriplegia are difficult to investigate and if this is associated with detrusor hyper-reflexia it is impossible to treat them in any way. Severely retarded patients with detrusor areflexia and infrequent voiding can benefit from bladder outlet surgery. Patients with moderate (especially mild) retardation can be investigated and treated in the same way as non-retarded people.

Major depression in Down's syndrome

Five patients with trisomy 21 (Down's syndrome (DS], referred to us for evaluation of dementia, were instead found to have major depression. All had shown cognitive and behavioural deterioration and this had led to a mistaken diagnosis of Alzheimer's disease in two. We outline and contrast the features of major depression and Alzheimer's disease in DS, and suggest that electroconvulsive therapy is an effective treatment for major depression in DS.

Self-injurious behaviour and the Gilles de la Tourette syndrome: a clinical study and review of the literature

Thirty (33%) of 90 patients with the Gilles de la Tourette syndrome exhibited self-injurious behaviour. Fourteen were head bangers, of whom two had cavum septum pellucidum. Clinical correlates of self-injury were the severity of Gilles de la Tourette syndrome symptoms and psychopathology, with special reference to obsessionality and hostility. We discuss an additional patient who died from a subdural haematoma as a result of head banging, and three who had permanent vision impairment from self inflicted eye injuries.

[Pharmacologic interventions in agitated mentally retarded patients]

Aggressive behavior of mental retardates is a frequent problem which semiological description is very polymorphic. Some psychiatric etiologies are listed, and then the different aspects of idiopathic aggressive behavior are described. These aspects give guidelines for more specific treatments which are further reviewed. Preferential indications and side effects are described for each in a way to suggest a therapeutic strategy. At the end, legal aspects involved are briefly exposed.

Psychopathology in adult mentally handicapped hospital patients

In a population of 100 adult mentally handicapped patients, 71% had one or more ICD-9 diagnoses. The most common diagnosis was behavioural disorder, followed by affective psychosis and neurosis. Maladaptive behaviour was highest in younger, brighter patients and in patients who were psychiatrically disturbed. These findings have implications for the selection of patients for community living programmes, and for the appropriateness of providing treatment for particular mentally handicapped patients in psychiatric settings.

Behavioural symptoms and autistic psychosis in the mentally retarded adult

302 mentally retarded (MR) adults, representative of the total Danish MR population, were examined with regard to behavioural symptoms and psychiatric disorder. Deviant behaviour was found in 123 (41%) and was correlated to origin and degree of retardation, epilepsy and place of living. The distribution of the symptoms strongly indicates that organic brain damage is the major etiological cause. By grouping behavioural symptoms on three axes: A: social withdrawal (27%), B: abnormal bodily movements and sensory stimulation (22%) and C: conduct behaviour (17%), different patterns of abnormal behaviour were demonstrated. Behavioural symptoms occurred in 74 (87%) of 85 persons given present state psychiatric diagnoses. Behavioural symptoms are prominent in the group of autistic psychosis (childhood autism), which is classified by the triad of 1) autism, 2) abnormal language, and 3) stereotypic behaviour. This diagnosis was established in 23 (7.6%), and differences in psychopathology are basically determined by degree of intellectual resources, with the subgroup of Kanner's early childhood autism constituting the upper level.

The prevalence of psychiatric morbidity in mentally retarded adults

302 mentally retarded adults, sampled by epidemiological criteria, were examined with regard to handicaps, behaviour, skills and psychopathology by use of the MRC HBS-schedule and a list of psychiatric items. Based on research criteria, a computerized psychiatric diagnosis was made on a hierarchial scale. A psychiatric disorder was diagnosed in 85 (27.1%), which is a smaller prevalence rate than found in other studies. Next to behaviour disorder (10.9%), psychosis of uncertain type (5%) was the most common disorder. Dementia and early childhood autism were found equally often (3.6% each). Neurosis was seldom (2%), while schizophrenia (1.3%) and affective disorder (1.7%) occurred at about the same rates as found in similar investigations. No cases of alcohol or drug abuse were found.

Psychiatric illness among the mentally retarded. A swedish population study

Object--The aim of this investigation was in the first place to study the relation between mental retardation and other mental disturbances. The second aim was to study the frequency of severe and mild mental retardation in an adult Swedish population and to throw some light on the socio-medical situation of the adult mentally retarded. Methods--A primary sample, stratified with respect to population density, was extracted from the population in the age group 20-60 years, resident in Kopparberg County, Sweden, on 1 July 1977. The mildly and severely mentally retarded in this sample were identified. Enquiry was made into the presence of additional handicaps in the mentally retarded. Social conditions including alcohol consumption and the occurrence of abuse and criminality were studied in the two retarded groups and a control group representing the rest of the population. The three groups were compared by rating with the Comprehensive Psychopathological Rating Scale (CPRS), by classification of any mental illness present according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and by determining their intake of psychotropic drugs and anti-epileptics. The mildly mentally retarded and the control group were also compared with respect to neuroticism and extraversion-introversion by rating with the Eysenck Personality Inventory (EPI). Results--The study revealed a prevalence of 0.27% for severe (IQ less than 53) and 0.32% for mild (IQ 53-73.7) mental retardation in the age group 20-60 years. All the severely retarded, but only just over half the mildly retarded, were known to the care authority. The majority of the former were living in some form of institution, whereas this applied to only 15% of the mildly retarded. Nineteen per cent of the severely retarded and 4% of the mildly retarded had manifest epilepsy. Defects of movement and of hearing were most prominent among the mildly retarded, while the frequency of specific speech disturbances was greater among the severely retarded, approximately 10% of whom had no power of verbal communication. Visual defects were recorded in about one-third of both groups. The study showed that alcohol intake was lower among both the severely and mildly mentally retarded than among the persons in the control group and that the frequency of abuse and criminality was as high among persons of higher intelligence as among the mentally retarded. The severely retarded, particularly the men, showed a raised psychiatric morbidity as compared with the mildly retarded and the control group.(ABSTRACT TRUNCATED AT 400 WORDS)

Behaviour disturbance and mental handicap: typology and longitudinal trends

Behaviour disturbance was investigated in mentally handicapped adults who were living in hospital or at home. The first part of the study describes an empirically derived typology of disturbed behaviour patterns and gives the details of a scale by means of which behaviour disturbance can be quantified along six dimensions: aggression, mood disturbance, communicativeness, antisocial conduct, idiosyncratic mannerisms, and self-injury. The second part of the study used the scale in a longitudinal study of behavioural disturbance. Different forms of disturbed behaviour exhibited different kinds of longitudinal stability, and the long-term changes in one aspect of disturbance depended on subjects' other disturbance scores.

The natural history of behavioural symptoms among severely and profoundly mentally retarded patients

In a study of the evolution of behavioural symptoms in severely and profoundly mentally retarded adults in hospital over a period of six years, items of abnormal behaviour were found to be remarkably persistent. There is a high prevalence rate of psychiatric disorder in this population, when this disorder is defined in a widely descriptive sense. A substantially improved living environment, and increased staff-patient ratios, are prerequisites for improving disturbed behaviour in these patients.

'Addiction' to a strait jacket: a case report of treatment of self-injurious behaviour in an autistic child

A 14-year-old autistic girl presented with severe, chronic head-banging, some relief being obtained by restraint harnesses. Withdrawal of her straitjacket resulted in extreme SIB. Exhibition of fluphenazine relieved the condition.

The Eastern Ontario survey: a study of drug-treated psychiatric problems in the mentally handicapped

This study surveyed psychiatric problems treated with psychotropic medication among mentally handicapped at five regional centres in Eastern Ontario. Of the 2,158 residents studied, 920 (43%) were identified as problem cases, ranging from 36% to 83% in different institutions. Aggressivity, hyperactivity, and self-injury are the most prevalent conditions among more than thirty problem categories. Analysis of multidimensional contingency tables revealed that each of these three problems is involved with a distinct pattern of interactions with the set of demographic and clinical variables. The diversity of these interaction patterns points out the inadequacy of any unitary hypothesis of the pathogenesis and the inadvisability of adopting over-generalized treatment modalities. It is proposed that rational planning of service should rely on a realistic estimation of individuals' needs and a better understanding of the scope and nature of the problem.

Cluster analysis of symptoms in elderly demented patients

One hundred elderly patients with chronic organic brain syndromes were assessed by standard interviews, nursing ratings and from historical information. The data were subjected to cluster analysis and eight clusters were isolated. The significance of these clusters is discussed and other features of the patients reviewed.

A double-blind, placebo controlled, crossover trial of carbamazepine in overactive, severely mentally handicapped patients

A double-blind, placebo controlled, crossover trial of carbamazepine in 12 severely and profoundly mentally retarded, overactive adult patients is described. The trial lasted 7 months and those patients in whom overactivity was the dominant problem responded to some degree to carbamazepine with a reduction in overactivity. This was particularly so in patients in whom overactivity was accompanied by some elevation of mood. Patients in whom overactivity was part of a wider spectrum of multiple behaviour disorders showed a scatter of responses. There was no relationship between response to carbamazepine and the presence or absence of epilepsy. The trial identified a small group of mentally retarded patients in whom carbamazepine might be clinically useful.

Psychiatric disorders in mentally handicapped children: a clinical and follow-up study

The clinical psychiatric syndromes encountered in sixty mentally retarded children treated in a child psychiatric out-patient clinic setting are described. It was possible to classify these syndromes according to the multi-axial classification scheme for psychiatric disorders in childhood and adolescence. The children were followed-up for some years in many cases and the natural history of these disorders was in the main comparable to that of similar disorders in children of normal intelligence, although there was a tendency for some of the disorders to prove unusually persistent. Sometimes the persistence of these disorders seemed to be related to the children's continuing dependency needs arising from their mental retardation and to stresses within the family circle. The disorders responded reasonably satisfactorily to standard child psychiatric treatment techniques, and child psychiatric services should include the assessment and treatment of psychiatric disorders in mentally handicapped children within their remit.

Physiological and psychiatric investigations into a group of mentally handicapped subjects with self-injurious behaviour

Seventeen mentally handicapped patients with SIB (head banger) group are compared with a non-SIB group of similar grade and their behavioural and psychiatric ratings described. The recognition of a specific syndrome in SIB group is demonstrated and shown to lead to serious psychiatric disturbances. The importance of psychiatric diagnosis and treatment intervention among such a group is described.