Psychometric properties of the revised Developmental Behaviour Checklist scales in Dutch children with intellectual disability

Caregiver reported behavior, sleep and quality of life in children with Dravet syndrome: A population-based study

OBJECTIVE

The aim of this population-based study was to assess behavior, sleep, and quality of life, and explore factors associated with these in children with Dravet syndrome.

METHODS

The Developmental Behavior Checklist, the Insomnia Severity Index, and a global question regarding quality of life from the Epilepsy and Learning Disabilities Quality of Life scale were completed by primary caregivers of 42/48 Swedish children with Dravet syndrome, born 2000-2018. Factors associated with problems with insomnia, behavior and quality of life were analyzed using multivariable linear regression.

RESULTS

Scores indicating significant behavioral problems were seen in 29/40 (72 %) children, scores indicating moderate or severe clinical insomnia in 18/42 (43 %) and scores indicating poor or very poor quality of life in 7/41 (17 %). On multivariable analysis, autistic symptoms were significantly associated with behavioral problems (p = 0.013), side-effects of anti-seizure medications (ASMs) were associated with insomnia (p = 0.038), whilst insomnia was significantly associated with poor quality of life (p = 0.016).

SIGNIFICANCE

Dravet syndrome in children is associated with significant problems with behavior, sleep and quality of life. There is a need to optimize treatment via ASMs and develop and evaluate interventions to treat behavioral and sleep difficulties to optimize outcomes.

Clinical and cost-effectiveness of an adapted intervention for preschoolers with moderate to severe intellectual disabilities displaying behaviours that challenge: the EPICC-ID RCT

Background

Stepping Stones Triple P is an adapted intervention for parents of young children with developmental disabilities who display behaviours that challenge, aiming at teaching positive parenting techniques and promoting a positive parent-child relationship.

Objective

To evaluate the clinical and cost-effectiveness of level 4 Stepping Stones Triple P in reducing behaviours that challenge in children with moderate to severe intellectual disabilities.

Design, setting, participants

A parallel two-arm pragmatic multisite single-blind randomised controlled trial recruited a total of 261 dyads (parent and child). The children were aged 30-59 months and had moderate to severe intellectual disabilities. Participants were randomised, using a 3 : 2 allocation ratio, into the intervention arm (Stepping Stones Triple P; n = 155) or treatment as usual arm (n = 106). Participants were recruited from four study sites in Blackpool, North and South London and Newcastle.

Intervention

Level 4 Stepping Stones Triple P consists of six group sessions and three individual phone or face-to-face contacts over 9 weeks. These were changed to remote sessions after 16 March 2020 due to the coronavirus disease 2019 pandemic.

Main outcome measure

The primary outcome measure was the parent-reported Child Behaviour Checklist, which assesses the severity of behaviours that challenge.

Results

We found a small non-significant difference in the mean Child Behaviour Checklist scores (-4.23, 95% CI -9.98 to 1.52, p = 0.146) in the intervention arm compared to treatment as usual at 12 months. Per protocol and complier average causal effect sensitivity analyses, which took into consideration the number of sessions attended, showed the Child Behaviour Checklist mean score difference at 12 months was lower in the intervention arm by -10.77 (95% CI -19.12 to -2.42, p = 0.014) and -11.53 (95% CI -26.97 to 3.91, p = 0.143), respectively. The Child Behaviour Checklist mean score difference between participants who were recruited before and after the coronavirus disease 2019 pandemic was estimated as -7.12 (95% CI -13.44 to -0.81) and 7.61 (95% CI -5.43 to 20.64), respectively (p = 0.046), suggesting that any effect pre-pandemic may have reversed during the pandemic. There were no differences in all secondary measures. Stepping Stones Triple P is probably value for money to deliver (-£1057.88; 95% CI -£3218.6 to -£46.67), but decisions to roll this out as an alternative to existing parenting interventions or treatment as usual may be dependent on policymaker willingness to invest in early interventions to reduce behaviours that challenge. Parents reported the intervention boosted their confidence and skills, and the group format enabled them to learn from others and benefit from peer support. There were 20 serious adverse events reported during the study, but none were associated with the intervention.

Limitations

There were low attendance rates in the Stepping Stones Triple P arm, as well as the coronavirus disease 2019-related challenges with recruitment and delivery of the intervention.

Conclusions

Level 4 Stepping Stones Triple P did not reduce early onset behaviours that challenge in very young children with moderate to severe intellectual disabilities. However, there was an effect on child behaviours for those who received a sufficient dose of the intervention. There is a high probability of Stepping Stones Triple P being at least cost neutral and therefore worth considering as an early therapeutic option given the long-term consequences of behaviours that challenge on people and their social networks.

Future work

Further research should investigate the implementation of parenting groups for behaviours that challenge in this population, as well as the optimal mode of delivery to maximise engagement and subsequent outcomes.

Study registration

This study is registered as NCT03086876 (https://www.clinicaltrials.gov/ct2/show/NCT03086876?term=Hassiotis±Angela&draw=1&rank=1).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: HTA 15/162/02) and is published in full in Health Technology Assessment; Vol. 28, No. 6. See the NIHR Funding and Awards website for further award information.

General Measurement Tools for Assessing Mental Health Problems Among Children and Adolescents with an Intellectual Disability: A Systematic Review

There is a need for more knowledge of valid and standardized measures of mental health problems among children and adolescents with intellectual disability (ID). In this study, we systematically reviewed and evaluated the psychometric properties of instruments used to assess general mental health problems in this population. Following PRISMA guidelines, we reviewed empirical research published from 1980 through February 2020 with an updated search in March 2021 in Medline, Embase, PsycINFO, Health and Psychological Instruments, CINAHL, ERIC, and Web of Science databases. Forty-nine empirical articles were included in this review. Overall, the review indicated consistently better documentation of the reliability and validity of instruments designed for the ID population compared to instruments developed for the general child population.

An evaluation of the German teacher version of the Developmental Behaviour Checklist in children and adolescents with intellectual disability

BACKGROUND

The Developmental Behaviour Checklist (DBC) is an established, internationally used questionnaire for assessing behavioural and emotional problems among young people with developmental or intellectual disabilities (ID). The present study aims to evaluate the psychometric properties of its German teacher version (DBC-T).

METHOD

The German DBC-T was administered to 397 school staff members who reported twice on 1177 children and adolescents with ID over a period of 7-9 months. Data were analysed within an exploratory structural equation modelling framework.

RESULTS

Our results supported the five-factor structure of the DBC-T and found good reliability for all scales. Analyses on the relationship of DBC-T scores with students' age, gender, and adaptive behaviour provided further evidence for the validity of the DBC-T.

CONCLUSIONS

Our study endorses the notion that the German DBC-T is an important instrument both for research and practice. Limitations and further directions are discussed.

Using a Delphi Process to Update the Nisonger Child Behavior Rating Form

The Nisonger Child Behavior Rating Form (NCBRF) was developed to specifically screen psychopathology and problem behavior in children and adolescents with IDD. This study aimed to update the NCBRF to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and screen for the most prevalent psychopathologies that affect children and adolescents with IDD. The authors re-aligned the existing items to fit within a DSM-5 framework, and then used the Delphi method with a panel of experts in IDD to evaluate the NCBRF items. The revision process included deleting and revising existing items and formulating new items. We obtained a final item pool after three iterations. The Delphi process and resulting item pool are described in this article.

Age-related changes in behavioural and emotional problems in Smith-Magenis syndrome measured with the Developmental Behavior Checklist

Smith-Magenis syndrome (SMS) is a genetic syndrome most often caused by a deletion on chromosome 17 or more rarely by a mutation in the retinoic acid-induced 1 gene. The aim of this study was to investigate the Developmental Behavior Checklist (DBC) profile of persons with SMS and the associations between behavioural and emotional problems, age, gender, adaptive behaviour and autism symptomatology. Twenty-eight persons with SMS were represented by their parents in this study. DBC Total scores are reduced with age, but they still show a mean that is clearly above the cut-off of 46. The differences between the age groups <9 years and 9-17 years (p = 0.024) and between the age groups <9 years and >18 years (p = 0.007) are significant. We found a significant decrease in behavioural and emotional problems with age in SMS. We did not find a relationship between adapted behaviour and communication and behavioural and emotional problems.

Prevalence estimates of mental health problems in children and adolescents with intellectual disability: A systematic review and meta-analysis

BACKGROUND

Children and adolescents with intellectual disability are at risk of developing psychiatric symptoms and disorders; yet, the estimates reported in the literature have been inconsistent, presenting a potential barrier for service planning and delivery. Sources of variability could arise from differences in measurement instruments as well as subgroup membership by severity of intellectual disability, gender and age. This systematic review aimed to address these gaps.

METHOD

MEDLINE and PsycINFO databases were searched from inception to 2018 and selected studies were reviewed. Studies were included if they reported point prevalence estimates of mental health symptomology or diagnoses in a general population of 6- to 21-year-old individuals with intellectual disability. The Joanna Briggs Institute Prevalence Critical Appraisal Checklist was applied to eligible papers to appraise their scientific strength. Pooled prevalence for mental health symptomology was determined using a random-effects meta-analysis.

RESULTS

A total of 19 studies were included, including 6151 children and adolescents. The pooled prevalence estimate captured by the Developmental Behaviour Checklist was 38% (95% confidence interval = [31, 46]), contrasting with 49% (95% confidence interval = [46, 51]) captured by the Child Behaviour Checklist; both rates were higher than a non-intellectual disability population. Severity of intellectual disability did not significantly influence the Developmental Behaviour Checklist risks. Insufficient data were available to conduct statistical analyses on the effects of age, gender and socioeconomic status. Of diagnosed psychiatric disorders, attention deficit/hyperactivity disorder (30%), conduct disorder (3-21%) and anxiety disorders (7-34%) were the most prevalent conditions.

CONCLUSION

This review consists of the largest sample hitherto evaluated. In the intellectual disability population, mental health comorbidities could be better detected by a symptom phenotype than a psychiatric diagnostic phenotype. Crucially, future research needs to address the effect of measurement validity in the intellectual disability population. Estimated prevalence rates were high compared to the general population, indicating the importance of systematic screening, case detection and appropriate management.

Clinical and cost effectiveness of a parent mediated intervention to reduce challenging behaviour in pre-schoolers with moderate to severe intellectual disability (EPICC-ID) study protocol: a multi-centre, parallel-group randomised controlled trial

BACKGROUND

Children with intellectual disabilities are likely to present with challenging behaviour. Parent mediated interventions have shown utility in influencing child behaviour, although there is a paucity of UK research into challenging behaviour interventions in this population. NICE guidelines favour Stepping Stones Triple P (SSTP) as a challenging behaviour intervention and this trial aims to evaluate its clinical and cost effectiveness in preschool children with moderate to severe intellectual disabilities.

METHODS

This trial launched in 2017 at four sites across England, with the aim of recruiting 258 participants (aged 30-59 months). The Intervention Group receive nine weeks of SSTP parenting therapy (six group sessions and three individualised face to face or telephone sessions) in addition to Treatment as Usual, whilst the Treatment as Usual only group receive other available services in each location. Both study groups undergo the study measurements at baseline and at four and twelve months. Outcome measures include parent reports and structured observations of behaviour. Service use and health related quality of life data will also be collected to carry out a cost effectiveness and utility evaluation.

DISCUSSION

Findings from this study will inform policy regarding interventions for challenging behaviour in young children with moderate to severe intellectual disabilities.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov, NCT03086876. Registered 22nd March 2017, https://clinicaltrials.gov/ct2/show/NCT03086876.

Pharmacological and non-pharmacological interventions for non-respiratory sleep disturbance in children with neurodisabilities: a systematic review

BACKGROUND

There is uncertainty about the most appropriate ways to manage non-respiratory sleep disturbances in children with neurodisabilities (NDs).

OBJECTIVE

To assess the clinical effectiveness and safety of NHS-relevant pharmacological and non-pharmacological interventions to manage sleep disturbance in children and young people with NDs, who have non-respiratory sleep disturbance.

DATA SOURCES

Sixteen databases, including The Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE, were searched up to February 2017, and grey literature searches and hand-searches were conducted.

REVIEW METHODS

For pharmacological interventions, only randomised controlled trials (RCTs) were included. For non-pharmacological interventions, RCTs, non-randomised controlled studies and before-and-after studies were included. Data were extracted and quality assessed by two researchers. Meta-analysis and narrative synthesis were undertaken. Data on parents' and children's experiences of receiving a sleep disturbance intervention were collated into themes and reported narratively.

RESULTS

Thirty-nine studies were included. Sample sizes ranged from 5 to 244 participants. Thirteen RCTs evaluated oral melatonin. Twenty-six studies (12 RCTs and 14 before-and-after studies) evaluated non-pharmacological interventions, including comprehensive parent-directed tailored (n = 9) and non-tailored (n = 8) interventions, non-comprehensive parent-directed interventions (n = 2) and other non-pharmacological interventions (n = 7). All but one study were reported as having a high or unclear risk of bias, and studies were generally poorly reported. There was a statistically significant increase in diary-reported total sleep time (TST), which was the most commonly reported outcome for melatonin compared with placebo [pooled mean difference 29.6 minutes, 95% confidence interval (CI) 6.9 to 52.4 minutes; p = 0.01]; however, statistical heterogeneity was extremely high (97%). For the single melatonin study that was rated as having a low risk of bias, the mean increase in TST was 13.2 minutes and the lower CI included the possibility of reduced sleep time (95% CI -13.3 to 39.7 minutes). There was mixed evidence about the clinical effectiveness of the non-pharmacological interventions. Sixteen studies included interventions that investigated the feasibility, acceptability and/or parent or clinician views of sleep disturbance interventions. The majority of these studies reported the 'family experience' of non-pharmacological interventions.

LIMITATIONS

Planned subgroup analysis was possible in only a small number of melatonin trials.

CONCLUSIONS

There is some evidence of benefit for melatonin compared with placebo, but the degree of benefit is uncertain. There are various types of non-pharmacological interventions for managing sleep disturbance; however, clinical and methodological heterogeneity, few RCTs, a lack of standardised outcome measures and risk of bias means that it is not possible to draw conclusions with regard to their effectiveness. Future work should include the development of a core outcome, further evaluation of the clinical effectiveness and cost-effectiveness of pharmacological and non-pharmacological interventions and research exploring the prevention of, and methods for identifying, sleep disturbance. Research mapping current practices and exploring families' understanding of sleep disturbance and their experiences of obtaining help may facilitate service provision development.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016034067.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Training staff to promote self-management in people with intellectual disabilities

BACKGROUND

People with intellectual disabilities have increasing difficulties managing their daily affairs. This study examined the effectiveness of a staff training, which teaches staff to promote self-management in people with intellectual disabilities.

METHOD

Effectiveness was assessed with questionnaires addressing clients' (n = 26) independence and self-reliance, support needs and challenging behaviour, using a pre-posttest control group design. Additionally, focus groups were conducted with trained staff members 6 months after the training.

RESULTS

In the long term, the intervention group showed a significant increase in independence and self-reliance, in contrast to the comparison group. No effect was found on support needs and challenging behaviour. Trained staff members reported limited benefits of the training, but had noticed changes in their attitude and method of working afterwards.

CONCLUSIONS

Further self-management research is required to investigate how independence and self-reliance can be promoted more effectively in this population. Future trainings should carefully consider their content, format, and implementation.

Impact of Attention Training on Academic Achievement, Executive Functioning, and Behavior: A Randomized Controlled Trial

Children with intellectual and developmental disabilities (IDD) experience significant difficulties in attention, learning, executive functions, and behavioral regulation. Emerging evidence suggests that computerized cognitive training may remediate these impairments. In a double blind controlled trial, 76 children with IDD (4-11 years) were randomized to either an attention training (n = 38) or control program (n = 38). Both programs were completed at home over a 5-week period. Outcome measures assessed literacy, numeracy, executive functioning, and behavioral/emotional problems, and were conducted at baseline, post-training, and 3-month follow-up. No training effects were observed at post-training; however, children in the training group showed greater improvements in numeracy skills at the 3-month follow-up. These results suggest that attention training may be beneficial for children with IDD; however, the modest nature of the intervention effects indicate that caution should be taken when interpreting clinical significance.

Parent and Teacher Concordance on the Social Responsiveness Scale for Children with Autism

There are inconsistent findings regarding parent and teacher agreement on behavioral ratings of their children with autism. One possible reason for this inconsistency is that studies have not taken autism severity into account. This study examined parent and teacher concordance of social behavior based on symptom severity for children with autism. Participants were 123 parent-teacher dyads who completed the Social Responsiveness Scale. Symptom severity was assessed using the Autism Diagnostic Observation Schedule (ADOS). Results indicated that parent and teacher ratings were statistically significantly correlated at the beginning and end of the academic year, but only for severely affected children. Teacher report of social deficits was correlated with symptom severity as measured by the ADOS; parent report was not. These findings have implications for improving assessment procedures and parent-teacher collaboration.

Informant agreement for youth with autism spectrum disorder or intellectual disability: a meta-analysis

This study investigated informant agreement on emotional and behavior problems and social skills in youth with autism spectrum disorder or intellectual disability using meta-analytic methods. Forty-nine studies were included, consisting of 107 effect sizes. The mean weighted effect size across all raters and all behaviors was .36, reflecting moderate agreement. Consistent with meta-analyses in typically developing youth, pairs of similar informants (e.g., parent-parent) demonstrated higher agreement compared to pairs of different raters (e.g., parent-teacher). With all rater pairs combined, agreement was significantly higher for externalizing problems (r = .42) than either internalizing problems (r = .35) or social skills (r = .30). Several factors appear to moderate the level of agreement among informants, including the youth's diagnosis, age, and IQ.

Anxiety disorders in children and adolescents with intellectual disability: Prevalence and assessment

Children and adolescents with intellectual disability are known to experience mental health disorders, but anxiety disorders in this population have received relatively little attention. Firstly, this paper provides a review of published studies reporting prevalence rates of anxiety disorders in children and adolescents with intellectual disability. Secondly, the paper reviews measures of anxiety that have been evaluated in children/adolescents with intellectual disability, and details the associated psychometric properties. Seven studies reporting prevalence rates of anxiety disorders in this population were identified, with reported rates varying from 3% to 22%. Two-one studies evaluating a measure of anxiety in a sample of children/adolescents with intellectual disability were identified. While these studies indicate that several measures show promise, further evaluation studies are needed; particularly those that evaluate the capacity of measures to screen for anxiety disorders, not only measure symptoms.

Coping, daily hassles and behavior and emotional problems in adolescents with high-functioning autism/Asperger's Disorder

Although daily hassles and coping are associated with behavior and emotional problems in non-clinical populations, few studies have investigated these relationships in individuals with high-functioning autism/Asperger's Disorder (HFASD). This study examined the relationships between daily hassles, coping and behavior and emotional problems in adolescents with HFASD. Thirty-one adolescents with HFASD completed questionnaires assessing their coping and behavior and emotional problems, and completed an Ecological Momentary Assessment run via a mobile phone application on their coping and daily hassles. Parents completed questionnaires of the adolescents' daily hassles, coping, and behavior and emotional problems. The disengagement coping style was associated with significantly higher levels of behavior and emotional problems regardless of respondent or methodology, suggesting it may be a valuable target for intervention.

Predicting health utilities for children with autism spectrum disorders

Comparative effectiveness of interventions for children with autism spectrum disorders (ASDs) that incorporates costs is lacking due to the scarcity of information on health utility scores or preference-weighted outcomes typically used for calculating quality-adjusted life years (QALYs). This study created algorithms for mapping clinical and behavioral measures for children with ASDs to health utility scores. The algorithms could be useful for estimating the value of different interventions and treatments used in the care of children with ASDs. Participants were recruited from two Autism Treatment Network sites. Health utility data based on the Health Utilities Index Mark 3 (HUI3) for the child were obtained from the primary caregiver (proxy-reported) through a survey (N = 224). During the initial clinic visit, proxy-reported measures of the Child Behavior Checklist, Vineland II Adaptive Behavior Scales, and the Pediatric Quality of Life Inventory 4.0 (start measures) were obtained and then merged with the survey data. Nine mapping algorithms were developed using the HUI3 scores as dependent variables in ordinary least squares regressions along with the start measures, the Autism Diagnostic Observation Schedule, to measure severity, child age, and cognitive ability as independent predictors. In-sample cross-validation was conducted to evaluate predictive accuracy. Multiple imputation techniques were used for missing data. The average age for children with ASDs in this study was 8.4 (standard deviation = 3.5) years. Almost half of the children (47%) had cognitive impairment (IQ ≤ 70). Total scores for all of the outcome measures were significantly associated with the HUI3 score. The algorithms can be applied to clinical studies containing start measures of children with ASDs to predict QALYs gained from interventions.

Outcomes in young adulthood: are we achieving community participation and inclusion?

BACKGROUND

Despite recognition of the importance of integrated community living and support, there is evidence that parents remain the primary caregivers of young adults with intellectual disability (ID). In addition, employment rates remain low in this population. This study aimed to investigate the changes in living arrangements and participation in daytime activities over time in a community population of young people with ID.

METHOD

The sample consisted of 536 participants aged 4.0-18.9 years at Wave 1, followed up at Wave 5 when aged 20.5-37.6 years. Information was collected on their living arrangements and daytime activities at both time points, along with living skills and information on community social inclusion at Wave 5. For parents still caring for their adult child with ID, information was also collected on parental ratings of their own mental and physical health, and their satisfaction with the long-term care arrangements for their adult child.

RESULTS

A significant proportion of young people were still living with their parents at Wave 5. A greater proportion of those with a severe-profound degree of ID were living in residential care. Parents caring for their adult child reported high levels of mental health problems and dissatisfaction with the long-term care arrangements for their child. A small proportion of young people were in paid employment, and the majority was engaged in structured activities provided for those with an ID. Over one-third of the sample participated in a structured daytime activity for 10 or fewer hours per week, and 7% were not engaged in any structured daytime activity.

CONCLUSIONS

These results suggest that adequate provision of accommodation and employment services for young adults with an ID is lacking. In many cases the responsibility of care continues to reside with parents as their children transition from childhood to adulthood. Greater attention is needed to address these issues and facilitate social inclusion and integration for young people with ID.

Psychometric properties of a Dutch version of the behavior problems inventory-01 (BPI-01)

There are only a limited number of Dutch validated measurement instruments for measuring behavioral problems in people with a moderate to profound intellectual disability. In this study, the psychometric properties of a Dutch version of the behavior Problems Inventory-01 (BPI-01; Rojahn et al., 2001) have been investigated among 195 people with a moderate to profound intellectual disability who live in a residential facility. The BPI-01 was completed by 42 informants (staff members) of 23 care units. The inter-rater reliability, intra-rater reliability and internal consistency turned out to be good. Factor analysis confirmed two of the three a priori factors and the third factor was a mix of self-injurious (SIB) behavior and stereotypic behavior. The BPI-01 was compared to the Aberrant Behavior Checklist (Aman et al., 1985a) and showed a good convergent validity. This study shows that a Dutch version of the BPI-01 has good psychometric properties for measuring behavior problems in individuals with moderate to profound intellectual disability.

Development, cognition, and behaviour in Pitt-Hopkins syndrome

AIM

The aim of the study was to collect detailed data on behavioural, adaptive, and psychological functioning in 10 individuals with Pitt-Hopkins syndrome (PTHS), with specific attention to manifestations of autism spectrum disorder (ASD).

METHOD

The participants (four females, six males), residing in the Netherlands and Belgium, were ascertained through the Dutch national PTHS support group. Median age of participants was 10 years, the age range was between 32 and 289 months. They underwent psychiatric examinations and neuropsychological measurements using a comprehensive assessment battery. Additionally, parental information was gathered through standardized interviews and questionnaires. Findings were compared with those from the literature.

RESULTS

All participants showed profound intellectual disability, amiable demeanour with minimal maladaptive behaviours, severe impairments of communication and language, and intense, frequent motor stereotypies. Impairments in all participants were beyond what would be expected for cognitive abilities, fitting a classification of ASD.

INTERPRETATION

Patients with PTHS are characterized not only by specific physical and genetic manifestations but also by specific behavioural and cognitive characteristics. Studying behaviour and cognition may improve diagnosis and prognosis, allows recognition of comorbidities, and contributes to adequate counselling of families.

Behavioral problems in children with motor and intellectual disabilities: prevalence and associations with maladaptive personality and marital relationship

Prevalence rates of behavioral problems in children with motor disabilities are commonly based on questionnaires developed for a general population (e.g., Child Behavior CheckList). These questionnaires do not take into account lower levels of intellectual functioning. The first aim of this study was to examine the prevalence of parent-reported and daily caretaker-reported behavioral problems in children with motor and intellectual disabilities (MID) using the Developmental Behavior Checklist. Second, we investigated whether behavioral problems were related to sex and age. Our third and fourth aim were to determine whether behavioral problems are related to maladaptive personality traits and to marital stress and conflict. Participants were 101 Flemish children with MID (mean age=14 years 6 months). For total behavioral problems, we found prevalence rates of 18% and 8% based on parent and daily caretaker reports, respectively. Based on parent reports, twenty seven percent of the children with MID exhibited anxiety problems. Behavioral problems were not related to sex. Older children showed fewer behavioral problems than younger children. Multiple hierarchical regression analyses revealed that lower scores on Compulsivity and higher scores on Emotional Instability and Disagreeableness were related to behavioral problems. In addition to personality traits, stress and conflict in the marital relationship was also positively associated with behavioral problems. Given the importance of behavioral problems in children with MID, this study is of theoretical and clinical interest and has the potential to inform targeted clinical interventions.

Trajectory of behavior and emotional problems in autism

High rates of behavior and emotional problems have been consistently reported in children and adolescents with autism. Elevated rates of mental health problems have also been reported in adults with autism. Little is known, however, about the longitudinal development of behavior and emotional problems in autism. This study followed a cohort of children and adolescents over 18 years. Outcomes were evaluated in terms of behavior and emotional problems and autism symptomatology. The role of childhood factors (age, gender, IQ, behavior, and emotional problems) and the environment (socioeconomic disadvantage) were considered in terms of adult outcomes. Overall, improvements in comorbid behavior and emotional problems and autism symptomatology were observed. However, rates of comorbid behavior and emotional problems in adulthood remained high.

Scaling methods to measure psychopathology in persons with intellectual disabilities

Psychopathology prior to the last four decades was generally viewed as a set of problems and disorders that did not occur in persons with intellectual disabilities (ID). That notion now seems very antiquated. In no small part, a revolutionary development of scales worldwide has occurred for the assessment of emotional problems in persons with ID. The first standardized test to emerge was the Psychopathology Instrument for Mentally Retarded Adults (PIMRA) in 1984. Since that time, an impressive number of measures of general psychopathology have emerged for adults and children as well as for persons across the full range of levels of ID. The purpose of this review was to provide a description of available measures, to review papers published on these measures, and to discuss emerging trends in test development. The trends in this body of information for enhancing differential diagnosis of psychopathology in persons with ID are discussed.

Challenging behaviors among children with autism spectrum disorders and multiple disabilities attending special schools in Singapore

This study sought to understand the profile of and the factors which impact upon challenging behaviors among children with autism spectrum disorders (ASD) and multiple disabilities (MD). Teachers of 322 and 132 children with ASD and MD, respectively, attending special schools in Singapore, completed the Developmental Behavior Checklist, Teacher Version (DBC-T; Einfeld & Tonge, 1995). The findings suggest that children with ASD exhibit elevated levels of challenging behavior in all areas, relative to children with MD. Multiple regression analyses also indicate that diagnostic category was associated with all aspects of challenging behavior measured by the DBC-T. In addition, age was associated with only disruptive/antisocial behaviors in this study. Theoretical and practical implications were discussed.

The longitudinal relationship between behavior and emotional disturbance in young people with intellectual disability and maternal mental health

Although elevated rates of parent psychosocial distress have been associated with child behavior and emotional problems, little is known about the nature of this relationship over time. This study followed an epidemiological cohort of children and adolescents over 11 years with 4 waves of data collection. Within this cohort, complete data were available on 238 mothers and their children. Behavior and emotional problems were assessed using the DBC, maternal mental health with the GHQ. Multivariate growth curve modelling was used to evaluate the commonality of individual change patterns. High levels of mental health problems were reported, which were stable over time. Higher scores on the DBC were associated with higher rates of mental health problems. Increases in child social relating problems were associated with increases mental health symptoms, particularly depression and anxiety.

Behavioural and emotional problems in people with severe and profound intellectual disability

BACKGROUND

People with severe and profound levels of intellectual disability (ID) are frequently examined as a single group in research. However, these two groups may be significantly different, particularly in the area of emotional and behavioural difficulties.

METHOD

The Developmental Behaviour Checklist (DBC) was completed by parents and caregivers of 107 people with severe ID and 22 people with profound ID at four time periods across 12 years. Regression analyses were used to examine trends in sub-scale scores across time and groups.

RESULTS

Significant differences between the groups of people with severe and profound ID were found. People with profound ID had significantly lower scores across all sub-scales except Social Relating. This was usually related to fewer items being selected as present for people with profound ID, as opposed to the scores being attributable to lower item severity scores.

CONCLUSIONS

There are significant differences between groups of people with severe and profound ID in scores on the DBC, indicating differences in behavioural and emotional problems. Caution should be exercised by researchers treating these two disparate groups as a single group, and by practitioners translating such findings into practice.

Health-Related Quality of Life in children with autism spectrum disorders: results from the autism treatment network

We examined data collected as a part of the Autism Treatment Network, a group of 15 autism centers across the United States and Canada. Mean Health-Related Quality of Life (HRQoL) scores of the 286 children assessed were significantly lower than those of healthy populations (according to published norms). When compared to normative data from children with chronic conditions, children with ASD demonstrated worse HRQoL for total, psychosocial, emotional and social functioning, but did not demonstrate differing scores for physical and school functioning. HRQoL was not consistently related to ASD diagnosis or intellectual ability. However, it was consistently related to internalizing and externalizing problems as well as repetitive behaviors, social responsiveness, and adaptive behaviors. Associations among HRQoL and behavioral characteristics suggest that treatments aimed at improvements in these behaviors may improve HRQoL.

Effekte des Stepping Stones Elterngruppentrainings für Familien mit behinderten Kindern

Stepping Stones Triple P wurde als verhaltenstherapeutisch orientiertes Elterngruppentraining bereits in Australien erfolgreich evaluiert. Im Rahmen einer Multicenterstudie in verschiedenen Sozialpädiatrischen Zentren (SPZ) und weiterer Versorgungseinrichtungen wurde Stepping Stones Triple P als Elterngruppentraining eingeführt und auf seine Wirksamkeit im deutschen Sprachraum überprüft. Unsere Daten zeigen eine signifikante Reduktion dysfunktionalen Erziehungsverhaltens, elterlicher Belastungen und kindlicher Verhaltensprobleme. Die vorliegende Analyse zeigt, dass ungünstige psychosoziale Belastungen den Therapieerfolg stark reduzieren. Gute bzw. eingeschränkte elterlicher Mitarbeit beeinflussen dagegen den Therapieerfolg nur leicht.

Correlated and coupled within-person change in emotional and behavioral disturbance in individuals with intellectual disability

Individual change and variation in emotional/behavioral disturbance in children and adolescents with intellectual disability has received little empirical investigation. Based on 11 years of longitudinal data from the Australian Child to Adult Development Study, we report associations among individual differences in level, rate of change, and occasion-specific variation across subscales of the Developmental Behavior Checklist (DBC) with 506 participants who had intellectual disability and were ages 5 to 19 years at study entry. Correlations among the five DBC subscales ranged from .43 to .66 for level, .43 to .88 for rate of change, and .31 to .61 for occasion-specific variation, with the highest correlations observed consistently between disruptive, self-absorbed, and communication disturbance behaviors. These interdependencies among dimensions of emotional/behavioral disturbance provide insight into the developmental dynamics of psychopathology from childhood through young adulthood.

Does visual impairment lead to additional disability in adults with intellectual disabilities?

BACKGROUND

This study addresses the question to what extent visual impairment leads to additional disability in adults with intellectual disabilities (ID).

METHOD

In a multi-centre cross-sectional study of 269 adults with mild to profound ID, social and behavioural functioning was assessed with observant-based questionnaires, prior to expert assessment of visual function. With linear regression analysis the percentage of variance, explained by levels of visual function, was calculated for the total population and per ID level.

RESULTS

A total of 107/269 participants were visually impaired or blind (WHO criteria). On top of the decrease by ID visual impairment significantly decreased daily living skills, communication & language, recognition/communication. Visual impairment did not cause more self-absorbed and withdrawn behaviour or anxiety. Peculiar looking habits correlated with visual impairment and not with ID. In the groups with moderate and severe ID this effect seems stronger than in the group with profound ID.

CONCLUSION

Although ID alone impairs daily functioning, visual impairment diminishes the daily functioning even more. Timely detection and treatment or rehabilitation of visual impairment may positively influence daily functioning, language development, initiative and persistence, social skills, communication skills and insecure movement.

Developmental course of psychopathology in youths with and without intellectual disabilities

BACKGROUND

We aimed to describe similarities and differences in the developmental course of psychopathology between children with and without intellectual disabilities (ID).

METHODS

Multilevel growth curve analysis was used to analyse the developmental course of psychopathology, using the Child Behavior Checklist (CBCL), in two longitudinal multiple-birth-cohort samples of 6- to 18-year-old children with ID (N = 978) and without ID (N = 2,047) using three repeated measurements across a 6-year period.

RESULTS

Children with ID showed a higher level of problem behaviours across all ages compared to children without ID. A significant difference between the samples in the developmental courses was found for Aggressive Behaviour and Attention Problems, where children with ID showed a significantly larger decrease. Gender differences in the development of psychopathology were similar in both samples, except for Social Problems where males with ID showed a larger decrease in problem behaviour across time than females with ID and males and females without ID.

CONCLUSIONS

Results indicate that children with ID continue to show a greater risk for psychopathology compared to typically developing children, although this higher risk is less pronounced at age 18 than it is at age 6 for Aggressive Behaviour. Contrary to our expectations, the developmental course of psychopathology in children with ID was quite similar from age 6 to 18 compared to children without ID. The normative developmental trajectories of psychopathology in children with ID, presented here, can serve as a yardstick against which development of childhood psychopathology can be detected as deviant.

Pervasive developmental disorder, behavior problems, and psychotropic drug use in children and adolescents with mental retardation

OBJECTIVE

This study investigated the interrelationship between psychopharmacotherapy in general and the use of specific psychotropic drugs and pervasive developmental disorder and other behavior problems in children and adolescents with mental retardation.

METHODS

A total of 862 participants 4 to 18 years of age, including all levels of mental retardation, were recruited through facilities for children with mental retardation in Friesland, The Netherlands. Information on medication was collected through parent interviews. Behavior problems were investigated with a standardized parent questionnaire (Developmental Behavior Checklist). A pervasive developmental disorder classification was based on the Pervasive Developmental Disorder in Mental Retardation Scale, completed by psychologists or teachers. Logistic regression analysis was used to investigate the relationship between the use of psychotropic drugs and pervasive developmental disorder and other behavioral problems, in the presence of possible confounders.

RESULTS

One of 10 participants used psychotropic medication. The main factors associated with psychotropic drug use were pervasive developmental disorder and disruptive behavior. The level of functioning was also associated. Self-absorbed behavior was statistically significantly associated with clonidine use and disruptive behavior with stimulant use. Pervasive developmental disorder and communication problems were the main factors associated with the use of antipsychotic drugs. Age also played a role, whereas gender, living situation, and level of mental retardation did not.

CONCLUSIONS

Antipsychotic drugs were associated with pervasive developmental disorder, whereas clonidine and stimulants were associated with self-absorbed and disruptive behavior, respectively. Although clonidine and risperidone are not registered for the problems reported and the other nonstimulants were only sometimes used on-label, their use was associated with specific psychiatric or behavioral problems.

Systems analysis of stress and positive perceptions in mothers and fathers of pre-school children with autism

Systemic analyses of psychological functioning in families of children with autism have typically shown that parents report different experiences (e.g., stress) and that siblings may also be affected. The purpose of the present research was more explicitly to address relationships between child, partner, and parent variables. Parents of 48 children with autism (41 mother-father pairs) reported on child characteristics, and their own stress and mental health. Mothers were found to report both more depression and more positive perceptions than fathers. Regression analyses revealed that paternal stress and positive perceptions were predicted by maternal depression; maternal stress was predicted by their children's behavior problems (not adaptive behavior or autism symptoms) and by their partner's depression. The future testing of the mechanisms underlying these results is discussed. In addition, the need is emphasized for more systemic analyses to understand the psychological functioning of children with autism and their siblings and parents.

Genotype-phenotype correlations of 39 patients with Cornelia De Lange syndrome: the Dutch experience

BACKGROUND

Cornelia de Lange syndrome (CdLS) is a multiple congenital anomaly syndrome characterised by a distinctive facial appearance, prenatal and postnatal growth deficiency, psychomotor delay, behavioural problems, and malformations of the upper extremities. Recently mutations in NIPBL, the human homologue of the Drosophila Nipped-B gene, were found to cause CdLS. Mutations have been found in 39% of reported cases.

METHODS

Patients were enrolled in the study and classified into one of four groups based on clinical examination: classic, mild, possible, or definitively not CdLS. Three dimensional photography was taken of 20 subjects, and compared between groups. Behaviour was assessed with specific attention to autism. We searched for mutations in NIPBL and correlated genotype with phenotype.

RESULTS

: We found mutations in 56% of cases.

CONCLUSIONS

Truncating mutations were generally found to cause a more severe phenotype but this correlation was not absolute. Three dimensional facial imaging demonstrated the potential for classifying facial features. Behavioural problems were highly correlated with the level of adaptive functioning, and also included autism. No correlation of behaviour with the type of mutation was found.

Der Verhaltensfragebogen bei Entwicklungsstörungen (VFE)

Zusammenfassung. Hintergrund: Im deutschsprachigen Bereich besteht ein signifikantes Defizit an Verhaltensfragebögen zur Diagnostik bei Kindern mit schweren Entwicklungsstörungen, speziell geistiger Behinderung. Fragestellung: Die aus Australien stammende Developmental Behaviour Checklist (DBC) ist ein in der Verhaltensdiagnostik bei Kindern und Jugendlichen mit schweren Entwicklungsstörungen international breit eingesetzter Fragebogen zur Erfassung von Problemen des Verhaltens und der Emotionen. Die DBC wurde als Verhaltensfragebogen bei Entwicklungsstörungen (VFE) übersetzt und anhand der Daten einer umfangreiche Stichprobe von N = 721 Kindern und Jugendlichen mit geistiger Behinderung in Deutschland hinsichtlich ihrer psychometrischen Eigenschaften überprüft. Methode: Die psychometrischen Analysen umfassten verschiedene Analysen zur Validität und Reliabilität. Für die Normierung wurden Effekte von Alter, Geschlecht und Behinderungsgrad überprüft. Ergebnisse: Die fünf Faktoren der DBC konnten für den VFE repliziert werden. Neben der faktoriellen konnte auch die diskriminante und die kriteriumsbezogene Validität nachgewiesen werden. Die internen Konsistenzen waren für vier der fünf Subskalen gut bis sehr gut. Die Retest-Reliablität war nach einem beträchtlichen Intervall von 1.8 Jahren sehr hoch. Die Normierung berücksichtigt den Grad der Behinderung. Schlussfolgerungen: Mit der VFE in Übersetzung der DBC liegt ein sorgfältig konstruiertes Verhaltensinventar für Kinder und Jugendliche mit schweren Entwicklungsstörungen vor, das angemessene psychometrische Kennwerte aufweist und über deutsche Normwerte verfügt.

Symptoms of ADHD and their correlates in children with intellectual disabilities

Existing research suggests that children with intellectual disabilities are at increased risk for ADHD, and that the symptoms of the disorder might successfully be treated with stimulant drugs. However, there has been little exploration of ADHD symptoms and their correlates in children with intellectual disabilities. Analyses of three samples of children with intellectual disabilities are presented (total N=338). Correlational analyses showed that younger children, and those with a diagnosis of Autism were rated as having more ADHD/hyperactivity symptoms. There was little evidence of a sex difference, and no strong associations with domains of adaptive behavior (socialization, communication, and daily living skills). However, there was a small but significant negative association between mental age and ratings of symptoms. Finally, an increased prevalence of ADHD/hyperactivity symptoms was confirmed in the children with intellectual disabilities compared to their siblings. This effect remained after controlling for chronological and mental age differences between the siblings. These findings support those from previous research and suggest that ADHD/Hyperkinesis may be a valid psychiatric diagnosis for children with intellectual disabilities. However, a great deal more research is needed to explore the phenomenology of ADHD in intellectual disability and to develop an evidence base for psychosocial intervention.

Preschool children with and without developmental delay: behaviour problems, parents' optimism and well-being

BACKGROUND

Children with intellectual disability are at heightened risk for behaviour problems, and these are known to increase parenting stress. This study explored the relation of behaviour problems to less child-related domains of parent well-being (depression and marital adjustment), as well as the moderating effect of a personality trait, dispositional optimism.

METHOD

Participating children (N = 214) were classified as developmentally delayed, borderline, or nondelayed. Mothers' and fathers' well-being and child behaviour problems were assessed at child ages 3 and 4 years.

RESULTS

Parents of delayed and nondelayed preschoolers generally did not differ on depression or marital adjustment, but child behaviour problems were strongly related to scores on both measures. Optimism moderated this relationship, primarily for mothers. When child behaviour problems were high, mothers who were less optimistic reported lower scores on measures of well-being than did mothers who were more optimistic.

CONCLUSIONS

Interventions for parents that aim to enhance both parenting skills and psychological well-being should be available in preschool. It may be beneficial for such programmes to focus not only on behaviour management strategies aimed at child behaviour change, but also on parents' belief systems, with the aim of increasing dispositional optimism.

The Psychometric Properties of the Vineland Adaptive Behavior Scales in Children and Adolescents with Mental Retardation

The psychometric properties of the Vineland Adaptive Behavior Scales Survey Form were studied in a total population of children and adolescents with MR, and in the specific levels of functioning (n=826, age 4-18 years). The original division into (sub)domains, as assigned by the authors, was replicated in the total population and in the mild and moderate levels of functioning. In the severe and profound levels of functioning the structure was less well recognized. The reliability of the instrument proved to be good in the total population and the subgroups. The construct validity was high in all groups. The implications of these findings are discussed with respect to the usefulness of the Vineland for the population with MR.

Emotional and behavioural needs of children and adolescents with intellectual disabilities in an urban conurbation

BACKGROUND

Over the past decade, increased attention has been paid to identifying and responding to the emotional and behavioural needs of children and adolescents with intellectual disability (ID). The aims of the present study were to add to this body of knowledge by identifying factors associated with emotional and behavioural needs among a sample of children with ID drawn from a large urban conurbation.

METHOD

Information was collected by postal questionnaire (or interview for family carers who did not have English as their first language) from teachers and from family carers of 615 children administratively identified as having ID (47% of all children with ID).

RESULTS

Results indicated that: (1) the administrative prevalence of moderate but not severe ID was associated with social deprivation whereas the prevalence of severe but not moderate ID appeared to be associated with ethnicity; (2) 54% of children scored above the threshold on the Developmental Behaviour Checklist (DBC)-primary family carer, and 37% of children scored above the threshold on the DBC-teacher; (3) social deprivation, male gender, less severe ID and having fewer physical or sensory impairments were associated with antisocial and disruptive behaviour; and (4) more severe ID and additional impairments were associated with anxiety, communication disturbance, social relating and self-absorbed behaviours.

CONCLUSIONS

These results identify a range of risk factors associated with behavioural and emotional problems experienced by children with ID.

DSM-IV disorders in children with borderline to moderate intellectual disability. I: prevalence and impact

OBJECTIVE

To assess the prevalence, comorbidity, and impact of DSM-IV disorders in 7- to 20-year-olds with intellectual disability.

METHOD

A total of 474 children (response 86.8%) were randomly selected from a sample of students from Dutch schools for the intellectually disabled. Parents completed the anxiety, mood, and disruptive disorder modules of the Diagnostic Interview Schedule for Children.

RESULTS

A total of 21.9% of the children met the DSM-IV symptom criteria for anxiety disorder, 4.4% for mood disorder, and 25.1% for disruptive disorder. Similar prevalence rates were found for children who screened positive or negative for pervasive developmental disorder. More than half of the children meeting the criteria for a DSM-IV disorder were severely impaired in everyday functioning, and about 37% had a comorbid disorder. Children with multiple disorders were more likely to be impaired across various areas of everyday functioning. Almost 27% of the diagnosed children received mental health care in the last year. Comorbidity and impairment in everyday functioning increased the likelihood of referral.

CONCLUSIONS

Most disorders can be observed in intellectually disabled children. Impairment and comorbidity are high. The finding that less than one third of the children with a psychiatric disorder receive mental health care deserves attention.

DSM-IV disorders in children with borderline to moderate intellectual disability. II: child and family predictors

OBJECTIVE

To identify child and family factors that predict DSM-IV disorders in children with intellectual disability.

METHOD

In 1997, a total of 968 6- to 18-year-olds were randomly selected from Dutch schools for intellectual disability (response 69.3%). Parents completed the Child Behavior Checklist, Developmental Behavior Checklist, Vineland Screener, and instruments addressing their child's physical health, family functioning, and parental mental health. One year later, parents of 474 children, randomly selected from the 1997 participants (response 86.8%), completed the anxiety, mood, and disruptive disorder modules of the Diagnostic Interview Schedule for Children-IV.

RESULTS

Both child and family factors were significantly related to DSM-IV outcome 1 year later. Social incompetence, inadequate daily living skills, child health problems, negative life events, emotional and behavioral problems, and parental mental health problems were the strongest predictors of DSM-IV disorders 1 year later. After correcting for the level of behavioral problems in the previous year, the first four factors proved to be significant risk factors for DSM-IV outcome.

CONCLUSIONS

These factors can improve the identification of children at risk and point to topics that need attention in diagnostic and intervention procedures.