Identifying bipolar disorders in individuals with intellectual disability

Intellectual disability and mental disorders in a US population representative sample of adolescents

BACKGROUND

Most research on the prevalence, distribution, and psychiatric comorbidity of intellectual disability (ID) relies on clinical samples, limiting the generalizability and utility of ID assessment in a legal context. This study assessed ID prevalence in a population-representative sample of US adolescents and examined associations of ID with socio-demographic factors and mental disorders.

METHODS

Data were drawn from the National Comorbidity Survey Adolescent Supplement (N = 6256). ID was defined as: (1) IQ ⩽ 76, measured using the Kaufman Brief Intelligence Test; (2) an adaptive behavior score ⩽76, and (3) age of onset ⩽18 measured using a validated scale. The Composite International Diagnostic Interview assessed 15 lifetime mental disorders. The Sheehan disability scale assessed disorder severity. We used logistic regression models to estimate differences in lifetime disorders for adolescents with and without ID.

RESULTS

ID prevalence was 3.2%. Among adolescents with ID, 65.1% met lifetime criteria for a mental disorder. ID status was associated with specific phobia, agoraphobia, and bipolar disorder, but not behavior disorders after adjustment for socio-demographics. Adolescents with ID and mental disorders were significantly more likely to exhibit severe impairment than those without ID.

CONCLUSIONS

These findings highlight how sample selection and overlap between ID and psychopathology symptoms might bias understanding of the mental health consequences of ID. For example, associations between ID and behavior disorders widely reported in clinical samples were not observed in a population-representative sample after adjustment for socio-demographic confounders. Valid assessment and understanding of these constructs may prove influential in the legal system by influencing treatment referrals and capital punishment decisions.General Scientific SummaryCurrent definitions of intellectual disability (ID) are based on three criteria: formal designation of low intelligence through artificial problem-solving tasks, impairment in one's ability to function in his/her social environment, and early age of onset. In a national population sample of adolescents, the majority of those with ID met criteria for a lifetime mental disorder. Phobias and bipolar disorder, but not behavior disorders, were elevated in adolescents with ID. Findings highlight the need to consider how behavioral problems are conceptualized and classified in people with ID.

Characterizing Mood States in Individuals Diagnosed with Bipolar Disorder and Intellectual Disability

INTRODUCTION

The purpose of this study was to gain additional insight on patterns of behavior of three individuals dually diagnosed with Intellectual disability (ID) and Bipolar disorder as they cycled between elevated and depressed mood states.

METHODS

Data were collected from weekly, one hour observations across a period of several months. The total duration of time spent engaged in target responses (pacing, rocking, and talking), in addition to indirect measures of activity (irritability and hyperactivity subscale of the Aberrant Behavior Checklist-Community; ABC-C), were assessed to characterize and monitor changes in overall state.

RESULTS

While observable behavior seemed to be a good indicator of overall state, ABC-C irritability and hyperactivity subscales were not. Additional analyses included lag sequential analyses of environmental stimuli and conditions potentially correlated with observed behavior.

CONCLUSIONS

Our findings suggest that observable behavior may be one way to monitor the progression of Bipolar disorder in those with ID; however, further research needs to be conducted.

Psychiatric disorders in adolescents and young adults with Down syndrome and other intellectual disabilities

BACKGROUND

Relative to other aspects of Down syndrome, remarkably little is known about the psychiatric problems experienced by youth and young adults with this syndrome and if these problems differ from others with intellectual disabilities. Yet adolescence and young adulthood are particularly vulnerable time periods, as they involve multiple life transitions in educational, medical, and other service systems.

METHODS

This study compared the psychiatric diagnoses of 49 adolescent and young adult patients with Down syndrome to 70 patients with other intellectual disabilities (IDs). The groups were similar in age, gender, and level of intellectual impairment. The 119 participants, aged 13 to 29 years (M = 21) were evaluated in one of two specialized psychiatric clinics.

RESULTS

In contrast to previous literature, those with Down syndrome versus other IDs had significantly higher rates of psychosis NOS or depression with psychotic features (43% versus 13%). Unlike the ID group, psychosis was predominantly seen in females with Down syndrome. Marked motoric slowing in performing routine daily activities or in expressive language was manifested in 17% of patients with Down syndrome. No group differences were found in anxiety or depressive disorders, and the ID group had significantly higher rates of bipolar and impulse control disorders.

CONCLUSIONS

These preliminary observations warrant further studies on genetic, neurological, and psychosocial factors that place some young people with Down syndrome or other IDs at high risk for severe psychiatric illness.

Clients with intellectual disabilities on psychiatric units: care coordination for positive outcomes

The transition from residential facilities to and from the psychiatric hospital setting is difficult for individuals with intellectual disabilities (ID). In the U.S.A., specialized psychiatric units for individuals with ID are uncommon and this population is usually served in generalized services. Nevertheless, providers of mental health services in the U.S.A. receive little training in their specific needs. Best practices call for coordination of plans between psychiatric units and community agencies, multidisciplinary care plans, staff education and comprehensive discharge planning in order to improve outcomes of psychiatric hospitalization. An inner city psychiatric unit in a major academic medical centre and a community agency providing residential care for individuals with ID cooperated to provide a plan of care for a client with ID both for hospitalization and for discharge leading to improved outcomes.

Depression in adults with intellectual disability: symptoms and challenging behaviour

BACKGROUND

Psychiatric evaluation of adults with intellectual disability (ID) remains complex because of limitations in verbal abilities, atypical clinical presentation and challenging behaviour. This study examines the clinical presentation of adults with depression compared with bipolar disorder, anxiety disorders and non-psychiatric control patients.

METHOD

This study is a retrospective record review of the initial psychiatric diagnostic evaluation for 300 adult patients with ID drawn from a clinic population. Patients with major depression (n = 85) were compared with those with bipolar disorder (n = 70), anxiety disorders (n = 30) and control patients without psychiatric disorder (n = 27). Key symptoms of depression assessed during the interview were examined as well as challenging behaviour.

RESULTS

Three symptoms were useful in differentiating depressed patients from all other groups: sad mood, crying, and anhedonia. Withdrawal, suicidality, and awakening during the night were significant compared with anxiety patients and controls; however, few patients reported suicidality. Bipolar patients were significantly different from depressed patients for elevated mood, acute anger episodes, increase in verbalization, pressure of speech, talk of sexual themes, increase in appetite and poor concentration. Anxiety patients had more fearfulness without withdrawal, sad mood, crying, anhedonia and suicidality. Challenging behaviour was most pronounced in bipolar patients; for depressed patients, aggression and impulsivity were significant compared with anxiety patients and controls. Overall, the control patients presented with few symptoms in any category.

CONCLUSIONS

Sad mood, crying and anhedonia are key significant features of depression. Most patients with ID cannot meet the required number of DSM criteria or suggested DM-ID adapted criteria for major depression. Many depressive symptoms were reported in modest numbers and this was probably related to deficiencies in self-report or observational skills of caregivers. Challenging behaviour is not diagnostically specific. It is, however, a key atypical feature of depression.

What symptoms predict the diagnosis of mania in persons with severe/profound intellectual disability in clinical practice?

BACKGROUND

While researchers have attempted to address the difficulties of diagnosing affective disorders in the intellectually disabled population, diagnosing bipolar disorder in an individual with severe intellectual disability (ID) remains a challenge. The aim of this study was to identify what symptoms can predict a diagnosis of mania in the intellectually disabled population.

METHODS

Three groups of persons with ID participated in this study: (1) individuals with a bipolar diagnosis who were currently manic; (2) individuals with an Axis I diagnosis other than bipolar disorder; and (3) individuals without an Axis I diagnosis. Two recognized measures of mania (i.e. Diagnostic Assessment for the Severely Handicapped-Revised and Parent Version of Young Mania Rating Scale) were used to evaluate symptoms of mania. A logistical regression procedure was conducted on mania items to identify which items correctly identify persons with ID who were currently manic.

RESULTS

Psychomotor agitation, decreased sleep, changes in mood and aggression were significantly related to the diagnosis of mania. Further, psychomotor agitation and disturbed sleep were significant predictors of a diagnosis of mania.

CONCLUSIONS

Problems of sleep and psychomotor agitation should alert clinicians that further assessment of bipolar symptomatology is warranted. Focusing on observable behaviours based on Diagnostic and Statistical Manual of Mental Disorder-IV criteria can be useful in formulating a diagnosis of bipolar disorder in persons with ID.

Behavioural equivalents of anxiety in children with fragile X syndrome: parent and teacher report

BACKGROUND

Identifying many of the diagnostic criteria for anxiety and depression in individuals with intellectual disability (ID) can be challenging because they may be unable to recognize and communicate their emotional experiences accurately. The purpose of this study is to identify behavioural equivalents of anxiety in children with fragile X syndrome (FXS), the leading inherited cause of ID.

METHODS

Parents and teachers of 43 children (aged 6-14 years) with full mutation FXS completed two standardized questionnaires on children's problem behaviour and psychiatric symptoms. Items from the questionnaires thought to be possible behavioural equivalents of anxiety were identified and grouped into four domains: Avoidance Behaviours - Confrontational; Avoidance Behaviours - Non-confrontational; Anxiety Continuum Behaviours; and Behavioural Dysregulation. The mean rating for the four groups of items was used to predict the children's status for exhibiting significant problems with anxiety as defined by the Diagnostic and Statistical Manual of Mental Disorders-oriented Anxiety Subscale from the problem behaviour scale.

RESULTS

The predictor variables classified 81% (parent rating) and 86% (teacher rating) of the children correctly. Avoidance Behaviours - Confrontational and Avoidance Behaviours - Non-confrontational (teacher rating) and Anxiety Continuum Behaviours (parent and teacher rating) made unique contributions to the models.

CONCLUSIONS

Children who are unable to identify and communicate that they worry about general day-to-day events may exhibit more observable behaviours resembling active and passive avoidance (e.g. arguing, avoiding difficult tasks, staring off) or have specific phobias and compulsions. These findings suggest that there are behavioural equivalents for anxiety disorder in children with FXS and, more generally, support the notion of behavioural equivalents in ID.

The relationship between manic symptoms on the DASH II and YMRS and feeding/mealtime behavior problems

This study represents the first to assess whether a relationship between manic symptoms and feeding/mealtime behavior problems exists in individuals with ID. Participants were compared across three groups (manic, non-manic psychiatrically impaired, and controls) on the diagnostic assessment for the severely handicapped-revised (DASH-II) and young mania rating scale (YMRS) and items of the screening tool of feeding problems (STEP). Individuals in the manic group exhibited clinically significant symptoms of mania (n=18), those in the non-manic psychiatrically impaired group exhibited symptoms of psychopathology other than mania (n=18), and those in the control group did not exhibit symptoms of mania or any other psychopathology (n=18). Significant differences were found across the groups for a number of items. Specifically, individuals exhibiting symptoms of mania were significantly more likely to 'continue to eat as long as food was available', 'to require special positioning during feeding, and 'to engage in problem behaviors during mealtime (e.g., aggression)'. These individuals were also significantly less likely to 'eat foods of only certain textures'. Implications of these data are discussed.

Neuropsychiatric syndromes in adults with intellectual disability: issues in assessment and treatment

The purpose of this article is to present a survey of important neuropsychiatric issues and recent findings regarding the evaluation and treatment of neuropsychiatric symptoms and syndromes in patients with intellectual disability (ID). The cause of ID, environmental or genetic, can be determined in few patients. Etiology is idiopathic in most patients. ID and psychiatric illness are not mutually exclusive; individuals with ID have increased rates of psychiatric illness. Although recognition of significant axis I psychopathology is important, not all challenging behaviors in persons with ID will have a clear axis I diagnosis. Psychologic, behavioral, and environmental treatments are appropriate measures, but pharmacotherapy often is needed. Our experience has shown us that the more severe, disruptive, and dangerous the behavior, the stronger the indication for empirical drug treatment trials. Community-based models of support with neuropsychiatric intervention can be a potent therapeutic combination in the management of challenging behaviors in individuals with ID.