Pathways to social well-being of children with intellectual disability: testing the Family Investment Model

BACKGROUND

Social well-being, including prosocial and peer relationship skills, independence and co-operation, is a particularly important developmental outcome in intellectual disability (ID). The present study investigated pathways to social well-being through the early years' family environment, particularly the role of parental investments in mediating the path from family poverty to child social well-being.

METHODS

In line with the Family Investment Model (FIM), we tested whether parental investments between 3 and 5 years of age mediate the impact of family poverty at 9 months of age on children's social well-being at 7 years. Structural equation models were fitted to data from 555 children with ID identified from a UK population-based cohort.

RESULTS

Findings indicated that home learning investments and the structural home environment (though not play) significantly mediated the effect of family poverty on children's social skills, albeit in different directions. While all parental investments reduced in the presence of poverty, the home learning environment appeared to promote social well-being, whereas the structural home environment did not. Sensitivity analyses controlling for co-occurring autism confirmed the pattern of findings. Child gender, ethnicity and parental educational qualifications did not moderate the mediational relationships, suggesting that FIM pathways to social well-being were relevant to all families.

CONCLUSIONS

The FIM provides a helpful framework to map developmental pathways for children with an ID. Parental investments related to home learning, the structural home environment and play are reduced in the presence of poverty although their impact on child social well-being appears to differ.

The mental health and well-being of adolescents with/without intellectual disability in the UK

AIMS

To estimate the self-reported and parent-reported mental well-being of adolescents (aged 14 and 17) with/without intellectual disability in a sample of young people representative of the UK population.

METHODS

Secondary analysis of data collected in Waves 6 and 7 of the UK's Millennium Cohort Study. The analytic sample consisted of 10,838 adolescent respondents at age 14 (361 with intellectual disability and 10,477 without) and 9,408 adolescent respondents at age 17 (292 with intellectual disability and 9,116 without).

RESULTS

Parental reports of adolescent problems on the Strengths and Difficulties Questionnaire (SDQ) indicated that adolescents with intellectual disability at ages 14 and 17 were more likely to have problems than those without intellectual disability across all SDQ domains. Adolescent self-report data at age 17 indicated that adolescents with intellectual disability were more likely to (self)-report that they had problems than those without intellectual disability on all but one SDQ domain. The magnitude of relative inequality between those with and without intellectual disability was consistently lower for self-report than parental report. On indicators of depression, mental well-being, self-harm, positive mental health, happiness and general psychological distress at ages 14 and 17, we found no self-reported group differences between adolescents with and without intellectual disability.

CONCLUSIONS

Further research is needed to understand: (1) why the magnitude of mental health inequalities between those with and without intellectual disability on the SDQ may be dependent on the identity of the informant; and (2) whether such differences are also apparent for other measures of mental health or well-being.

Predictors and moderators of the response of adults with intellectual disabilities and depression to behavioural activation and guided self-help therapies

BACKGROUND

No previous studies have reported predictors and moderators of outcome of psychological therapies for depression experienced by adults with intellectual disabilities (IDs). We investigated baseline variables as outcome predictors and moderators based on a randomised controlled trial where behavioural activation was compared with guided self-help.

METHODS

This study was an exploratory secondary data analysis of data collected during a randomised clinical trial. Participants (n = 161) were randomised to behavioural activation or guided self-help and followed up for 12 months. Pre-treatment variables were included if they have previously been shown to be associated with an increased risk of having depression in adults with IDs or have been reported as a potential predictor or moderator of outcome of treatment for depression with psychological therapies. The primary outcome measure, the Glasgow Depression Scale for Adults with Learning Disabilities (GDS-LD), was used as the dependant variable in mixed effects regression analyses testing for predictors and moderators of outcome, with baseline GDS-LD, treatment group, study centre and antidepressant use as fixed effects, and therapist as a random effect.

RESULTS

Higher baseline anxiety (mean difference in outcome associated with a 1 point increase in anxiety 0.164, 95% confidence interval [CI] 0.031, 0.297; P = 0.016), lower performance intelligence quotient (IQ) (mean difference in outcome associated with a 1 point increase in IQ 0.145, 95% CI 0.009, 0.280; P = 0.037) and hearing impairment (mean difference 3.449, 95% CI 0.466, 6.432; P = 0.024) were predictors of poorer outcomes, whilst greater severity of depressive symptoms at baseline (mean difference in outcome associated with 1 point increase in depression -0.160, 95% CI -0.806, -0.414; P < 0.001), higher expectation of change (mean difference in outcome associated with a 1 point increase in expectation of change -1.013, 95% CI -1.711, -0.314; p 0.005) and greater percentage of therapy sessions attended (mean difference in outcome with 1 point increase in percentage of sessions attended -0.058, 95% CI -0.099, -0.016; P = 0.007) were predictors of more positive outcomes for treatment after adjusting for randomised group allocation. The final model included severity of depressive and anxiety symptoms, lower WASI performance IQ subscale, hearing impairment, higher expectation of change and percentage of therapy sessions attended and explained 35.3% of the variance in the total GDS-LD score at 12 months (R2  = 0.353, F4, 128  = 17.24, P < 0.001). There is no evidence that baseline variables had a moderating effect on outcome for treatment with behavioural activation or guided self-help.

CONCLUSIONS

Our results suggest that baseline variables may be useful predictors of outcomes of psychological therapies for adults with IDs. Further research is required to examine the value of these potential predictors. However, our findings suggest that therapists consider how baseline variables may enable them to tailor their therapeutic approach when using psychological therapies to treat depression experienced by adults with IDs.

Mouse models of NADK2 deficiency analyzed for metabolic and gene expression changes to elucidate pathophysiology

NADK2 encodes the mitochondrial form of NAD Kinase, which phosphorylates nicotinamide adenine dinucleotide (NAD). Rare recessive mutations in human NADK2 are associated with a syndromic neurological mitochondrial disease that includes metabolic changes such as hyperlysinemia and 2,4 dienoyl CoA reductase (DECR) deficiency. However, the full pathophysiology resulting from NADK2 deficiency is not known. Here we describe two chemically-induced mouse mutations in Nadk2, S326L and S330P, which cause a severe neuromuscular disease and shorten lifespan. The S330P allele was characterized in detail and shown to have marked denervation of neuromuscular junctions by 5 weeks of age and muscle atrophy by 11 weeks of age. Cerebellar Purkinje cells also showed progressive degeneration in this model. Transcriptome profiling on brain and muscle was performed at early and late disease stages. In addition, metabolomic profiling was performed on brain, muscle, liver, and spinal cord at the same ages, and plasma at 5 weeks. Combined transcriptomic and metabolomic analyses identified hyperlysinemia, DECR deficiency, and generalized metabolic dysfunction in Nadk2 mutant mice, indicating relevance to the human disease. We compared findings from the Nadk model to equivalent RNAseq and metabolomic datasets from a mouse model of infantile neuroaxonal dystrophy, caused by recessive mutations in Pla2g6. This enabled us to identify disrupted biological processes that are common between these mouse models of neurological disease, as well as those processes that are gene-specific. These findings improve our understanding of the pathophysiology of neuromuscular diseases, and describe mouse models that will be useful for future preclinical studies.

The willingness of UK adults with intellectual disabilities to take COVID-19 vaccines

BACKGROUND

Given the much greater COVID-19 mortality risk experienced by people with intellectual disabilities (ID), understanding the willingness of people with ID to take a COVID-19 vaccine is a major public health issue.

METHOD

In December 2020 to February 2021, across the United Kingdom, 621 adults with ID were interviewed remotely and 348 family carers or support workers of adults with ID with greater needs completed an online survey, including a question on willingness to take a COVID-19 vaccine if offered.

RESULTS

Eighty-seven per cent of interviewees with ID were willing to take a COVID-19 vaccine, with willingness associated with white ethnicity, having already had a flu vaccine, gaining information about COVID-19 from television but not from social media, and knowing COVID-19 social restrictions rules. A percentage of 81.7% of surveyed carers of adults with ID with greater needs reported that the person would be willing to take a COVID-19 vaccine, with willingness associated with white ethnicity, having a health condition of concern in the context of COVID-19, having had a flu vaccine, being close to someone who had died due to COVID-19, and having shielded at some point during the pandemic.

CONCLUSIONS

Reported willingness to take the COVID-19 vaccine is high among adults with ID in the United Kingdom, with factors associated with willingness having clear implications for public health policy and practice.

The impact of the COVID-19 pandemic on the health of adults with intellectual impairment: evidence from two longitudinal UK surveys

BACKGROUND

People with an intellectual impairment experience high levels of social and health inequalities. We investigated the impact of COVID-19 on the physical and mental health of people with intellectual impairment, controlling for demographic risk, socio-economic circumstances and pre-pandemic health levels.

METHOD

Data were drawn from two UK birth cohorts that surveyed their participants on the impact of COVID-19 in May 2020: the Millennium Cohort Study (20-year-old participants) and the British Cohort Survey (50-year-old participants). Health outcomes (COVID-19 infection, COVID-19 symptoms, self-reported physical health, mental health, health service use and impact on health behaviours) were compared between people with and without intellectual impairment, adjusting for gender and ethnicity. Differences were further adjusted for self-reported health pre-pandemic and the impact of COVID-19 on socio-economic circumstances.

RESULTS

Controlling for gender and ethnicity, poor health was reported less often by younger adults [relative risks (RR): 0.44 95% confidence interval (CI) 0.23, 0.86] and more often by older adults (RR: 1.99 95% CI 1.45, 2.73) with intellectual impairment compared with peers. Older adults were also more likely to experience fever and loss of taste/smell. Adjusting for pre-pandemic health and socio-economic circumstances eliminated some differences in the older cohort, but not in the younger one.

CONCLUSION

In young adulthood, the impact of COVID-19 on health outcomes was not negative. The pattern was reversed in later adulthood, although differences were mostly eliminated after adjustment suggesting a socio-economic and age gradient of COVID-19 impacts on intellectual impairment.

The prevalence of potential drug-drug interactions in adults with intellectual disability

BACKGROUND

There is a high use of medications in adults with intellectual disability (ID). One implication of taking multiple medications is the potential for drug-drug interactions (DDIs). However, despite this being well highlighted in the mainstream literature, little is known about the incidence or associations of DDIs in the ID population.

METHODS

This study describes the prevalence, patterns and associations of potential DDIs in a total administrative sample of adults with ID known to services in Jersey. Demographic, health-related and medication data were collected from 217 adults known to ID services. Data were collected using a face-to-face survey. The Anatomical Therapeutic Chemical classification system was used to categorise medications, and Stockley's Drug Interaction Checker was used to classify potential DDIs. Drug-drug pairings were considered to be of clinical significance if they were to be 'avoided, adjusted, monitored or required further information'.

RESULTS

Potential DDIs of clinical significance were common. Exposure to potential DDIs of clinical significance was associated with being female, taking more than five medications (polypharmacy), living in residential care and having more health conditions. A simple regression was used to understand the effect of number of prescribed medications on potential DDIs of clinical significance. Every prescribed drug led to a 0.87 (95% confidence interval: 0.72-1.00) increase in having a potential DDI of clinical significance.

CONCLUSION

Adults with ID who live in residential care, who are female, exposed to polypharmacy and have more health conditions may be more likely to have potential DDIs of clinical significance. Urgent consideration needs to be given to the potential of DDIs in this population given their exposure to high levels of medication.

Polypharmacy and psychotropic polypharmacy in adults with intellectual disability: a cross-sectional total population study

BACKGROUND

Adults with intellectual disability (ID) are prescribed high levels of medication, with polypharmacy and psychotropic polypharmacy common. However, reported rates vary between studies, and there has been an over-reliance on obtaining data from convenience samples. The objective of this study was to determine the prevalence of medication use and polypharmacy in a population-level sample of adults with IDs. Factors associated with polypharmacy and psychotropic polypharmacy are explored.

METHODS

We used a total population sample of 217 adults with IDs known to services in Jersey (sampling frame n = 285). The Anatomical Therapeutic Chemical classification system was used to categorise medications that participants were currently taking on a regular basis. We examined associations of polypharmacy and psychotropic polypharmacy with socio-economic status, health and demographic variables using univariate and multivariate analyses.

RESULTS

A total of 83.4% of participants were prescribed medication, with high doses common. Of the participants, 38.2% were exposed to polypharmacy while 23% of participants were exposed to psychotropic polypharmacy. After controlling for demographic, health and socio-economic characteristics, polypharmacy was significantly associated with older age, increased severity of ID, living in a residential setting and having increased comorbidities. Psychotropic polypharmacy was associated with being male, being aged 50+ years and having had a psychiatric diagnosis over the life course. Being prescribed psychotropic drugs above the defined daily dose was not associated with having had a psychiatric diagnosis over the life course, suggesting the possibility of 'off label' prescribing.

CONCLUSIONS

Our results indicate that medication use, in high doses, alongside polypharmacy and psychotropic polypharmacy are highly prevalent in adults with ID. The exposure to multiple medications increases the risk of developing adverse drug events, drug-drug interactions and medication-related problems. Future population-level, prospective cohort studies should examine the prevalence of polypharmacy and psychotropic polypharmacy using standardised definitions and consider the potential impact of adverse drug events, drug-drug interactions and medication-related problems in this population.

Quality and Costs in a Residential Education Facility for People with Dual Sensory Impairments

The study evaluated the quality and costs of services for 16 young adults with dual sensory impairments and mental retardation before and during their placement at a specialist community-based residential further education facility. The results indicated that, overall, both the quality and costs of services were higher than in previous placements. However, there were wide variations among clients on all the dimensions studied, and there was no overall relationship between the costs and quality of services.

Risk of exposure to air pollution among British children with and without intellectual disabilities

BACKGROUND

Exposure to outdoor air pollution is a well-established risk factor for a range of adverse health conditions. No previous study has quantified the extent to which children with intellectual disability (ID) may be exposed to outdoor air pollution.

METHODS

Secondary analysis of data extracted from the UK's Millennium Cohort Study, a nationally representative sample of over 18 000 UK children born 2000-2002.

RESULTS

Averaging across ages, children with IDs were 33% more likely to live in areas with high levels of diesel particulate matter, 30% more likely to live in areas with high levels of nitrogen dioxide, 30% more likely to live in areas with high levels of carbon monoxide and 17% more likely to live in areas with high levels of sulphur dioxide.

CONCLUSIONS

Levels of exposure to outdoor air pollution among children with ID are significantly higher than those of families of children without ID. Exposure to outdoor air pollution may be one of the pathways that contributes to the health inequities experienced by people with IDs.

Total chemical synthesis of lassomycin and lassomycin-amide

Herein we report a practical synthetic route to the lasso peptide lassomycin () and C-terminal variant lassomycin-amide (). The biological evaluation of peptides and against Mycobacterium tuberculosis revealed that neither had any activity against this bacterium. This lack of biological activity has led us to propose that naturally occurring lassomycin may actually exhibit a standard lasso peptide threaded conformation rather than the previously reported unthreaded structure.

Predictors of self-reported alcohol use and attitudes toward alcohol among 11-year-old British children with and without intellectual disability

BACKGROUND

Reducing harmful levels of alcohol consumption among children is an important public health concern internationally and in many high income countries. Little is known about levels and predictors of alcohol use among children with intellectual disability (ID).

METHOD

Secondary analysis of child self-report data at age 11 years collected in the UK's Millennium Cohort Study.

RESULTS

Children with ID were significantly more likely to: have used alcohol in the last 4 weeks; to have had five or more alcoholic drinks on one occasion; to have had five or more alcoholic drinks or been intoxicated on one occasion; to have more positive attitudes about the psychological and social benefits of drinking; and to have less negative attitudes about the social and physical costs of drinking. Potentially harmful levels of drinking (intoxication or 5+ alcoholic drinks on one occasion) among children with ID were associated with child smoking, having friends who use alcohol, reporting that drinking makes it easier to make friends, and reporting that drinking reduces worrying. Children with ID accounted for 9% of all children with potentially harmful levels of drinking.

CONCLUSION

Public health interventions to reduce potentially harmful drinking among children in general must recognise that children with ID are a potentially high risk group and ensure that interventions are appropriately adjusted to take account of their particular needs and situation. Future research in this area is needed to untangle the causal pathways between attitudes toward alcohol and alcohol use among children with ID and the extent to which levels of alcohol use and predictors of alcohol use may be moderated by severity of ID.

Exposure to second hand tobacco smoke at home and child smoking at age 11 among British children with and without intellectual disability

BACKGROUND

The exposure of children to second hand tobacco smoke (SHS) is a well-established risk factor for a range of adverse health conditions in childhood and later life. Little is known about the extent to which children with intellectual disability (ID) may be exposed to SHS. Our aim in this study was to estimate the risk of childhood exposure to SHS and early experience of smoking among children with and without ID in a nationally representative cohort of British children.

METHOD

Secondary analysis of data extracted from the UK's Millennium Cohort Study, a nationally representative sample of over 18,000 UK children born 2000-2002.

RESULTS

Children with ID are significantly more likely than their peers to be exposed to SHS and to have themselves experimented with smoking by age 11. Controlling for between-group differences in socio-economic position eliminated the increased risk of exposure to SHS and significantly attenuated, but did not eliminate, increased risk of experimenting with smoking by age 11.

CONCLUSIONS

Levels of exposure to SHS among children with ID are typical of those of families of children without ID living in similar socio-economic circumstances. The results lend no support to the hypothesis that increased rates of parental smoking may be associated with any additional 'burden of care' experienced by parents of children with ID. Nevertheless, it will be important to ensure that evidence-based interventions to reduce exposure to SHS are tailored to the specific needs of families supporting children with ID (e.g. through the provision of disability-friendly child care arrangements).

The health of parents with and without intellectual impairment in the UK

BACKGROUND

Little is known about the health and well-being of the 'hidden majority' of parents with mild intellectual disability (ID), who are less likely to be in contact with disability services.

METHOD

We sought to add to knowledge in this area by examining the health and living conditions of parents with and without intellectual impairment in a large contemporary nationally representative sample of UK parents aged between 16 and 49 years old (n = 14 371).

RESULTS

Our results indicated that, as expected, parents with intellectual impairment were at significantly greater risk than other parents of having poorer self-reported general, mental and physical health. They were also at significantly greater risk of experiencing higher rates of household socio-economic disadvantage and environmental adversities and lower rates of neighbourhood social capital and intergenerational support. Adjusting risk estimates to take account of between group differences in household socio-economic disadvantage eliminated statistically significant differences in health status between parents with and without intellectual impairment on all but one indicator (obesity). Further adjusting risk estimates to take account of between group differences in neighbourhood adversity, neighbourhood social capital and intergenerational support had minimal impact on the results.

CONCLUSIONS

That controlling for between-group differences in exposure to socio-economic disadvantage largely eliminated evidence of poorer health among parents with intellectual impairment is consistent with the view that a significant proportion of the poorer health of people with IDs may be attributable to their poorer living conditions rather than biological factors associated with ID per se.

A preliminary controlled trial of a trans-diagnostic programme for cognitive behaviour therapy with adults with intellectual disability

BACKGROUND

Several studies have found a heightened prevalence of mental health disorders in people with intellectual disabilities (ID). There have been a number of successful case series and two promising controlled treatment trials of cognitive behaviour therapy (CBT) for emotional disorders (excluding anger) for people with ID. Several authors have promoted the development of trans-diagnostic approaches to cognitive treatment. The present study extends this work with the development and evaluation of a trans-diagnostic treatment manual for CBT in people with ID.

METHOD

A controlled treatment trial was conducted with 12 participants in treatment and waiting list control data. Each treatment participant was matched to a control on age, IQ, presenting problem, and Brief Symptom Inventory (BSI) global severity index (GSI) score. The treatment group was also evaluated on the Glasgow anxiety and depression scales and was followed up for 3 to 6 months after treatment.

RESULTS

There were no significant differences between groups at baseline. Following treatment, the CBT group was significantly improved when compared with the control group on the GSI scale of the BSI. The ancovas for all other measures were not significant but there were significant improvements for the treatment group on all scaled except BSI depression from pre to post-CBT. Gains were maintained to follow up, and changes were associated with large effect sizes.

CONCLUSIONS

It was possible to treat a range of symptoms and psychiatric diagnoses with a general trans-diagnostic CBT manual. The effects of therapy were promising, suggesting that the participants could respond to treatment in a meaningful and helpful manner and supporting the case for further evaluation of the trans-diagnostic approach in ID.

A prospective study of the relationship between adverse life events and trauma in adults with mild to moderate intellectual disabilities

BACKGROUND

Research has demonstrated a relationship between the experience of life events and psychopathology in people with intellectual disabilities (ID), however few studies have established causal links and to date no prospective studies have utilised a measure of trauma that has been developed specifically for this population group.

METHOD

This 6-month prospective study examined longitudinal relationships between adverse life events and trauma in 99 adults with mild to moderate ID.

RESULTS

Life events during the previous 6 months were significantly predictive of levels of trauma as measured by the self-report Lancaster and Northgate trauma scales (LANTS), and the informant LANTS behavioural changes, frequency and severity sub-scales. This prospective causal relationship was demonstrated while controlling for any prior life events or pre-existing trauma, though the relationship was not moderated by social support.

CONCLUSIONS

Evidence of a causal relationship between adverse life events and trauma symptoms is important for treatment planning and funding allocation.

Using direct payments to fund short breaks for families with a disabled child

BACKGROUND

A clear policy trend exists towards promoting the use of direct payments (DPs), including those for families with disabled children who use short breaks. However, uptake has been slow and use of DPs has been socially patterned. Recent programmes in England have dramatically increased investment in short break provision including breaks funded through DPs. This research examines the characteristics, circumstances and experiences of families who use DPs to fund short breaks with those who use short breaks funded in other ways.

METHOD

The paper draws on surveys totalling 348 parents and carers in families with disabled children using short breaks. We investigate associations between the use of DPs and a range of demographic, socio-economic, well-being, service use and satisfaction indicators. Logistic regression identifies which variables are most strongly associated with use of DPs. We also draw on open-ended survey responses which highlight important aspects of families' experience of using DPs.

RESULTS

Characteristics significantly associated with increased use of DPs include the presence of main carers who are female, more highly educated and from White British backgrounds, younger children, lower levels of area deprivation, greater access to service and social networks and use of more hours of short breaks. Characteristics not found to be significantly associated with use of DPs include various health and well-being indicators, impairment characteristics of children and service satisfaction. A range of benefits of DPs are described along with problems accessing and using them.

CONCLUSIONS

Direct payments can have a number of benefits for families using short breaks, but access to them is currently problematic and socially patterned. If the uptake of DPs is to be increased and made more equitable, more attention must be paid to promoting and supporting their use in ways which meet the needs of individual families.

The Lancaster and Northgate Trauma Scales (LANTS): the development and psychometric properties of a measure of trauma for people with mild to moderate intellectual disabilities

People with intellectual disabilities are exposed to a high number of adverse life events, and evidence supports a link between the experience of adverse life events and trauma. Interventions for trauma have been found to be efficacious if case recognition can be facilitated. However to date there are no psychometrically validated measures of trauma for people with intellectual disabilities. This study describes the development of the Lancaster and Northgate Trauma Scales (LANTS), which comprise a self-report and an informant measure of the effects of traumatic life events on people with intellectual disabilities. The pool of items for the measures was created via a systematic review, and consultation with key stakeholders. 99 service users and 88 staff completed the LANTS measures during a pilot. The 29-item self-report LANTS and the 43-item informant LANTS were found to have good psychometric properties, including internal and test retest reliability, plus convergent and construct validity. The findings suggest the LANTS are promising trauma screening tools for use in clinical and research settings.

British Society of Haematology, Slide Session presented at the Annual Scientific Meeting, Brighton 2009

Seven cases were discussed by an expert panel at the 2009 Annual Scientific Meeting of the British Society of Haematology. These cases are presented in a similar format to that adopted for the meeting. There was an initial discussion of the presenting morphology, generation of differential diagnoses and then, following display of further presenting and diagnostic information, each case was concluded with provision of a final diagnosis.

The social context of parenting 3-year-old children with developmental delay in the UK

BACKGROUND

Children with intellectual or developmental disability have significantly poorer health and mental health than their non-disabled peers and are at high risk of social exclusion. The aim of the present paper is to provide information on the circumstances in which 3-year-old children at risk of intellectual or developmental disability are growing up in the UK.

METHODS

Secondary analysis of data on 12 689 families in English-speaking monolingual households from the first two waves of the UK's Millennium Cohort Study. A total of 440 children (3% of the weighted sample) were identified as being developmentally delayed.

RESULTS

When compared with other children, children with developmental delays were more disadvantaged on every indicator of social and economic disadvantage examined. Two out of three children with developmental delays had been exposed to repeated disadvantage as measured by income poverty, material hardship, social housing and receipt of means-tested benefits. The effect of repeated disadvantage on the risk of developmental delay remained after account was taken of parental education and occupational status.

CONCLUSIONS

Young children with delayed development in the UK are likely to be exposed to repeated socio-economic disadvantage. Implications for policy and understanding the nature of the link between poverty and child disability are discussed.

Poverty, socio-economic position, social capital and the health of children and adolescents with intellectual disabilities in Britain: a replication

Background When compared with their nonintellectually disabled peers, people with intellectual disabilities (IDs) have poorer health and are more likely to be exposed to poverty during childhood. Given that exposure to child poverty has been linked to poorer health outcomes, we attempted to estimate the extent to which the health inequalities faced by children and adolescents with IDs may be accounted for by their more disadvantaged socio-economic position. Methods Secondary analysis of data on a nationally representative sample of 12 160 British children aged under 17 years extracted from the Department of Work and Pensions' Families and Children Study. Results After controlling for age and sex, children with IDs were significantly more likely (corrected odds ratio = 2.49) to be reported to have less than good health than their nonintellectually disabled peers. However, 31% of the elevated risk for poorer health was accounted for by between-group differences in socio-economic position and social capital. Conclusions A socially and statistically significant proportion of the increased risk of poorer health among children and adolescents with IDs may be attributed to their increased risk of socio-economic disadvantage.

Person-centred planning: factors associated with successful outcomes for people with intellectual disabilities

BACKGROUND

Recent research in the USA and UK indicates that person-centred planning (PCP) can lead to improvements in lifestyle-related outcomes for people with intellectual disabilities (ID). It is clear, however, that the introduction of PCP does not have an equal impact for all participants. The aim of the present paper was to identify factors associated with the probability of delivering a plan and with improvements in outcomes for those who did receive a plan.

METHODS

Information on the life experiences of participants was collected over a period of approximately 2 years for a cohort of 93 adults with ID.

RESULTS

There were powerful inequalities in both access to and the efficacy of PCP in relation to participant characteristics, contextual factors and elements of the PCP process.

CONCLUSIONS

Results are discussed in relation to implications for policy and practice for increasing the effectiveness of PCP and reducing inequalities in the life experiences of people with ID.

Socio-economic position, household composition, health status and indicators of the well-being of mothers of children with and without intellectual disabilities

BACKGROUND

Many previous studies have reported that mothers of children with intellectual disabilities (IDs) are more likely to show signs of psychological distress and have lower well-being than mothers of 'typically developing' children. Our aim was to estimate the extent to which these differences may be accounted for by between-group differences in socio-economic position.

METHODS

This study involved secondary analysis of happiness, self-esteem and self-efficacy variables in a nationally representative sample of 6954 British mothers with dependent children under the age of 17 years, 514 of whom were supporting a child with an ID.

RESULTS

Mothers of children with IDs reported lower levels of happiness, self-esteem and self-efficacy than mothers of children without IDs. Statistically controlling for differences in socio-economic position, household composition and maternal characteristics fully accounted for the between-group differences in maternal happiness, and accounted for over 50% of the elevated risk for poorer self-esteem and self-efficacy.

CONCLUSIONS

A socially and statistically significant proportion of the increased risk of poorer well-being among mothers of children with IDs may be attributed to their increased risk of socio-economic disadvantage.

The response to challenging behaviour by care staff: emotional responses, attributions of cause and observations of practice

BACKGROUND

Previous studies have attempted to apply Weiner's attributional model of helping behaviour to care staff who work with service users with intellectual disabilities and challenging behaviours by using studies based on vignettes. The aims of the current study were to investigate the application of Weiner's model to 'real' service users with intellectual disabilities and challenging behaviours and to observe the care staff's actual responses to challenging behaviours displayed by service users. Also, to compare care staff attributions, emotions, optimism, willingness to help and observed helping behaviours for self-injurious behaviours in comparison to other forms of challenging behaviours.

METHOD

A total of 27 care staff completed two sets of measures, one set regarding a self-injurious behaviour and the other regarding other forms of challenging behaviour. An additional 16 staff completed one set of measures. The measures focused on care staff attributions, emotions, optimism and willingness to help. Also, 16 of the care staff were observed interacting with the service users to collect data regarding their responses to challenging behaviours.

RESULTS

For both self-injurious behaviours and other forms of challenging behaviour, associations were found between the care staff internal, stable and uncontrollable attribution scores and care staff negative emotion scores. However, no associations were found between the care staff levels of emotion, optimism and willingness to help. Some associations were found between the care staff levels of willingness to help and observed helping behaviours. There were significant differences between the care staff attribution scores with higher scores being obtained for uncontrollable and stable attributions for other forms of challenging behaviours. No significant differences were found between the care staff emotions, optimism, willingness to help and observed helping behaviours.

CONCLUSIONS

The results did not provide support for Weiner's attributional model of helping behaviour. However, a preliminary model of negative care staff behaviour was derived from the exploratory analyses completed. This model proposes that there are associations between internal, stable and uncontrollable attributions and negative emotions in care staff and also between negative emotions and negative behaviours displayed by care staff in response to the actions of service users.

Self-reported anti-social behaviour: prevalence and risk factors amongst adolescents with and without intellectual disability

BACKGROUND

Research has suggested increased risk of anti-social behaviour amongst individuals with intellectual disability (ID).

METHODS

This study reports the results of a secondary analysis of data relating to self-reported anti-social behaviour, obtained from the 1999 Office for National Statistics (ONS) study of the mental health of children and adolescents in Great Britain. Self-report data from 4174 adolescents was available. Within this group, a sub-group of 98 adolescents with ID was identified. Data covered a variety of sub-types of anti-social behaviour.

RESULTS

Comparisons of individuals with ID and those without ID indicated a significantly higher prevalence of a number of types of self-reported anti-social behaviour in the ID sample. Further analyses indicated however, that these between group differences were accounted for by the higher rates of social deprivation and child mental health problems among the ID sample.

CONCLUSIONS

Rather than ID per se being associated with increased rates of anti-social behaviour, adolescents with ID may be more likely to experience risk factors (lower socio-economic status and mental health problems) known to be associated with anti-social behaviour. The clinical implications of this and possible future directions for research are discussed.

The reliability and validity of general psychotic rating scales with people with mild and moderate intellectual disabilities: an empirical investigation

BACKGROUND

Whilst assessment tools have been developed to diagnose schizophrenia in people with mild intellectual disabilities (IDs), little attention has been paid to developing reliable and valid dimensional measures of psychotic experiences with this population. This study investigates the reliability and validity of two such measures developed for the general adult psychiatric population, the Positive and Negative Syndrome Scale (PANSS) and the Psychotic Symptom Rating Scales (PSYRATS), with a population of adults with mild IDs.

METHOD

Sixty-two adults with mild IDs were interviewed using the PANSS and PSYRATS, and independently interviewed using the Psychiatric Assessment Schedule--Adults with Developmental Disability (PAS-ADD) to obtain psychiatric diagnoses to the criteria of the International Classification of Diseases--Tenth Revision (ICD-10). On the basis of ICD-10 diagnosis, participants were divided into three groups: psychosis (n=11); other mental health problem (n=14); no mental health problem (n=37). PANSS and PSYRATS subscale scores were compared across these three groups and were correlated with PAS-ADD symptom scores across a number of PAS-ADD symptom domains.

RESULTS

All PANSS and PSYRATS subscales showed adequate internal reliability, largely good test-retest reliability, and logical inter-correlations between subscales. The PANSS positive symptoms and the PSYRATS auditory hallucinations subscales differentiated between the psychosis group and the other groups; the PANSS general symptoms subscale differentiated between the psychosis and no mental health problem groups; and the PANSS negative symptoms and the PSYRATS delusions subscales did not differentiate between the three groups.

CONCLUSIONS

The PANSS and PSYRATS are promising measures for use with people with mild IDs and psychotic experiences, although further investigation of items relating to negative symptoms and delusions is warranted.

Emotional and behavioural responses to music in people with dementia: an observational study

Using continuous time sampling and direct observation methodology, this study examined the impact of social interaction in music listening on behavioural responses of people with moderate-to-severe dementia (n = 24). Using Kitwood's theory of personhood as a framework, it was hypothesized that levels of well-being and engagement would be greatest during a live music condition compared with recorded and no music conditions and that levels of challenging behaviour would decrease most in the live music conditions compared with the other music conditions. The relationship between severity of cognitive impairment and well-being, engagement and challenging behaviours across conditions was also examined. The findings suggest that live music was significantly more effective in increasing levels of engagement and well-being regardless of level of cognitive impairment. No significant differences across conditions were found for challenging behaviours, but the correlation between these and cognitive impairment revealed mixed results. Clinical implications regarding the use of live music in dementia care settings are highlighted and recommendations for future research of interventions aimed at reducing challenging behaviours are discussed.

The Resident Choice Scale: a measure to assess opportunities for self-determination in residential settings

BACKGROUND

A 26-item Resident Choice Scale was designed to assess service practices for promoting resident choice.

METHOD

The staff working with 560 UK/Irish adults with intellectual disability were interviewed. Specific examples of practices promoting resident choice were requested and independently rated by the interviewer.

RESULTS

The interrater reliability of Resident Choice items was found to be acceptable (subsample n = 50). The psychometric properties of the Resident Choice Scale total score and scores on eight subscales were also acceptable. Consistently strong associations were found between greater resident choice and greater resident ability and, to a lesser extent, fewer resident challenging behaviours. Few associations were found between resident choice and autism or mental health problems. Even when controlling for resident ability and challenging behaviour, consistent associations were found between greater resident choice and the concurrent variables of greater community presence, fewer institutional practices, and greater user self-reported satisfaction (subsample n = 50).

CONCLUSIONS

Taken together, this pattern of results indicates that the Resident Choice Scale shows promise as a measure of the environmental opportunities available for adults with intellectual disability to exercise self-determination. Areas for future research testing the reliability and validity of the Resident Choice Scale are outlined.

Life events and psychiatric symptoms in adults with intellectual disabilities

BACKGROUND

Previous research has indicated that children and adults with intellectual disabilities (ID) may respond to traumatic and other life events in a similar way to the general population. However, few studies have charted the extent of exposure to recent life events in samples of adults with ID and the association of such exposure with general psychiatric problems.

METHODS

Adults with ID (n = 1155) in community and residential services in a county district in North-east England were assessed using the Psychiatric Assessment for Adults with Developmental Disabilities Checklist (PAS-ADD Checklist), which includes a checklist of recent life events. Data were provided by informants who knew the index client well.

RESULTS

Within the 12 months before data collection, the five most frequently experienced life events were: moving residence (15.5% of sample), serious illness of close relative or friend (9.0%), serious problem with close friend, neighbour or relative (8.8%), serious illness or injury to self (8.5%), and death of close family friend or other relative (8.3%). Overall, 46.3% had experienced one or more significant life events in the previous 12 months and 17.4% had experienced two or more. Logistic regression analysis revealed that the presence of one or more life events in the previous 12 months added significantly to the classification of psychiatric caseness predicted by demographic variables (age, sex, residence in community or hospital) on the PAS-ADD Affective Disorder scale. Overall, the odds ratio for affective disorder given exposure to one or more life events was 2.23 [95% confidence interval (CI) = 1.56, 3.18].

CONCLUSIONS

Small, but potentially significant relationships were found between life events exposure and psychiatric problems in adults with ID. Further research is needed to explore the causal direction of this relationship and also to develop more sensitive measures of life events relevant to the situation of adults in residential and community service environments.

Music interventions for people with dementia: a review of the literature

This paper provides a qualitative review of 21 published articles of clinical empirical studies looking at the effects of a variety of music activities on the emotional and behavioural responses in people with dementia. General information is reviewed such as the setting and context of studies, research findings and explanatory variables. Methodological issues are also discussed, particularly in relation to observational methods, and theoretical frameworks such as the progressively lowered stress threshold model are evaluated. Music appears to have a range of applications in dementia care but previous reviews have highlighted methodological weaknesses of studies. Recommendations for future research include the use of continuous time sampling methodology and to record the duration of observed behaviours. This review paper also argues for the use of Kitwood's theory of personhood as a framework to inform and guide future research.

Screening for psychiatric symptoms: PAS-ADD Checklist norms for adults with intellectual disabilities

BACKGROUND

The Psychiatric Assessment Schedule for Adults with Developmental Disabilities Checklist (PAS-ADD Checklist) is a screening instrument designed to help carers recognize likely mental health problems in people with intellectual disabilities (ID). To date there are no published PAS-ADD Checklist data on a large nonpsychiatric population of adults with ID, an important step towards developing norms for comparative purposes.

METHODS

Informants who had known participants for a median 24 months completed the PAS-ADD Checklist on 1155 adults with ID living in community, residential care and hospital settings in a county district in the North-east of England.

RESULTS

Normative data were obtained for the PAS-ADD Checklist for the study population with reference to gender, age, and type of residence. The overall prevalence of mental health problems was 20.1%, and the rates for affective/neurotic, organic and psychotic disorders were 14%, 3.9%, and 10.2%, respectively. Significant differences in the rates for particular disorders were found across gender, age and, residence type.

CONCLUSIONS

The rates of mental disorders found in the study population were consistent with previous studies of general populations of people with ID using over-inclusive screening instruments. The PAS-ADD Checklist appears to be an easy-to-use and sensitive tool for identifying mental health cases in ID populations, but further investigation is required concerning the specificity of the instrument.

Vascular patterns in reactive lymphoid tissue and in non-Hodgkin's lymphoma

The few studies published on angiogenesis in lymphoma have raised the question of whether or not microvessel density (MVD) is associated with more aggressive disease and have reported the observation that in follicular lymphomas, vessels are mature rather than immature. We investigated MVD and the vascular phenotype within follicular or diffuse large B-cell lymphomas, reactive nodes and tonsils. Vascular phenotype was defined by the expression or loss of reactivity to the antibody LH39 (detecting the LH39 laminin epitope of the basement membrane in mature vessels) and by detection of alpha V beta 3 (expressed on immature vessels). In reactive nodes and in follicular lymphomas, MVD was higher in the paracortex than in germinal centres or in neoplastic follicles. However, in neoplastic follicles an increase in alpha V beta 3-positive endothelium suggested the activation of an angiogenic pathway different from that present in the reactive follicles. In large B-cell lymphomas, MVD was higher than in reactive and neoplastic follicles but lower than in the reactive paracortex. The number of immature vessels (LH39 negative) and of alpha V beta 3-positive vessels was higher than in reactive lymph nodes and follicular lymphoma suggesting that a switch to a different angiogenic pathway has occurred. Finally, we have demonstrated that within reactive and neoplastic follicles vascular regression is occurring, perhaps constraining the growth of reactive follicles alongside other phenomena such as apoptosis. Vascular regression was previously believed to occur in adults only in ovarian and endometrial tissue. We conclude that different types of angiogenesis are present in follicular lymphomas and large B-cell lymphomas. This has implications for possible future therapies.

Recessive inheritance and variable penetrance of slow-channel congenital myasthenic syndromes

BACKGROUND

Slow-channel congenital myasthenic syndromes (SCCMS) typically show dominant inheritance. They are caused by missense mutations within the subunits of muscle nicotinic acetylcholine receptors (AChR) that result in prolonged ion channel activations. SCCMS mutations within the AChR subunit are located in various functional domains, whereas fully described mutations in AChR non- subunits have, thus far, been located only in the M2 channel-lining domain. The authors identified and characterized two -subunit mutations, located outside M2, that underlie SCCMS in three kinships. In two of the three kinships, the syndrome showed an atypical inheritance pattern.

METHODS

These methods included clinical diagnosis, mutation detection, haplotype analysis, and functional expression studies using single-channel recordings of mutant AChR transiently transfected into HEK293 cells.

RESULTS

The authors identified two SCCMS mutations in the AChR subunit, L78P and L221F. Both mutations prolonged ACh-induced ion channel activations. L78P is present in a consanguineous family and appears to be pathogenic only when present on both alleles, and L221F shows variable penetrance in one of the two families that were identified harboring this mutation.

CONCLUSION

SCCMS mutations may show a recessive inheritance pattern and variable penetrance. A diagnosis of SCCMS should not be ruled out in cases of CMS with an apparent recessive inheritance pattern.

Costs of village community, residential campus and dispersed housing provision for people with intellectual disability

BACKGROUND

In recent years, a growing volume of research evidence has been generated about the relative cost-effectiveness of various types of community-based residential supports for people with intellectual disability (ID) in the UK. However, few reliable data are available to inform planners, commissioners or service providers about the quality and costs of providing support within residential or village communities.

METHODS

The evaluation described in the present paper aimed to fill some of the gaps in knowledge by examining the comparative costs of supporting people in village community settings, in National Health Service (NHS) residential campuses and in dispersed, community-based housing schemes. The complete service package received by each study participant was described and costed, and a series of statistical analyses was undertaken to identify factors associated with variations in the cost of support. The analyses reported in the present paper were based on comparisons of 86 people living in village communities, 133 in residential campuses and 281 in dispersed housing schemes.

RESULTS

Wide variations in cost were found, not only between models of accommodation, but between individual organizations, settings and service users. Multivariate analysis revealed that higher costs were associated with supports for people with higher levels of ID and more severe challenging behaviour. The cost of support was affected by the size of the residential setting, with smaller facilities likely to be more expensive. Associations were also found between increased costs, and services for younger users, male users and people who had not moved from a NHS hospital. Generally, more sophisticated service processes within the setting were associated with higher costs; although systematic arrangements for supervision and training of staff had a negative effect on cost.

CONCLUSIONS

The cost findings should be considered alongside evidence on outcomes. A comparison of village communities and dispersed housing schemes suggests that both models of provision appear be associated with particular benefits, although different types of setting are appropriate for different individuals and therefore, the continued development of a range of residential models is important.

Lymphoplasmacytoid lymphoma presenting as severe osteoporosis

We report four cases presenting with severe osteoporosis which on further investigation were found to have an underlying lymphoplasmacytoid lymphoma (LPL). Common secondary causes of osteoporosis were excluded in each case. Three of the cases responded to treatment with a biphosphonate. As these lymphomas share some common pathological and clinical features with multiple myeloma (MM) an association with osteoporosis is likely to represent more than a coincidental finding. The incidence of osteoporosis occurring with LPL will become clearer if routine imaging is carried out in patients at presentation. Issues relating to the treatment of the osteoporosis as well as the lymphoma arise in patients that present in this way. Based on the model of bone disease in MM, correlating serum levels of osteoclast activating cytokines such as interleukin-1 (IL-1), interleukin-6 (IL-6), and tumour necrosis factor (TNF) with the actual finding of bone disease provides a basis for future research into the pathogenesis and management of bone disease in these rare forms of low grade non-Hodgkin's lymphoma.

An investigation of models of illness in carers of schizophrenia patients using the Illness Perception Questionnaire

BACKGROUND

Although carers' reactions to schizophrenic illness in a close family member may have important implications for the patient and for themselves, little is known of factors that influence the way carers respond. In the area of physical health problems, people's models of their illness or illness representations have been found to be related to the ways they react and cope with their illness. This study examines the use of a modified form of the Illness Perception Questionnaire (IPQ) to investigate illness models in a sample of carers of schizophrenia patients.

METHODS

Forty-seven carers participated. The psychometric properties of the modified IPQ were examined, and a number of carer and patient outcomes were investigated in relation to carer scores on the illness identity, consequences, control-cure and timeline subscales of the modified IPQ. These outcomes included measures of carer distress and burden, expressed emotion dimensions, and patient functioning.

RESULTS

The modified IPQ was found to be a reliable measure of carers' perceptions of schizophrenia. Carer functioning, the patient-carer relationship and patient illness characteristics were associated with different dimensions of illness perceptions.

CONCLUSIONS

The findings support the proposal that carer cognitive representations of the illness may have important implications for both carer and patient outcomes in schizophrenia.

Environmental opportunities and supports for exercising self-determination in community-based residential settings

Information was collected on the environmental opportunities for exercising self-determination among 281 adults with mental retardation receiving community-based residential supports. The results indicated that: (1) the majority of participants had little or no opportunity to exercise self-determination over major life decisions (e.g., with whom and where to live, the recruitment and retention of care staff); (2) even in more mundane areas, such as where and when to eat, the majority of participants were not supported to exercise effective control; (3) variation in environmental opportunities to exercise self-determination was strongly related to a range of factors including participant ability, previous residential history, and structural and procedural aspects of the residential supports currently provided.

Quality and costs of supported living residences and group homes in the United Kingdom

Information was collected on 63 adults in supported living residences, 55 adults in small group homes, and 152 adults in large group homes. Results indicated that (a) there were no statistically significant differences in service costs once these had been adjusted to take account of participant characteristics; (b) compared with participants living in small group homes, those in supported living residences had greater choice, participated in more community-based activities, experienced fewer scheduled activities, were more likely to have had their home vandalized, and were considered at greater risk of exploitation; (c) compared with participants living in large group homes, those in small group homes had larger social networks, more people in their social networks who were not staff, not family, and did not have mental retardation. These residents were considered at less risk of abuse.

Factors associated with expressed satisfaction among people with intellectual disability receiving residential supports

The aim of the present study was to identify factors associated with variations in the levels of expressed satisfaction among adults with intellectual disability (ID) receiving residential supports. Semi-structured interviews were conducted with 96 people with ID. Forty-five subjects lived in village communities and 51 received community-based residential supports. Ratings were made of the participants' expressed levels of satisfaction in seven domains: (1) their home; (2) daytime activities; (3) social and recreational activities; (4) support from services; (5) friendships and relationships; (6) choices available to them; and (7) risks. The data indicated that: (1) interviewees living in village communities expressed greater satisfaction with friendships and relationships than interviewees living in community-based residential supports; (2) in the other six domains of life satisfaction which were investigated, there were no statistically significant differences between groups; (3) interviewees expressed greater satisfaction with their accommodation and day activities than with friendships, risks and support received; and (4) a wide range of variables relating to the personal characteristics of the interviewees and support received were associated with variations in levels of expressed satisfaction. Variation in the levels of expressed satisfaction was reliably associated with variables relating to the personal characteristics of the interviewees and the nature of the support received.

The adaptive behavior scale-residential and community (part I): towards the development of a short form

A potential 24-item short form (SABS) of the 73-item Adaptive Behavior Scale-Residential and Community (Part I) (ABS-RC2; Nihira et al., 1993a, b) was developed, based on data from two diverse UK samples of adults with intellectual disabilities living in residential services (n = 560 and 254). SABS factor and total scores showed good internal reliability in both samples (alpha 0.89-0.98), and were highly correlated with their full ABS-RC2 Part I equivalents (r = 0.97-0.99). Regression equations were calculated for SABS factor and total scores against their full ABS-RC2 Part I equivalents. Levels of agreement between predicted quartile scores (derived from the regression equations) and actual full ABS-RC2 Part I quartile scores were high (kappa 0.75-0.89; percentage agreement 82%-92%). It is concluded that the SABS is a potentially useful research tool, although further work is clearly needed to establish the reliability and cross-cultural validity of the instrument.

Factors associated with intended staff turnover and job search behaviour in services for people with intellectual disability

Staff turnover is a major problem in services for people with intellectual disability (ID). Therefore, understanding the reasons for staff turnover is vital for organizations seeking to improve their performance. The present study investigates the factors directly and indirectly associated with an intention to leave an organization and actual job search behaviour amongst staff in services for people with ID. As part of a large-scale survey of staff in services for people with ID, information was collected from 450 staff concerning intended turnover, job search behaviour and a wide range of factors potentially associated with these outcomes. Path analyses revealed that work satisfaction, job strain, younger staff age and easier subjective labour conditions were directly associated with intended turnover. The same factors, with the exception of younger staff age, were also directly associated with job search behaviour. Factors indirectly associated with these outcomes included wishful thinking, alienative commitment to the organization, lack of staff support, role ambiguity, working longer contracted hours, having a low-status job, a lack of influence over decisions at work and less orientation to working in community settings with people with ID. The models of staff turnover empirically derived in the present study confirm and extend previous research in this area. The implications for organizations are discussed.