Oliver Chadwick

Psychiatric diagnoses and behaviour problems from childhood to early adolescence in young people with severe intellectual disabilities

BACKGROUND While general population studies indicate an increase in the rate of psychiatric disorder in adolescence, little is known about the course of mental health and behaviour problems between childhood and adolescence in young people with severe intellectual disabilities. METHOD From a sample of 111 children with severe intellectual disability who had been identified from the registers of six special schools at 4-11 years of age, 82 were traced and reassessed 5 years later at the age of 11-17 years. Behaviour problems were assessed by means of parental interviews conducted in the family home and parent and teacher questionnaires. Parental reports of psychiatric diagnoses were checked against health records. RESULTS With most behaviour problems, including aggression, destructive behaviour and self-injury, there was little difference in rates between the two assessment occasions. However, in spite of this overall pattern of stability, the rates of some behaviour problems, including overactivity, showed significant reductions between childhood and early adolescence. Persistence rates for most behaviour problems appeared comparable to those reported for similar behaviours in general population studies of children. There was no significant difference in the proportion of cases with psychiatric diagnoses between the two assessment occasions, although brief psychotic episodes emerged in three cases in adolescence. CONCLUSIONS The findings suggest that the prevalence of mental health and behavioural problems in young people with severe learning disabilities remains relatively stable between childhood and adolescence, although some specific behaviour problems diminish. However, a small minority of children may develop severe psychiatric disorders in adolescence.

Randomized controlled double-blind trial of optimal dose methylphenidate in children and adolescents with severe attention deficit hyperactivity disorder and intellectual disability

BACKGROUND Attention deficit hyperactivity disorder is increased in children with intellectual disability. Previous research has suggested stimulants are less effective than in typically developing children but no studies have titrated medication for individual optimal dosing or tested the effects for longer than 4 weeks. METHOD One hundred and twenty two drug-free children aged 7-15 with hyperkinetic disorder and IQ 30-69 were recruited to a double-blind, placebo-controlled trial that randomized participants using minimization by probability, stratified by referral source and IQ level in a one to one ratio. Methylphenidate was compared with placebo. Dose titration comprised at least 1 week each of low (0.5 mg/kg/day), medium (1.0 mg/kg/day) and high dose (1.5 mg/kg/day). Parent and teacher Attention deficit hyperactivity disorder (ADHD) index of the Conners Rating Scale-Short Version at 16 weeks provided the primary outcome measures. Clinical response was determined with the Clinical Global Impressions scale (CGI-I). Adverse effects were evaluated by a parent-rated questionnaire, weight, pulse and blood pressure. Analyses were by intention to treat. TRIAL REGISTRATION ISRCTN 68384912. RESULTS Methylphenidate was superior to placebo with effect sizes of 0.39 [95% confidence intervals (CIs) 0.09, 0.70] and 0.52 (95% CIs 0.23, 0.82) for the parent and teacher Conners ADHD index. Four (7%) children on placebo versus 24 (40%) of those on methylphenidate were judged improved or much improved on the CGI. IQ and autistic symptoms did not affect treatment efficacy. Active medication was associated with sleep difficulty, loss of appetite and weight loss but there were no significant differences in pulse or blood pressure. CONCLUSIONS Optimal dosing of methylphenidate is practical and effective in some children with hyperkinetic disorder and intellectual disability. Adverse effects typical of methylphenidate were seen and medication use may require close monitoring in this vulnerable group.

Self-Report of Attention Deficit and Hyperactivity Disorder in Adolescents

The validity of self-report measurement varies widely according to the type of behaviour investigated. For behaviour of overactivity and inattention, adolescents seem to underestimate their problems. Well validated instruments for self-report of attention deficit and hyperactivity disorder (ADHD) are lacking yet, and research on ADHD beyond childhood relies quite heavily on self-report. In this study, an attempt is made to validate an adolescent interview scale for DSM-based ADHD symptoms. Results show that the measure has a high inter-rater reliability and is a good predictor of general outcome. However, adolescents do not validly report on symptoms specifically of ADHD. Possible implications for research and clinical practice are formulated.

A RANDOMIZED TRIAL OF BRIEF INDIVIDUAL VERSUS GROUP PARENT TRAINING FOR BEHAVIOUR PROBLEMS IN CHILDREN WITH SEVERE LEARNING DISABILITIES

Primary school aged children with severe learning disabilities and behavioural problems were identified from those attending special needs schools in three adjacent Inner London boroughs. In two of the boroughs their parents/carers were randomly allocated to receive 5-7 group- or individually-based intervention sessions aimed at preventing or reducing their childs behaviour problems; teaching and support staff at their schools received a 2-day workshop with the same aims. Children in the third borough served as a “no treatment” control group. Follow-up assessments were carried out shortly after the interventions were completed and 6 months later. Individually-based intervention was superior to group-based intervention in acceptability, attendance, levels of participant satisfaction and the likelihood of reported behavioural improvement. Within the individual intervention group, behaviours that had been targeted for intervention were more likely to show improvements than those that were untargeted. However, in spite of these improvements, there were no significant differences between groups in the absolute frequency or severity of the childs behaviour problems at either post-intervention assessment, and reductions in levels of parental distress noted on completion of the interventions were no longer apparent 6 months later.

Factors associated with the risk of behaviour problems in adolescents with severe intellectual disabilities

BACKGROUND Little is known about the factors affecting the risk of behavioural and emotional problems in young people with severe intellectual disability (ID), although such evidence as there is suggests that there may be differences between the pattern of risk factors in this group and those that operate in general population samples of the same age. METHOD From a sample of 111 children with severe ID who had been initially identified from the registers of six special schools at 4-11 years, 82 were traced and reassessed on average 5 years 4 months later. The relationships between potential risk factors and behaviour problems, reported here for 11:00-17:04 year olds, were assessed by means of parental interview conducted in the family home. RESULTS Behaviour problems were associated with the severity of ID and the severity of autistic symptomatology. Perhaps surprisingly, they were also more common in pre-pubertal than post-pubertal adolescents. Family factors such as a history of interrupted/disrupted maternal care, parental criticism of the child and aggressive parental disciplinary practices were also associated with behaviour problems, although the direction of causation was unclear. Several factors, including gender, social disadvantage and epilepsy, well established as risk factors in children without ID, were not significantly associated with behaviour problems in the present sample. CONCLUSION The findings suggest that the pattern of factors associated with behaviour problems in children with severe ID differs from that found both in the general population and in children with mild ID.

Respite Care for Children with Severe Intellectual Disability and their Families: Who Needs It? Who Receives It?

Need for, and receipt of, respite care services were examined in a representative sample of 103 5-11-year-old children with severe intellectual disability and their families. Children for whom respite care was wanted had significantly more severe disabilities and behaviour problems than those whose parents felt they did not need it; their parents also reported significantly higher levels of stress. However, among those who wanted respite care, none of these factors appeared relevant to whether or not they had received it. The results suggest the need for greater account to be taken of the severity of the childs behaviour problems and intellectual disabilities in the allocation of respite care services, and also for measures to improve the supply of respite care placements capable of managing children with more challenging behaviour.

Hyperactivity and Reading Disability: A Longitudinal Study of the Nature of the Association

In order to investigate the possible causal relationships between hyperactivity and educational underachievement that might account for their frequent co-occurrence, four groups of boys, defined by the presence or absence of hyperactivity and specific reading retardation, were identified in an epidemiological study of 7 8-year-old children. They were examined in detail by means of parental interviews and psychological tests and reassessed 9 years later at the age of 16-18 years on a similar range of measures. The findings provided little support for the idea that persistent reading disabilities either lead to the development of hyperactivity de novo or increased the likelihood that hyperactivity, when present, would persist. Similarly, although features of hyperactivity persisted to follow-up, there was little evidence that they either lead to the development of reading disabilities or increased the likelihood that reading disabilities, when present, would persist. Socioeconomic adversity and a history of speech therapy were more common in the group with both hyperactivity and reading disability, but the strength of these associations made it unlikely that these factors could account for the frequent co-occurrence of the two conditions.

The adolescent outcome of hyperactive girls:self-reported interpersonal relationships and coping mechanisms

Abstract The aim of the study was to clarify the developmental risk for interpersonal relationship problems and ineffective coping strategies associated with hyperactive behaviour in girls in a longitudinal epidemiological design. This was investigated in a follow-up study of girls who were identified by parent and teacher ratings in a large community survey of 6- and 7-year-olds as showing pervasive hyperactivity or conduct problems or the comorbid mixture of both problems or neither problem. They were later investigated, at the age of 14–16 years, in a detailed interview. Childhood hyperactivity was a risk for disrupted relationships in adolescence with peers and the opposite sex, but not parents. Findings were independent of the existence of conduct problems. Hyperactivity was a risk for the use of a wide variety of ineffective coping strategies. On the other hand, conduct problem girls reported applying specific coping strategies, but rated these to be ineffective. It is concluded that early therapeutic interventions targeting the development of social skills and problem-solving skills are required in order to help overcome these problems in later life.

The effect of off-task behaviors on the task performance of hyperkinetic children

Hyperactive children have been observed to be off-task more frequently during experimental tasks compared with controls. It is possible that these off-task behaviors could directly account for their poor task performance.