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Mania and behavioral equivalents: A preliminary study
Research in Developmental Disabilities 31 (2010) 1008–1014
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Research in Developmental Disabilities
Mania and behavioral equivalents: A preliminary study Peter Sturmey a, Rinita B. Laud b, Christopher L. Cooper b, Johnny L. Matson b, Jill C. Fodstad b,* a b
Department of Psychology, Queens College, and the Graduate Center, City University of New York, United States Department of Psychology, Louisiana State University, Gonzales, LA 70737, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 March 2010 Received in revised form 3 April 2010 Accepted 19 April 2010
Previous research has failed to address the possibility of behavioral equivalents in people with ID and mania. The relationship between a measure of mania and possible behavioral equivalents was assessed in 693 adults, most with severe or profound ID, living in a large residential setting. The mania subscale of the DASH-II proved to be a homogenous scale, suggesting that this may be a valid measure of mania in individuals with ID. Both item and factor analyses and correlations showed that many behavioral items acceptably correlated with the mania items. There may be some challenging behaviors that are related to mania in individuals with ID. A factor analysis noted a decreased need for sleep, restlessness, agitation, and irritability as items associated with mania. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Challenging behaviors Mania Behavioral equivalents DASH-II Intellectual disability
Individuals with intellectual disability (ID) are often observed to exhibit pervasive symptoms associated with psychiatric illness. In fact, researchers have posited that individuals with ID are more likely to suffer from psychopathology than the general population (Borthwick-Duffy, 1994). With prevalence estimates ranging from 0.9% to 4.8% and upwards (BorthwickDuffy, 1994; Deb, Thomas, & Bright, 2001), bipolar disorders are one mental health category which significantly impacts the quality of life for those with ID. According to the Diagnostic and Statistical Manual-Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000), bipolar disorder is a collection of mood disorders (i.e., Bipolar I, Bipolar II, Cyclothymia, Bipolar Disorder-Not otherwise Specified, etc.) characterized by depressive and/or manic symptoms. Per the DSM-IV-TR (APA, 2000), a major depressive episode occurs when an individual presents with pervasive impairments in areas such as depressed mood/sadness most of the day, diminished interest in preferred activities, feelings of worthlessness, diminished ability to think, and recurrent thoughts of death. For a Manic Episode, the DSM-IV-TR (APA, 2000) indicates that a person must experience impaired functioning due to presenting symptoms including inflated self-esteem, decreased need for sleep, pressured speech, psychomotor agitation, and involvement in risky activities. Through multiple investigations including a series of descriptive case studies (Sovner & Hurley, 1982a; Sovner & Hurley, 1982b), an observational study (Lowry & Sovner, 1992), and a literature review (Sovner, 1990), Sovner and Hurley were one of the first to establish that people with intellectual disabilities (IDs) do present with affective disorders, including symptoms consistent with mania. A number of more recent studies have investigated psychopathology in people diagnosed with ID and bipolar disorder (Bamburg, Cherry, Matson, & Penn, 2001; Dawson, Matson, & Cherry, 1998; Holden & Gitlesen, 2008; Matson, Cooper, Malone, & Moskow, 2008; Myrbakk & von Tetzchner, 2008). Cain et al. (2003) conducted a retrospective chart review study of 166 people with varying levels of ID (75% had borderline to moderate ID) referred to a clinic for assessment and treatment of aggressive behavior or complex behavioral or psychiatric disorders. Participants were placed into one of four psychopathology groups: bipolar disorder (n = 69), non-psychotic depression (n = 19), major depression with psychosis
* Corresponding author. E-mail address: [email protected] (J.C. Fodstad). 0891-4222/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2010.04.017
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(n = 30), and schizophrenia or psychotic disorder NOS (n = 48). Results indicated that when groups were compared, participants with bipolar disorder significantly differed from the other psychopathology groups in a variety of ways. First, participants diagnosed with bipolar disorder were more likely to show more mood (e.g., irritability, elevated mood, and euphoric mood) and non-mood (i.e., increased self-esteem, disturbed speech, increased energy, decreased need for sleep, disturbed ideation, distractibility, and decrease in engaging in previously pleasurable activities) symptoms. Second, participants in the bipolar group were more likely to show a range of challenging behaviors such as physical aggression, defiance, property destruction, self-injury, impulsivity, manipulative behavior, attention seeking, teasing, and intrusiveness. Lastly, participants with bipolar disorder were more likely to show a range of functional impairments, including impairments related to peers, staff, activities of daily living, and work. Based on these findings, Cain et al. (2003) concluded that individuals with bipolar disorder were more likely to be at an increased risk for having a wide range of problems, including behavioral challenges. Vanstraelen and Tyrer (1999) conducted a systematic literature review of rapid cycling bipolar affective disorders in people with ID using Medline and Psychlit. They located only 14 papers with a total of 40 participants. Most papers were on descriptive psychopathology and treatment; however, one study was on rating scales for mood disorders. The most commonly reported symptoms were observable behaviors, rather than self-reported mood states, such as episodes of mania, insomnia, hypersomnia, increased activity, pressured speech, agitation, withdrawal, and hyperactivity. While the literature posits that symptoms of bipolar disorder can be detected and diagnosed in individuals with mild and moderate ID, research on symptom expression has not been well recognized in those with severe to profound levels of ID (Cain et al., 2003; Sturmey, 2005). Historically, diagnosing bipolar disorder in the ID population is regarded as challenging due to deficits in communication skills, limitations in the ability to recognize and express feelings and thoughts, atypical symptom presentation, and a lack of clear diagnostic criteria (Arumainayagam & Kumar, 1990; Ross & Oliver, 2003; Sturmey, 2005). For those with severe and profound ID, the vast majority of these individuals are completely non-verbal. As such, the use of self-report is rendered useless since deficits associated with severe and profound ID make reporting feelings and moods difficult for the individual. Due to this under reliance on more traditional methods to assess psychopathology, misdiagnosing bipolar disorders in those with ID has become a common problem. This is primarily due to under-reporting of depressive and manic symptoms by parents and/or caregivers. While the DSM-IV-TR does contain items that do not require vast insight by the individual in terms of feelings and emotions (i.e., distractibility, excessive involvement in pleasurable activities, decreased need for sleep), there are still some criteria that are not always easy to apply to individuals who are not capable of communicating to others. For this reason, Sovner (1990) proposed that, instead of relying solely on current diagnostic classification (i.e., DSM-IV-TR and ICD-10) of depression and mania, clinicians and researchers should extrapolate, or make minor revisions to current diagnostic schemes to include overt behaviors (i.e., behavioral equivalents) which capture manic and depressed states in those with ID. Furthermore, through using this technique, the diagnostic process would become easier for clinicians assessing presenting symptoms. Since Sovner first suggested the utility of relying on alternative measures of bipolar disorder for those with ID, the notion of using behavioral equivalents of psychopathology ID has received increasing attention (Cooper, 2003; Cooper, Melville, & Einfeld, 2003; Ross & Oliver, 2003). However, upon closer investigation, the majority of literature pertaining to behavioral equivalency and mood/bipolar disorders in those with ID is largely relegated to depression and/or general mood disturbances (Charlot, 2005; Smiley & Cooper, 2003; Sturmey, Matson, & Lott, 2004; Sturmey, Tsiouris, & Patti, 2004; Tsiouris, Mann, Patti, & Sturmey, 2003; Tsiouris, Mann, Patti, & Sturmey, 2004). As such, there is a dearth of information related to behavioral equivalents of mania. In a case study, Lowry and Sovner (1992) utilized observational data to deduce possible behavioral equivalents of mood liability and mania in an individual diagnosed as having autistic disorder and profound ID. Target behaviors which were operationally defined as being observable indices of mood disturbances included excessive smiling and/or laughing, meal refusal, sleeping, and food requests. Target behaviors of mania were self-injury and physical aggression. The researchers found that, with regards to symptoms of mood disturbance and mania, there was close covariation between observable behaviors which indexed mood and overt challenging behaviors (i.e., when an increase or decrease in behaviors associated with mood lability occurred there was an increase or decrease in manic behaviors, and vice versa). Given these results, Lowry and Sovner concluded that challenging behaviors appeared to be state-dependent indices of bipolar disorder. Other researchers have reached similar outcomes to those of Lowry and Sovner (1992). Osborne, Baggs, Darvish, and Blakelock (1992) reported on the behavioral treatment of possible ‘‘rapid cycling bipolar disorder’’ in a female with profound ID. Through extensive behavioral observations and antecedent-based data collection, mood dysfunctions were deduced to be punitively manifested through self-injury. Reid and Leonard (1977) treated ‘‘rapid cycling’’ self-induced vomiting with lithium based on the hypothesis that the individual’s self-injury was a manifestation of an underlying bipolar disorder. Weisler, Campbell, and Sonis (1988) used a rating scale system to track the rapid cycling of a male diagnosed with moderate ID and bipolar disorder using twice-daily ratings of mood and energy. The ratings of ‘‘energy’’ may have tapped a variety of behavioral manifestations of bipolar disorder. In an investigation by Rojahn, Matson, Naglieri, and Mayville (2004), correlations between the presence of behavior problems (i.e., self-injury, stereotypy, or aggressive/destructive behavior) and psychiatric symptoms were examined. These researchers found that individuals with ID who had serious aggressive/ destructive behavior were more likely to have extreme scores for depression and mania on a standardized measure of psychopathology.
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There is some evidence in the literature for possible behavioral manifestations of mania in individuals with ID. However, the research on this topic is limited by the use of individual case studies, small sample sizes, the exclusion of individuals with severe and profound ID, and a lack of explicit rationales or adequate statistical analyses to test the hypothesis that challenging behaviors are behavioral equivalents of mania. Thus, the aim of this study is to extend previous research with regard to mania and attempt to establish behavioral equivalents of mania in individuals with ID. To examine the relationship between mania symptoms and overt behaviors, we utilized a standardized psychometric measure of mania for persons with ID, the Diagnostic Assessment for the Severely Handicapped-II (DASH-II; Matson, 1998). The DASH-II has been found to be a valid and reliable measure of psychopathology in adults with ID (see Section 1.2). Therefore, this measure should be sensitive enough to detect if there is a relationship between the expression of mania and observable behavioral equivalents in a large sample of adults with predominantly severe and profound ID. Additionally, a variety of challenging behaviors (i.e., stereotypy, impulse control, and self-injury) were included in our model of mania to better capture possible overt signs of mania. 1. Method 1.1. Participants Participants were 693 individuals who were residing at an Intermediate Care Facility for the Mentally Retarded (ICF-MR) accredited residential setting at the time of this study. This center provides medical and habilitation services to individuals diagnosed as functioning within the range of ID. There were 394 men (56.9%) and 299 women (43.1%). The average age of the participants was 48 years (SD = 15). The majority of the participants were Caucasian (n = 517; 74.6%); however, there were also individuals of African-American (n = 173; 25.0%), Hispanic (n = 2; 0.3%) and other (n = 1; 0.1%) ethnic origins. Varying levels of ID were included in this sample with 18 (2.6%) individuals having mild, 38 (5.5%) moderate, 89 (79.1%) severe, and 548 (79.1%) profound ID. Level of ID had been previously determined through a comprehensive evaluation by a licensed psychologist using the DSM-IV-TR (APA, 2000) criteria along with the following measures: standardized measures of intelligence (e.g., Stanford Binet-IV or the Leiter), behavioral observations, the Vineland Adaptive Behavior Scales (VABS; Sparrow, Balla, & Cicchetti, 1984), and the Matson Evaluation of Social Skills for the Severely Retarded (MESSIER; Matson, 1995). Participant groups were established based on the presence of psychopathology, specifically participants with ID and mania (n = 21) or ID without mania (n = 672). The 21 individuals included in the mania group were, at the time of data collection, found to be exhibiting significant and pervasive symptoms consistent with a diagnosis of a Manic Episode. Diagnoses of mania were determined by a licensed psychologist and a board certified psychiatrist using the DSM-IV-TR criteria, a mental status exam, a review of available records, staff interviews, and behavioral observations. 1.2. Measures Diagnostic Assessment for the Severely Handicapped-II (DASH-II; Matson, 1998). The DASH-II is an 84-item, informantbased questionnaire representing 113 diagnostic categories designed to assess behavioral and psychiatric symptoms among individuals with severe and profound levels of intellectual disability. The 13 subscales are (1) anxiety; (2) depression; (3) mania; (4) pervasive developmental disabilities/Autism; (5) schizophrenia; (6) stereotypy; (7) self-injury; (8) elimination disorders; (9) eating disorder; (10) sleep disorders; (11) sexual disorders; (12) organic syndromes; and (13) impulse control and other miscellaneous behaviors (Sturmey, Matson, et al., 2004). Each item is rated on a 3-point Likert-type rating scale with respect to frequency (0 = not at all; 1 = 1 to 10 times; 2 = more than 10 times), duration (0 = less than a month, 1 = 1–12 months, 2 = over 12 months), and severity (0 = no disruption or damage, 1 = no injury or damage but interrupted others; 2 = property damage or injury). For the purposes of this investigation, only the frequency ratings were retained for data analyses. Acceptable psychometric properties of the DASH-II have been established with good inter-rater (r = 0.86) and test– retest reliability (r = 0.84) and good to excellent validity of individual DASH-II subscales (Matson & Smiroldo, 1997; Matson et al., 1999). 1.3. Procedure Each participant received a comprehensive battery of mental health and other measures on a yearly basis as part of their annual assessment. These measures included the DASH-II (Matson, 1998). The DASH-II was administered to a direct-care staff member who had worked with the participant for a minimum of 6 months prior to the study. The assessors were master’s level clinical psychology doctoral students. These individuals were trained in administering the DASH-II and were supervised by a licensed psychologist. No prior informed consent was needed as the data was archival and no identifying information was used. Data collection and storage were conducted in accordance with accepted procedures to secure participant confidentiality. This study was approved by the Institutional Review Boards of Louisiana State University and the Louisiana Office for Citizens with Developmental Disabilities. 1.4. Statistical analyses The statistical analyses conducted here paralleled those reported in Tsiouris et al. (2003, 2004), which dealt with detecting behavioral equivalents of depression in individuals with ID. First, an item analysis was conducted on the DASH-II
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Table 1 The means and standard deviations for the DASH-II mania scale. Item
Means (SDs) All (n = 693)
Not manic (n = 672)
Manic (n = 21)
9. Is restless or agitated 16. Has decreased need for sleep 26. Is cranky or irritable 38. Is easily distracted 47. Is extremely happy or cheerful for no obvious reason 62. Talks loudly 69. Talks quickly
.27 .05 .28 .28 .15
.26 .05 .28 .27 .14
.52 .43 .38 .48 .38
* **
Item-total correlation
(.57) (.30) (.57) (.61) (.45)
.10 (.42) .05 (.31)
(.56) (.28) (.56) (.60) (.44)
.10 (.41) .05 (.29)
(.81)* (.68)** (.74) (.87) (.74)*
.51 .31 .48 .32 .37
.29 (.64)* .29 (.72)**
.33 .39
p < .05. p < .01.
mania subscale frequency items to identify a homogenous group of items measuring mania in this population. The means of the manic and non-manic groups on each item were then compared using multiple t-tests. Next, a new mania scale was created by adding the items from the following DASH-II subscales: Stereotypy (7 items), self-injury (5 items), mania (7 items), and control and miscellaneous behavior problems (17 items). In addition to items from the mania subscale, potential behavioral mania equivalents included the items ‘‘curses’’ and ‘‘is easily frustrated by the difficulty of the task.’’ An item analysis was then performed on this new scale to identify if behavioral equivalents were related to items from the mania subscale. If maladaptive behaviors were behavioral equivalents related to mania, then they should be correlated with the total score of this new mania scale. Another test of the hypothesis that maladaptive behaviors are behavioral equivalents is that the scores on items from the mania subscale should correlate with the maladaptive behaviors when combined in a new scale of mania. Multiple correlations were performed between the scores on the new mania scale and individual maladaptive items on the DASH-II. In order to correct for false positives the value of alpha was set to .01. Finally, if maladaptive behaviors are behavioral equivalents of mania, then a factor analysis should include factors that have both mania and behavioral equivalent items. A principal components analysis with varimax rotation was performed using items from the mania, stereotypy, self-injury, and impulse control and miscellaneous behavior problems subscales. 2. Results 2.1. Item analysis of the DASH-II mania scale Results of statistical analyses indicated that the DASH-II mania scale Cronbach’s alpha value was .67. This was comparable to previous reports of .61 (Matson, Coe, Gardner, & Sovner, 1991) and .52 (Matson, Gardner, Coe, & Sovner, 1991). The itemtotal (minus item) correlations were good (Mdn = .37, range .31–.51). The means and standard deviations of the items from the mania scale are reported in Table 1. When looking at mean frequency endorsement rates for all participants (i.e., both those with or without mania), the mean scores for 5 out of 7 items were greater than .05 with only 2 items (‘‘decreased need for sleep’’ and ‘‘talks quickly’’) being at or close to .05. The mean for the mania scale when all participants were included in the analysis was 1.19 (SD = 1.93). When the scores of people with and without mania were compared using multiple, onetailed t-tests the mean of people with mania was higher than people without mania on 5 of 7 items with those items being ‘‘is restless or agitated,’’ ‘‘has decreased need for sleep,’’ ‘‘is extremely happy or cheerful for no obvious reason,’’ ‘‘talks loudly,’’ and ‘‘talks quickly.’’ 2.2. Mania and behavioral equivalents The Cronbach’s alpha value for the total 36-item scale was .84, indicating a highly homogenous scale. The results of the item analysis for the entire scale and for groups of items from the stereotypy, self-injury, and impulse control subscales are summarized in Table 2. The median (and range) of item-total (minus item) correlations for behavioral items was .33 ( .024
Table 2 Median and range of item-total point bi-serial correlations for all items, stereotypies, self-injurious items and impulse control and miscellaneous behavior problem items. Group of items
Number of items
Median (and range) of item-total correlations
All items Sterotypies/tics Self-injurious behavior Impulse control, etc.
36 7 5 17
.33 .33 .27 .36
( .02 to .55) (.13 to .38) (.10 to .37) (.02 to .55)
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to .557), indicating that just over half of the behavioral items were acceptably correlated with the scale total and overlapped in value with some of the mania items. Table 2 shows that many behavioral items were as closely related to the scale total as were mania items. The behavioral items with the highest item-total correlations included ‘‘unprovoked screaming/yelling’’ (.56), ‘‘unprovoked temper tantrum/rage’’ (.50), ‘‘excessive need for attention’’ (.44), ‘‘easily frustrated’’ (.42), and ‘‘talks about the same subject or concern over and over’’ (.41). Four of these top 5 items came from the impulse control and miscellaneous behavior problems scale. The mean for this new scale was 5.52 (SD = 7.00). Correlations between individual behavioral items and the total of the mania scale were calculated. Of 36 correlations, 30 were significant at the .01 level of significance or better. 2.3. Factor analysis of mania and behavioral items The first 10 factors accounted for 19.4%, 7.2%, 5.9%, 4.7%, 4.2%, 4.0%, 3.5%, 3.4%, 3.3%, and 3.1% of the variance. All Eigenvalues for these factors were greater than 1.0. The scatterplot was somewhat ambiguous as the ‘‘elbow’’ in the screeplot was not clearly discernable. It was possible that there were 3 or 4 factors based on a review of the scatterplot. Therefore, the pattern of item loadings on the first 4 factors was reviewed (see Table 3). The first factor was characterized by externally directed verbal maladaptive items from the impulse control scale, such as ‘‘curses’’ and ‘‘verbally abuses others.’’ Items which loaded on the Factor 1 from the mania subscale of the DASH-II included ‘‘talks loudly,’’ ‘‘talks quickly,’’ and ‘‘cranky/ irritable.’’ The mania item ‘‘cranky/irritable’’ had a modest loading of .33 on this factor, but was noted to have a larger loading of .56 on Factor 4. Factor 2 was characterized by externally directed challenging behaviors from the impulse control scale, but most of which were non-verbal (e.g., ‘‘excessive need for attention’’ and ‘‘throws objects at people’’). Only one mania item loaded on this factor, which was ‘‘is easily distracted.’’ Factor 3 was characterized by items relating to stereotypical behaviors, such as ‘‘twitching, tapping, and yelling’’ and ‘‘repeats the same words.’’ The only mania item that loaded on this factor was ‘‘is extremely happy.’’ Factor 4 had larger loading from 3 items from the DASH-II mania subscale: ‘‘cranky/ irritable,’’ ‘‘decreased need for sleep,’’ and ‘‘restless agitated.’’ The item with the largest factor loading on this scale was ‘‘runs away.’’ Thus, this factor perhaps characterizes some aspects of behaviors related to mania and included a range of externally directed behaviors, some of which reflected increased motor behavior and some of which were not obviously related to mania. The fifth and sixth factors were both items characterized by loadings on couplets of similarly worded items. Factor 5 had loadings on two self-injury items (‘‘hits self’’ (.68) and ‘‘bangs head’’ (.59)). Factor 6 was characterized by loadings on 2 items: ‘‘sucks or mouths’’ (.75) and ‘‘bites self’’ (.69). Thus, these latter 2 factors were not very meaningful. Overall, the first 4 Table 3 Factor loadings on the first four factors of the principal component analysis with varimax rotation of the mania and behavioral items. Item
Factor 2
82. Curses 55. Verbally abuses people 49. Talks about the same subject or concern over and over 69. Talks quickly 62. Talks loudly 73. Is easily frustrated by the difficulty of a task 26. Is cranky or irritable 5. Exhibits excessive need for attention or approval from others 83. Exhibits excessive need for attention or approval from others 13. Throws objects at people 38. Is easily distracted 12. Is impatient when waiting for needs or demands to be met 1. Hits, kicks, or pinches other people 36. Exhibits a period of sudden motor or vocal activity such as twitching, tapping, or yelling 41. Repeats the same words or sounds 31. Engages in repetitive body movements such as rocking, spinning, or handflapping 47. Is extremely happy or cheerful for no obvious reason 69. Talks quickly 21. Amuses self with limited set of objects or highly repetitive activities 9. Is restless or agitated 23. Runs away from supervision 16. Has decreased need for sleep 9. Is restless and agitated 1. Hits, kicks, or pinches other people 20. Displays unprovoked temper tantrum or rage 30. Resists instruction or guidance from family or staff 50. Engages in unprovoked screaming or yelling
.82 .74 .58 .50 .55 .36 .33
Factor 2
Factor 3
Factor 4
.42 .50
.56 .80 .84 .51 .47 .42 .37 .64 .63 .52 .51 .50 .46 .32
Note: Only factor loadings greater than .3 in absolute value are included. Items from the DASH-II mania subscale are bolded.
.59 .57 .54 .52 .48 .48 .33
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factors appeared to be psychologically meaningful. Of all the factors which emerged from the factor analysis, Factor 4 was the salient measure of mania (i.e., contained the most items from the DASH-II with the highest factor loadings, thus most closely related to mania) which also included some challenging behaviors. 3. Discussion These data indicate that there may be some challenging behaviors that are related to mania. The item analysis indicated that the DASH-II mania scale is homogenous and 5 of 8 of the items differentiated people with and without mania. These observations suggest that this scale may be a valid measure of mania (Matson & Smiroldo, 1997). The item analysis of the extended scale, which included a variety of other challenging behaviors, found a tendency for larger item-total correlations between a number of items from the impulse control and miscellaneous behavior problems subscale of the DASH-II. The results of the factor analysis were ambiguous as to the number of factors, but the first 3 factors accounted for the greatest amount of the variance. If Factor 4 should be considered a mania factor, then other motor challenging behavior items, such as ‘‘running away’’ and ‘‘restless/agitated’’ should be considered candidates for behavioral equivalents of mania. These results are similar to previous work in this area. For example, Vanstraelen and Tyrer’s (1999) review of rapid cycling bipolar disorders in people with ID noted sleep disturbances as being reported in the case studies they reviewed. Similarly, our factor analysis noted a decreased need for sleep, restlessness, agitation, and irritability as items associated with mania. In contrast, Cain et al. (2003) noted a very broad range of challenging behaviors associated with mania. The findings of this study and related investigations raise the possibility of behavioral equivalents of mania in people with ID; however, the specificity of the associations has not yet been strongly tested. Although across all of these studies aggression and sleep disturbance were reported to be associated with mania, an association has also been reported in various investigations of behavioral equivalents of depression (Marston, Perry, & Roy, 1997; Reiss & Rojahn, 1993), whereas other researchers have not found such an association (Sturmey et al., 2010; Sturmey, Matson, et al., 2004; Sturmey, Tsiouris, et al., 2004; Tsiouris et al., 2003). Future research should build on these preliminary reports of associations between challenging behaviors and psychiatric disorders in people with ID. Specifically, a more fine-grained analysis to evaluate if any of these associations are as specific as might be hoped. Clinicians are instructed to interpret these results with caution as the associations between challenging behaviors and psychiatric disorders reported here and in similar investigations are not sufficient enough to use as evidence to support using certain behavioral equivalents as support for a diagnosis of psychopathology. Each individual is different and, therefore, the clinician should ascertain clear evidence of core symptoms of a mental health disorder on a case-by-case basis. Relying merely on the presence of a challenging behavior or even a challenging behavior coupled with a positive/ clinically significant psychopathology based on direct care staff reports may not be accurate. Therefore, at this time, clinicians should continue to focus on core symptoms as outlined in the current classification system (i.e., DSM-IV-TR [APA, 2000] or ICD-10 [WHO, 1992]) to aid them in the diagnosis of an emotional/mood-related disorder. 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British Journal of Psychiatry, 159, 404–409. Matson, J. L., Rush, K. S., Hamilton, M., Anderson, S. J., Bamburg, J. W., Baglio, C. S., et al. (1999). Characteristics of depression as assessed by the diagnostic assessment for the severely handicapped-II (DASHII). Research in Developmental Disabilities, 20, 305–313. Matson, J. L., & Smiroldo, B. S. (1997). Validity of the mania subscale of the DASH II. Research in Developmental Disabilities, 18, 221–226. Myrbakk, E., & von Tetzchner, S. (2008). Psychiatric disorders and behavior in people with intellectual disability. Research in Developmental Disabilities, 29, 316– 332. Osborne, J. G., Baggs, A. W., Darvish, R., & Blakelock, H. (1992). Cyclical self-injurious behavior, contingent water mist treatment, and the possibility of rapidcycling bipolar disorder. Journal of Behavior Therapy and Experimental Psychiatry, 23, 325–334. Reid, A. H, & Leonard, A. (1977). Lithium treatment of cyclical vomiting in a mentally defective patient. 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Menolascino (Eds.), Depression in mentally retarded children and adults (pp. 175–198). Netherlands: Logon Publications. Sovner, R., & Hurley, A. D. (1982a). Diagnosing depression in the mentally retarded. Psychiatric Aspects of Mental Retardation Newsletter, 1, 1–3. Sovner, R., & Hurley, A. D. (1982b). Diagnosing mania in the mentally retarded. Psychiatric Aspects of Mental Retardation Newsletter, 1, 9–11. Sparrow, S., Balla, D., & Cicchetti, D. V. (1984). The Vineland Adaptive Behavior Scales (Survey Form). Circle Pines, MN: American Guidance Service. Sturmey, P. (2005). Mood disorders in people with mental retardation. Kingston, NY: NADD Press. Sturmey, P., Laud, R. B., Cooper, C. L., Matson, J. L., & Fodstad, J. C. (2010). Challenging behaviors should not be considered depressive equivalents in individuals with intellectual disabilities. II. A replication study. Research in Developmental Disabilities, 31, 1002–1007. Sturmey, P., Matson, J. L., & Lott, J. D. (2004). The factor structure of the DASH-II. Journal of Developmental and Physical Disabilities, 16, 247–255. Sturmey, P., Tsiouris, J. A., & Patti, P. J. (2004). Symptoms of depression: A Bayesian analysis. Journal of Physical and Developmental Disabilities, 29, 65–69. Tsiouris, J. A., Mann, R., Patti, P. J., & Sturmey, P. (2003). Challenging behaviours should not be considered as depressive equivalents in individuals with intellectual disability. Journal of Intellectual Disability Research, 47, 14–21. Tsiouris, J. A., Mann, R., Patti, P. J., & Sturmey, P. (2004). Symptoms of depression and challenging behaviors in people with intellectual disabilities: A Bayesian analysis. Journal of Intellectual and Developmental Disabilities, 29, 65–69. Vanstraelen, M., & Tyrer, S. P. (1999). Rapid cycling bipolar affective disorder in people with intellectual disability: A systematic review. Journal of Intellectual Disability Research, 43, 349–359. Weisler, N. A., Campbell, G. J., & Sonis, W. (1988). 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Contents lists available at ScienceDirect
Research in Developmental Disabilities
Mania and behavioral equivalents: A preliminary study Peter Sturmey a, Rinita B. Laud b, Christopher L. Cooper b, Johnny L. Matson b, Jill C. Fodstad b,* a b
Department of Psychology, Queens College, and the Graduate Center, City University of New York, United States Department of Psychology, Louisiana State University, Gonzales, LA 70737, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 March 2010 Received in revised form 3 April 2010 Accepted 19 April 2010
Previous research has failed to address the possibility of behavioral equivalents in people with ID and mania. The relationship between a measure of mania and possible behavioral equivalents was assessed in 693 adults, most with severe or profound ID, living in a large residential setting. The mania subscale of the DASH-II proved to be a homogenous scale, suggesting that this may be a valid measure of mania in individuals with ID. Both item and factor analyses and correlations showed that many behavioral items acceptably correlated with the mania items. There may be some challenging behaviors that are related to mania in individuals with ID. A factor analysis noted a decreased need for sleep, restlessness, agitation, and irritability as items associated with mania. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Challenging behaviors Mania Behavioral equivalents DASH-II Intellectual disability
Individuals with intellectual disability (ID) are often observed to exhibit pervasive symptoms associated with psychiatric illness. In fact, researchers have posited that individuals with ID are more likely to suffer from psychopathology than the general population (Borthwick-Duffy, 1994). With prevalence estimates ranging from 0.9% to 4.8% and upwards (BorthwickDuffy, 1994; Deb, Thomas, & Bright, 2001), bipolar disorders are one mental health category which significantly impacts the quality of life for those with ID. According to the Diagnostic and Statistical Manual-Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000), bipolar disorder is a collection of mood disorders (i.e., Bipolar I, Bipolar II, Cyclothymia, Bipolar Disorder-Not otherwise Specified, etc.) characterized by depressive and/or manic symptoms. Per the DSM-IV-TR (APA, 2000), a major depressive episode occurs when an individual presents with pervasive impairments in areas such as depressed mood/sadness most of the day, diminished interest in preferred activities, feelings of worthlessness, diminished ability to think, and recurrent thoughts of death. For a Manic Episode, the DSM-IV-TR (APA, 2000) indicates that a person must experience impaired functioning due to presenting symptoms including inflated self-esteem, decreased need for sleep, pressured speech, psychomotor agitation, and involvement in risky activities. Through multiple investigations including a series of descriptive case studies (Sovner & Hurley, 1982a; Sovner & Hurley, 1982b), an observational study (Lowry & Sovner, 1992), and a literature review (Sovner, 1990), Sovner and Hurley were one of the first to establish that people with intellectual disabilities (IDs) do present with affective disorders, including symptoms consistent with mania. A number of more recent studies have investigated psychopathology in people diagnosed with ID and bipolar disorder (Bamburg, Cherry, Matson, & Penn, 2001; Dawson, Matson, & Cherry, 1998; Holden & Gitlesen, 2008; Matson, Cooper, Malone, & Moskow, 2008; Myrbakk & von Tetzchner, 2008). Cain et al. (2003) conducted a retrospective chart review study of 166 people with varying levels of ID (75% had borderline to moderate ID) referred to a clinic for assessment and treatment of aggressive behavior or complex behavioral or psychiatric disorders. Participants were placed into one of four psychopathology groups: bipolar disorder (n = 69), non-psychotic depression (n = 19), major depression with psychosis
* Corresponding author. E-mail address: [email protected] (J.C. Fodstad). 0891-4222/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2010.04.017
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(n = 30), and schizophrenia or psychotic disorder NOS (n = 48). Results indicated that when groups were compared, participants with bipolar disorder significantly differed from the other psychopathology groups in a variety of ways. First, participants diagnosed with bipolar disorder were more likely to show more mood (e.g., irritability, elevated mood, and euphoric mood) and non-mood (i.e., increased self-esteem, disturbed speech, increased energy, decreased need for sleep, disturbed ideation, distractibility, and decrease in engaging in previously pleasurable activities) symptoms. Second, participants in the bipolar group were more likely to show a range of challenging behaviors such as physical aggression, defiance, property destruction, self-injury, impulsivity, manipulative behavior, attention seeking, teasing, and intrusiveness. Lastly, participants with bipolar disorder were more likely to show a range of functional impairments, including impairments related to peers, staff, activities of daily living, and work. Based on these findings, Cain et al. (2003) concluded that individuals with bipolar disorder were more likely to be at an increased risk for having a wide range of problems, including behavioral challenges. Vanstraelen and Tyrer (1999) conducted a systematic literature review of rapid cycling bipolar affective disorders in people with ID using Medline and Psychlit. They located only 14 papers with a total of 40 participants. Most papers were on descriptive psychopathology and treatment; however, one study was on rating scales for mood disorders. The most commonly reported symptoms were observable behaviors, rather than self-reported mood states, such as episodes of mania, insomnia, hypersomnia, increased activity, pressured speech, agitation, withdrawal, and hyperactivity. While the literature posits that symptoms of bipolar disorder can be detected and diagnosed in individuals with mild and moderate ID, research on symptom expression has not been well recognized in those with severe to profound levels of ID (Cain et al., 2003; Sturmey, 2005). Historically, diagnosing bipolar disorder in the ID population is regarded as challenging due to deficits in communication skills, limitations in the ability to recognize and express feelings and thoughts, atypical symptom presentation, and a lack of clear diagnostic criteria (Arumainayagam & Kumar, 1990; Ross & Oliver, 2003; Sturmey, 2005). For those with severe and profound ID, the vast majority of these individuals are completely non-verbal. As such, the use of self-report is rendered useless since deficits associated with severe and profound ID make reporting feelings and moods difficult for the individual. Due to this under reliance on more traditional methods to assess psychopathology, misdiagnosing bipolar disorders in those with ID has become a common problem. This is primarily due to under-reporting of depressive and manic symptoms by parents and/or caregivers. While the DSM-IV-TR does contain items that do not require vast insight by the individual in terms of feelings and emotions (i.e., distractibility, excessive involvement in pleasurable activities, decreased need for sleep), there are still some criteria that are not always easy to apply to individuals who are not capable of communicating to others. For this reason, Sovner (1990) proposed that, instead of relying solely on current diagnostic classification (i.e., DSM-IV-TR and ICD-10) of depression and mania, clinicians and researchers should extrapolate, or make minor revisions to current diagnostic schemes to include overt behaviors (i.e., behavioral equivalents) which capture manic and depressed states in those with ID. Furthermore, through using this technique, the diagnostic process would become easier for clinicians assessing presenting symptoms. Since Sovner first suggested the utility of relying on alternative measures of bipolar disorder for those with ID, the notion of using behavioral equivalents of psychopathology ID has received increasing attention (Cooper, 2003; Cooper, Melville, & Einfeld, 2003; Ross & Oliver, 2003). However, upon closer investigation, the majority of literature pertaining to behavioral equivalency and mood/bipolar disorders in those with ID is largely relegated to depression and/or general mood disturbances (Charlot, 2005; Smiley & Cooper, 2003; Sturmey, Matson, & Lott, 2004; Sturmey, Tsiouris, & Patti, 2004; Tsiouris, Mann, Patti, & Sturmey, 2003; Tsiouris, Mann, Patti, & Sturmey, 2004). As such, there is a dearth of information related to behavioral equivalents of mania. In a case study, Lowry and Sovner (1992) utilized observational data to deduce possible behavioral equivalents of mood liability and mania in an individual diagnosed as having autistic disorder and profound ID. Target behaviors which were operationally defined as being observable indices of mood disturbances included excessive smiling and/or laughing, meal refusal, sleeping, and food requests. Target behaviors of mania were self-injury and physical aggression. The researchers found that, with regards to symptoms of mood disturbance and mania, there was close covariation between observable behaviors which indexed mood and overt challenging behaviors (i.e., when an increase or decrease in behaviors associated with mood lability occurred there was an increase or decrease in manic behaviors, and vice versa). Given these results, Lowry and Sovner concluded that challenging behaviors appeared to be state-dependent indices of bipolar disorder. Other researchers have reached similar outcomes to those of Lowry and Sovner (1992). Osborne, Baggs, Darvish, and Blakelock (1992) reported on the behavioral treatment of possible ‘‘rapid cycling bipolar disorder’’ in a female with profound ID. Through extensive behavioral observations and antecedent-based data collection, mood dysfunctions were deduced to be punitively manifested through self-injury. Reid and Leonard (1977) treated ‘‘rapid cycling’’ self-induced vomiting with lithium based on the hypothesis that the individual’s self-injury was a manifestation of an underlying bipolar disorder. Weisler, Campbell, and Sonis (1988) used a rating scale system to track the rapid cycling of a male diagnosed with moderate ID and bipolar disorder using twice-daily ratings of mood and energy. The ratings of ‘‘energy’’ may have tapped a variety of behavioral manifestations of bipolar disorder. In an investigation by Rojahn, Matson, Naglieri, and Mayville (2004), correlations between the presence of behavior problems (i.e., self-injury, stereotypy, or aggressive/destructive behavior) and psychiatric symptoms were examined. These researchers found that individuals with ID who had serious aggressive/ destructive behavior were more likely to have extreme scores for depression and mania on a standardized measure of psychopathology.
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There is some evidence in the literature for possible behavioral manifestations of mania in individuals with ID. However, the research on this topic is limited by the use of individual case studies, small sample sizes, the exclusion of individuals with severe and profound ID, and a lack of explicit rationales or adequate statistical analyses to test the hypothesis that challenging behaviors are behavioral equivalents of mania. Thus, the aim of this study is to extend previous research with regard to mania and attempt to establish behavioral equivalents of mania in individuals with ID. To examine the relationship between mania symptoms and overt behaviors, we utilized a standardized psychometric measure of mania for persons with ID, the Diagnostic Assessment for the Severely Handicapped-II (DASH-II; Matson, 1998). The DASH-II has been found to be a valid and reliable measure of psychopathology in adults with ID (see Section 1.2). Therefore, this measure should be sensitive enough to detect if there is a relationship between the expression of mania and observable behavioral equivalents in a large sample of adults with predominantly severe and profound ID. Additionally, a variety of challenging behaviors (i.e., stereotypy, impulse control, and self-injury) were included in our model of mania to better capture possible overt signs of mania. 1. Method 1.1. Participants Participants were 693 individuals who were residing at an Intermediate Care Facility for the Mentally Retarded (ICF-MR) accredited residential setting at the time of this study. This center provides medical and habilitation services to individuals diagnosed as functioning within the range of ID. There were 394 men (56.9%) and 299 women (43.1%). The average age of the participants was 48 years (SD = 15). The majority of the participants were Caucasian (n = 517; 74.6%); however, there were also individuals of African-American (n = 173; 25.0%), Hispanic (n = 2; 0.3%) and other (n = 1; 0.1%) ethnic origins. Varying levels of ID were included in this sample with 18 (2.6%) individuals having mild, 38 (5.5%) moderate, 89 (79.1%) severe, and 548 (79.1%) profound ID. Level of ID had been previously determined through a comprehensive evaluation by a licensed psychologist using the DSM-IV-TR (APA, 2000) criteria along with the following measures: standardized measures of intelligence (e.g., Stanford Binet-IV or the Leiter), behavioral observations, the Vineland Adaptive Behavior Scales (VABS; Sparrow, Balla, & Cicchetti, 1984), and the Matson Evaluation of Social Skills for the Severely Retarded (MESSIER; Matson, 1995). Participant groups were established based on the presence of psychopathology, specifically participants with ID and mania (n = 21) or ID without mania (n = 672). The 21 individuals included in the mania group were, at the time of data collection, found to be exhibiting significant and pervasive symptoms consistent with a diagnosis of a Manic Episode. Diagnoses of mania were determined by a licensed psychologist and a board certified psychiatrist using the DSM-IV-TR criteria, a mental status exam, a review of available records, staff interviews, and behavioral observations. 1.2. Measures Diagnostic Assessment for the Severely Handicapped-II (DASH-II; Matson, 1998). The DASH-II is an 84-item, informantbased questionnaire representing 113 diagnostic categories designed to assess behavioral and psychiatric symptoms among individuals with severe and profound levels of intellectual disability. The 13 subscales are (1) anxiety; (2) depression; (3) mania; (4) pervasive developmental disabilities/Autism; (5) schizophrenia; (6) stereotypy; (7) self-injury; (8) elimination disorders; (9) eating disorder; (10) sleep disorders; (11) sexual disorders; (12) organic syndromes; and (13) impulse control and other miscellaneous behaviors (Sturmey, Matson, et al., 2004). Each item is rated on a 3-point Likert-type rating scale with respect to frequency (0 = not at all; 1 = 1 to 10 times; 2 = more than 10 times), duration (0 = less than a month, 1 = 1–12 months, 2 = over 12 months), and severity (0 = no disruption or damage, 1 = no injury or damage but interrupted others; 2 = property damage or injury). For the purposes of this investigation, only the frequency ratings were retained for data analyses. Acceptable psychometric properties of the DASH-II have been established with good inter-rater (r = 0.86) and test– retest reliability (r = 0.84) and good to excellent validity of individual DASH-II subscales (Matson & Smiroldo, 1997; Matson et al., 1999). 1.3. Procedure Each participant received a comprehensive battery of mental health and other measures on a yearly basis as part of their annual assessment. These measures included the DASH-II (Matson, 1998). The DASH-II was administered to a direct-care staff member who had worked with the participant for a minimum of 6 months prior to the study. The assessors were master’s level clinical psychology doctoral students. These individuals were trained in administering the DASH-II and were supervised by a licensed psychologist. No prior informed consent was needed as the data was archival and no identifying information was used. Data collection and storage were conducted in accordance with accepted procedures to secure participant confidentiality. This study was approved by the Institutional Review Boards of Louisiana State University and the Louisiana Office for Citizens with Developmental Disabilities. 1.4. Statistical analyses The statistical analyses conducted here paralleled those reported in Tsiouris et al. (2003, 2004), which dealt with detecting behavioral equivalents of depression in individuals with ID. First, an item analysis was conducted on the DASH-II
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Table 1 The means and standard deviations for the DASH-II mania scale. Item
Means (SDs) All (n = 693)
Not manic (n = 672)
Manic (n = 21)
9. Is restless or agitated 16. Has decreased need for sleep 26. Is cranky or irritable 38. Is easily distracted 47. Is extremely happy or cheerful for no obvious reason 62. Talks loudly 69. Talks quickly
.27 .05 .28 .28 .15
.26 .05 .28 .27 .14
.52 .43 .38 .48 .38
* **
Item-total correlation
(.57) (.30) (.57) (.61) (.45)
.10 (.42) .05 (.31)
(.56) (.28) (.56) (.60) (.44)
.10 (.41) .05 (.29)
(.81)* (.68)** (.74) (.87) (.74)*
.51 .31 .48 .32 .37
.29 (.64)* .29 (.72)**
.33 .39
p < .05. p < .01.
mania subscale frequency items to identify a homogenous group of items measuring mania in this population. The means of the manic and non-manic groups on each item were then compared using multiple t-tests. Next, a new mania scale was created by adding the items from the following DASH-II subscales: Stereotypy (7 items), self-injury (5 items), mania (7 items), and control and miscellaneous behavior problems (17 items). In addition to items from the mania subscale, potential behavioral mania equivalents included the items ‘‘curses’’ and ‘‘is easily frustrated by the difficulty of the task.’’ An item analysis was then performed on this new scale to identify if behavioral equivalents were related to items from the mania subscale. If maladaptive behaviors were behavioral equivalents related to mania, then they should be correlated with the total score of this new mania scale. Another test of the hypothesis that maladaptive behaviors are behavioral equivalents is that the scores on items from the mania subscale should correlate with the maladaptive behaviors when combined in a new scale of mania. Multiple correlations were performed between the scores on the new mania scale and individual maladaptive items on the DASH-II. In order to correct for false positives the value of alpha was set to .01. Finally, if maladaptive behaviors are behavioral equivalents of mania, then a factor analysis should include factors that have both mania and behavioral equivalent items. A principal components analysis with varimax rotation was performed using items from the mania, stereotypy, self-injury, and impulse control and miscellaneous behavior problems subscales. 2. Results 2.1. Item analysis of the DASH-II mania scale Results of statistical analyses indicated that the DASH-II mania scale Cronbach’s alpha value was .67. This was comparable to previous reports of .61 (Matson, Coe, Gardner, & Sovner, 1991) and .52 (Matson, Gardner, Coe, & Sovner, 1991). The itemtotal (minus item) correlations were good (Mdn = .37, range .31–.51). The means and standard deviations of the items from the mania scale are reported in Table 1. When looking at mean frequency endorsement rates for all participants (i.e., both those with or without mania), the mean scores for 5 out of 7 items were greater than .05 with only 2 items (‘‘decreased need for sleep’’ and ‘‘talks quickly’’) being at or close to .05. The mean for the mania scale when all participants were included in the analysis was 1.19 (SD = 1.93). When the scores of people with and without mania were compared using multiple, onetailed t-tests the mean of people with mania was higher than people without mania on 5 of 7 items with those items being ‘‘is restless or agitated,’’ ‘‘has decreased need for sleep,’’ ‘‘is extremely happy or cheerful for no obvious reason,’’ ‘‘talks loudly,’’ and ‘‘talks quickly.’’ 2.2. Mania and behavioral equivalents The Cronbach’s alpha value for the total 36-item scale was .84, indicating a highly homogenous scale. The results of the item analysis for the entire scale and for groups of items from the stereotypy, self-injury, and impulse control subscales are summarized in Table 2. The median (and range) of item-total (minus item) correlations for behavioral items was .33 ( .024
Table 2 Median and range of item-total point bi-serial correlations for all items, stereotypies, self-injurious items and impulse control and miscellaneous behavior problem items. Group of items
Number of items
Median (and range) of item-total correlations
All items Sterotypies/tics Self-injurious behavior Impulse control, etc.
36 7 5 17
.33 .33 .27 .36
( .02 to .55) (.13 to .38) (.10 to .37) (.02 to .55)
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to .557), indicating that just over half of the behavioral items were acceptably correlated with the scale total and overlapped in value with some of the mania items. Table 2 shows that many behavioral items were as closely related to the scale total as were mania items. The behavioral items with the highest item-total correlations included ‘‘unprovoked screaming/yelling’’ (.56), ‘‘unprovoked temper tantrum/rage’’ (.50), ‘‘excessive need for attention’’ (.44), ‘‘easily frustrated’’ (.42), and ‘‘talks about the same subject or concern over and over’’ (.41). Four of these top 5 items came from the impulse control and miscellaneous behavior problems scale. The mean for this new scale was 5.52 (SD = 7.00). Correlations between individual behavioral items and the total of the mania scale were calculated. Of 36 correlations, 30 were significant at the .01 level of significance or better. 2.3. Factor analysis of mania and behavioral items The first 10 factors accounted for 19.4%, 7.2%, 5.9%, 4.7%, 4.2%, 4.0%, 3.5%, 3.4%, 3.3%, and 3.1% of the variance. All Eigenvalues for these factors were greater than 1.0. The scatterplot was somewhat ambiguous as the ‘‘elbow’’ in the screeplot was not clearly discernable. It was possible that there were 3 or 4 factors based on a review of the scatterplot. Therefore, the pattern of item loadings on the first 4 factors was reviewed (see Table 3). The first factor was characterized by externally directed verbal maladaptive items from the impulse control scale, such as ‘‘curses’’ and ‘‘verbally abuses others.’’ Items which loaded on the Factor 1 from the mania subscale of the DASH-II included ‘‘talks loudly,’’ ‘‘talks quickly,’’ and ‘‘cranky/ irritable.’’ The mania item ‘‘cranky/irritable’’ had a modest loading of .33 on this factor, but was noted to have a larger loading of .56 on Factor 4. Factor 2 was characterized by externally directed challenging behaviors from the impulse control scale, but most of which were non-verbal (e.g., ‘‘excessive need for attention’’ and ‘‘throws objects at people’’). Only one mania item loaded on this factor, which was ‘‘is easily distracted.’’ Factor 3 was characterized by items relating to stereotypical behaviors, such as ‘‘twitching, tapping, and yelling’’ and ‘‘repeats the same words.’’ The only mania item that loaded on this factor was ‘‘is extremely happy.’’ Factor 4 had larger loading from 3 items from the DASH-II mania subscale: ‘‘cranky/ irritable,’’ ‘‘decreased need for sleep,’’ and ‘‘restless agitated.’’ The item with the largest factor loading on this scale was ‘‘runs away.’’ Thus, this factor perhaps characterizes some aspects of behaviors related to mania and included a range of externally directed behaviors, some of which reflected increased motor behavior and some of which were not obviously related to mania. The fifth and sixth factors were both items characterized by loadings on couplets of similarly worded items. Factor 5 had loadings on two self-injury items (‘‘hits self’’ (.68) and ‘‘bangs head’’ (.59)). Factor 6 was characterized by loadings on 2 items: ‘‘sucks or mouths’’ (.75) and ‘‘bites self’’ (.69). Thus, these latter 2 factors were not very meaningful. Overall, the first 4 Table 3 Factor loadings on the first four factors of the principal component analysis with varimax rotation of the mania and behavioral items. Item
Factor 2
82. Curses 55. Verbally abuses people 49. Talks about the same subject or concern over and over 69. Talks quickly 62. Talks loudly 73. Is easily frustrated by the difficulty of a task 26. Is cranky or irritable 5. Exhibits excessive need for attention or approval from others 83. Exhibits excessive need for attention or approval from others 13. Throws objects at people 38. Is easily distracted 12. Is impatient when waiting for needs or demands to be met 1. Hits, kicks, or pinches other people 36. Exhibits a period of sudden motor or vocal activity such as twitching, tapping, or yelling 41. Repeats the same words or sounds 31. Engages in repetitive body movements such as rocking, spinning, or handflapping 47. Is extremely happy or cheerful for no obvious reason 69. Talks quickly 21. Amuses self with limited set of objects or highly repetitive activities 9. Is restless or agitated 23. Runs away from supervision 16. Has decreased need for sleep 9. Is restless and agitated 1. Hits, kicks, or pinches other people 20. Displays unprovoked temper tantrum or rage 30. Resists instruction or guidance from family or staff 50. Engages in unprovoked screaming or yelling
.82 .74 .58 .50 .55 .36 .33
Factor 2
Factor 3
Factor 4
.42 .50
.56 .80 .84 .51 .47 .42 .37 .64 .63 .52 .51 .50 .46 .32
Note: Only factor loadings greater than .3 in absolute value are included. Items from the DASH-II mania subscale are bolded.
.59 .57 .54 .52 .48 .48 .33
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factors appeared to be psychologically meaningful. Of all the factors which emerged from the factor analysis, Factor 4 was the salient measure of mania (i.e., contained the most items from the DASH-II with the highest factor loadings, thus most closely related to mania) which also included some challenging behaviors. 3. Discussion These data indicate that there may be some challenging behaviors that are related to mania. The item analysis indicated that the DASH-II mania scale is homogenous and 5 of 8 of the items differentiated people with and without mania. These observations suggest that this scale may be a valid measure of mania (Matson & Smiroldo, 1997). The item analysis of the extended scale, which included a variety of other challenging behaviors, found a tendency for larger item-total correlations between a number of items from the impulse control and miscellaneous behavior problems subscale of the DASH-II. The results of the factor analysis were ambiguous as to the number of factors, but the first 3 factors accounted for the greatest amount of the variance. If Factor 4 should be considered a mania factor, then other motor challenging behavior items, such as ‘‘running away’’ and ‘‘restless/agitated’’ should be considered candidates for behavioral equivalents of mania. These results are similar to previous work in this area. For example, Vanstraelen and Tyrer’s (1999) review of rapid cycling bipolar disorders in people with ID noted sleep disturbances as being reported in the case studies they reviewed. Similarly, our factor analysis noted a decreased need for sleep, restlessness, agitation, and irritability as items associated with mania. In contrast, Cain et al. (2003) noted a very broad range of challenging behaviors associated with mania. The findings of this study and related investigations raise the possibility of behavioral equivalents of mania in people with ID; however, the specificity of the associations has not yet been strongly tested. Although across all of these studies aggression and sleep disturbance were reported to be associated with mania, an association has also been reported in various investigations of behavioral equivalents of depression (Marston, Perry, & Roy, 1997; Reiss & Rojahn, 1993), whereas other researchers have not found such an association (Sturmey et al., 2010; Sturmey, Matson, et al., 2004; Sturmey, Tsiouris, et al., 2004; Tsiouris et al., 2003). Future research should build on these preliminary reports of associations between challenging behaviors and psychiatric disorders in people with ID. Specifically, a more fine-grained analysis to evaluate if any of these associations are as specific as might be hoped. Clinicians are instructed to interpret these results with caution as the associations between challenging behaviors and psychiatric disorders reported here and in similar investigations are not sufficient enough to use as evidence to support using certain behavioral equivalents as support for a diagnosis of psychopathology. Each individual is different and, therefore, the clinician should ascertain clear evidence of core symptoms of a mental health disorder on a case-by-case basis. Relying merely on the presence of a challenging behavior or even a challenging behavior coupled with a positive/ clinically significant psychopathology based on direct care staff reports may not be accurate. Therefore, at this time, clinicians should continue to focus on core symptoms as outlined in the current classification system (i.e., DSM-IV-TR [APA, 2000] or ICD-10 [WHO, 1992]) to aid them in the diagnosis of an emotional/mood-related disorder. 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