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Psychopathology in children and adolescents with developmental disorders
Pergamon
Research in Developmental Disabilities, Vol. 18, No. 5, pp. 369-382, 1997 Copyright © 1997 Elsevier Science Ltd Printed in the USA. All rights reserved 0891-4222/97 $17.00 + .00
PII S0891-4222(97)00016-4
Psychopathology in Children and Adolescents with Developmental Disorders Antonio Hardan and Robert Sahl Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
Children and adolescents with developmental disorders suffer from a wide range of psychopathology. However, there are no published studies examining this subject exclusively in this population using recent diagnostic criteria. The primary purpose of this paper is to report on the diagnosis encountered in a clinical setting using DSM-III-R. The medical records of all individuals assessed in a specialized program during a l-year period were reviewed looking at their demographic features, diagnoses, and target behaviors. Our sample consisted of 233 subjects and contained significantly more boys than girls. The most common psychiatric diagnoses were oppositional defiant disorder and attention deficit hyperactivi O, disorder. Pica, organic mental disorder NOS, and Autistic Disorder were more qften encountered in individuals with low intellectual functioning. Depressive disorders, posttraumatic stress disorder, and developmental speech/language disorders were diagnosed more in high functioning subjects. The most common symptom was impulsivi~. This retrospective study highlights the need for more rigorous examination of current diagnostic concepts and criteria in children and adolescents with developmental disorders. Prospective studies should be conducted with standardized instruments in clinics and community samples to provide more information on psychiatric disorders in this population. © 1997 Elsevier Science Ltd
The authors thank Cynthia Johnson, PhD, Michael DeBellis, MD, and Boris Birmaher, MD for their helpful comments during manuscript preparation. Requests for reprints should be sent to Antonio Hardan, 3811 O'Hara Street, Room 688, Pittsburgh, PA 15213; E-mail: [email protected].
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INTRODUCTION It has been increasingly recognized that individuals with mental retardation and/or developmental disabilities (MR/DD) suffer from a wide range of psychopathology similar to persons with normal cognitive abilities (Bernstein, 1970; Philips & Williams, 1975), although manifestations may differ depending on the degree of cognitive impairment (Balthazer & Stevens, 1975; Collins, 1971). The prevalence rates of psychiatric disorders in children and adolescents with MR/DD have been reported at 15% to 52% (Baker & Cantwell, 1987; Eaton & Menolascino, 1982; Parsons, May, & Menolascino, 1984; Ruedrich & Menolascino, 1984, Rutter, Tizzard, Yule, Graham, & Whitmore, 1976). In Rutter's early Isle of Wight study, 30.4% of the children with IQs less than 70 were found to have a psychiatric disorder on the parent questionnaire, and 41.8% on the teacher questionnaire (Rutter, Graham, & Yule, 1970). Comparable rates for persons without MR/DD were 7.7% and 9.5%, respectively. Children and adolescents with MR/DD have an increased rate of psychiatric disorders (Baker & Cantwell, 1987; Rutter et al., 1976), and they are at higher risk for emotional disturbances when compared with individuals with normal intelligence (Reid, 1980). However, limited information and research exist about psychiatric diagnoses in this population (Einfeld, 1982; Singh, Sood, Sonenklar, & Ellis, 1991; Vitiello & Behar, 1992). In an early study, Menolascino (1969) examined the emotional disturbances in 256 children with MR/DD. He found 134 to have Chronic Brain Syndrome (CBS) with behavioral reactions, 43 with CBS with psychotic reactions, 8 with functional psychoses, 4 with personality disorders, 58 with adjustment reaction and 15 with a psychiatric disorder not further specified.In another early study, Chess and Hassibi (1970) examined the psychiatric disorders of 52 children with mental retardation (MR). They found that 21 had no diagnosis, 18 had reactive behavior disorder, 1 had neurotic behavior disorder, 11 had cerebral dysfunction, and 1 had psychosis. Irving and Williams (1975) studied 100 children with MR referred to a psychiatric outpatient clinic. They found 38 with psychoses, 5 with neuroses, 16 with personality disorders, 26 with behavioral disorders, 2 with transient situational disorders, and 13 had no evidence of psychiatric disorder. Recently, Eaton and Menolascino (1982) assessed, from 1976 to 1979, a community-based sample of 114 individuals with MR, 56 of which were children and adolescents. They found that 8 were diagnosed with schizophrenia, 5 with personality disorders, 16 with adjustment reaction, and 27 with organic brain syndrome. More recently, Szymanski (unpublished data, 1994) conducted a detailed diagnostic assessment in a developmental disabilities' clinic, on 277 children and 123 adults with only mild/moderate MR. A DSM-III Axis I diagnosis of a mental disorder was made in 70% of children. The most common diagnoses were pervasive developmental disorders 22%, affective disorders 12%, and adjustment disorders 10%. Johnson, Lubetsky, and Sacco (1995) reported on the psychiatric and behavioral disorders in hospitalized preschoolers
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with developmental disabilities. The sample consisted of 169 children assessed on an inpatient unit. The most common diagnoses were attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). These researchers used recent diagnostic criteria, but they were not conducted in outpatient and inpatient settings, and the samples studied did not include exclusively children and adolescent with all levels of intellectual functioning. The paucity of information in the literature on the psychiatric diagnoses in children and adolescents with MR/DD may at least be partially explained by diagnostic overshadowing. It refers to the tendency of clinicians to attribute psychopathology to cognitive deficiency rather than to a diagnosable psychiatric disorder. The existence of this phenomenon was validated by Reiss, Levitan, and Szyszko (1986) leading to an increased awareness of this problem among mental health professionals working with individuals with MR/DD. In an attempt to provide more information about this topic, we conducted a retrospective, descriptive investigation of the psychopathology of a sample of children and adolescents with MR/DD. The aims of the present study were three folds: (a) to identify the psychiatric symptoms and diagnoses of children and adolescents with MR/DD assessed in a tertiary clinical setting, (b) to examine the demographic features of this population, and (c) to determine the relationships between identified target symptoms, psychiatric diagnosis, gender and cognitive level of functioning.
METHOD Subjects The study was conducted in a specialized program for developmental disorders that serves the needs of children and adolescents with MR/DD, and their families. It offers an afterschool program, a summer school, a school-based partial program, a 24-bed inpatient unit, and an outpatient clinic. The latter two programs are the port of entry of all patients. Patients' referral sources include other clinics within the university, pediatricians, child psychiatrists in the community, family members, various schools, and community mental health agencies.
Procedure The medical charts of all individuals who entered the program over a 12-month period were reviewed. The following variables were collected from each patient's record: age, race, sex, living situation, family psychiatric history, most recent cognitive testing (IQ), duration of present episode of the illness, symptom inventory/target behaviors, number of previous hospitalizations, inpatient versus outpatient status, psychotropic treatment and diagnoses (axes I, II, and IV). This information was gathered from the psychiatric evaluation forms, the discharge
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summaries, and the progress notes available in the medical record. Psychiatric diagnoses were made by a treatment team headed by a child psychiatrist or neurologist with several years of experience with the population studied. The other members of the team usually include one social worker, a child psychiatry fellow, a psychiatry resident, or a senior clinician, a developmental specialist, a master level behavioral specialist, a psychiatric nurse, and a faculty psychologist. Diagnoses were based on DSM-III-R criteria. The IQ was measured by a developmental psychologist using either the WISC-R or the Stanford-Binet (4th ed.). Patients who were not diagnosed with a developmental disorder were excluded. Patients with borderline intellectual functioning were included. Individuals with severe and profound mental retardation were combined in one group. When a patient had multiple hospitalization or outpatient assessments during the study period, only the last evaluation was considered.
Data Analysis The frequencies and percentages of different variables were calculated across gender, and level of cognitive functioning. The corrected chi-square test was conducted to determine statistical significance across gender, and level of cognitive functioning. The Fisher Exact test was used when the cell size was less than five. RESULTS The charts of 298 individuals were reviewed. One chart was not available. Eighteen were not included because the subjects were found not to have any developmental disorder or any level of mental retardation. Forty-six other charts were excluded. These subjects had multiple assessments during the study period, and only the data form from the last contact was considered. The study population consisted of 233 patients. Their ages ranged from 3.2 to 19.4 years with a mean of 9. Table 1 shows the demographics of the sample. The mean age for boys was 8.8 years (range 3.2-19.1), and 9.4 years for girls (range 3.8-19.4). There were significantly more boys than girls (X2 = 289.305, df= 1, p < 0.001), with a ratio of 2.5. Significantly more children came from a single-parent home (45.5%) than from any other living situation (X2 = 327.979, df= 6, p < 0.001). Among the patients assessed in the outpatient clinic, 14% (N = 16) had a history of one or more hospitalizations. The subjects had significantly more chronic ( > 12 months) than acute emotional problems (×2 = 340.236, df= 1, p < 0.001). Subjects had a significantly higher family history of drug and alcohol abuse/dependence (43%) as compared with other psychiattic disorders (X2 = 124.278, df = 6, p < 0.001). Sixty-two percent of our sample was treated with psychotropic medications. Table 2 presents the frequencies and percentages of the diagnoses across functioning levels. There are more than 233 because multiple diagnoses were
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TABLE 1 Demographic Features of the Population Feature Number of children Gender Boys Girls
N 233
i00
168 65
72 28
168 56 9 120 113
72 24 4 51.5 48,5
Race White Black Other
Inpatients Outpatients Stressors None Mild
Moderate Severe Extreme Catastrophic Unspecified Duration of illness < 12 months > 12 months
Family psych history None Affective disorders Psychotic disorders
Drugs and alcohol ADHD MR/autism Other
Living situation Biologic parents Single parent Biologic relative Foster parent Adoptive parents Group home Other
18 62 92 37 9 0 15
8 27 39 16 4 0 6
47 186
20 80
29 70 22 101 31 63 75
12 30 9 43 12 27 32
72 106 12 17 10 12 4
3I 45.5 5 7 4 5 1.5
used. The most common diagnoses for Axis I were: ODD, ADHD, other specified family circumstances, and organic mental disorder (OMD). The latter diagnosis, which includes organic mood disorder, organic personality disorder, organic anxiety disorder, and organic mental disorder, NOS, was significantly more encountered in the severe/profound group (×2 = 21.808, df= 5, p < 0.001). Pica also followed the same t r e n d (X 2 = 11.056, df= 5, p = 0.053), in occurring in the severe/profound group. Almost all subtypes of depressive disorders were reported in our sample: Major depression, single episode, unspecified (N = 5); Major depression, recurrent (N = 2); Depressive disorder, NOS (N = 8); and
105(45) 99(42) 62(26) 25(11) 23(10) 20 (8.5) 19 (8) 24(10) 10(10) 9 (4) 8 (3) 8 (3) 5 (2) 4 (1.5) 4 (1.5) 4 (1.5) 4 (1.5) 3 (1) 2 (1) 126(54) 36 (15.5) 27 (11.5) 7 (3) 10 (4) 5 (2)
ODD ADHD OSFC Enuresis OMD PCP Adjustment Depressive Pica Encopresis Bipolar Anxiety Tic PTSD IED Stereotypy Psychotic Conduct OCD Dev Sp/Lang Autistic PDD, NOS Dev read Dev D, NOS Other Dev D
16(44) 16(44) 13(36) 2 (5.5) 0 7(19) 6(17) 6(17) 0 1 (3) 1 (3) 0 0 3 (8) 0 0 1 (3) 2 (5.5) 0 32(89) 1 (3) 2 (5.5) 1 (3) 2 (5.5) O
BL N = 36
19(49) 16(41) 11(28) 5(13) 0 5(13) 5(13) 11(28) 0 0 0 2 (5) 3 (8) 1 (2.5) 1 (2.5) 0 2 (5) 0 1 (2.5) 14(36) 3 (8) 7(18) l (2.5) 1 (2.5) 1 (2.5)
Mild N = 39 18 (54.5) 14(42) 5(15) 2 (6) 3 (9) 2 (6) 1 (3) 2 (6) 0 0 4(12) 1 (3) 0 0 3 (9) 0 1 (3) 0 1 (3) 19 (57.5) 8(24) 6(18) 0 0 0
Mod N = 33 9(41) 8(36) 2 (9) 0 8(36) 0 0 1 (4.5) 3(14) 1 (4.5) 1 (4.5) 2 (9) 0 0 0 1 (4.5) 0 0 0 4(18) 9(41) 2 (9) 0 0 0
Sev/Pf N = 22 13 (32.5) 15 (37.5) 8(20) 4(10) 7 (17.5) 2 (5) 1 (2.5) 1 (2.5) 3 (7.5) 2 (5) 0 0 0 0 0 1 (2.5) 0 0 0 28(70) 5 (12.5) 0 0 1 (2.5) 0
Unsp N = 40 30(48) 30(48) 23 (36.5) 12(19) 5 (8) 4 (6) 6 (9.5) 3 (5) 4 (6) 5 (8) 2 (3) 3 (5) 2 (3) 0 0 2 (3) 0 1 (1.5) 0 29(46) 10(16) 10(16) 5 (8) 6 (9.5) 4 (6)
Average N = 63 4.782 1.514 11.447 0.111 21.808 9.693 9.592 21.267 11.056 5.925 10.463 5.515 8.904 12.267 13.614 3.785 5.451 6.952 4.557 40.061 19.366 10.725 8.234 7.401 8.206
X2 0.506 1.000 0.046 '9.152 0.000 0.090 0.094 0.000 0.053 0.350 0.067 0.401 0.122 0.032 0.019 0.680 0.409* 0.247* 0.542* 0.000 0.002 0.061 0.156 0.156 0.158
P
BL: borderline mental retardation (MR); Mod: moderate MR; Sev/Pf: severe/profound MR; Unsp: unspecified MR; average IQ; OSFC: other specified family circumstances; OMD: organic mental disorders; PCP: parent child problem; Depressive: major depressive disorder, recurrent, depressive disorder, NOS, and dysthymia; Anxiety: overanxious disorder, seperation anxiety disorder, anxiety disorder, NOS, phobias, and panic disorder; IED: intermittent explosive disorder; PDD, NOS: pervasive developmental disorder; Dev Sp/Lang: developmental speech/language disorder; Dev Read: developmental reading disorder; Dev D, NOS: developmental disorder, NOS; other; Dev D: Dev arithmetic disorder and developmental coordination disorder. *Fisher test nonsignificant.
Total N = 233
Diagnosis
TABLE 2 Diagnosis Across Functioning Levels (%)
(2)
I(< I) 13 15.5~ 110 (47) 14 (6) 176 (75) 47 (20) 13 (5.5)
1 (3) 26(74) 2 (5.5) 0 8(22) 0 1 (3) 0 25(69) 1 (3) 16 (7) 8(22) 10 (4) 2 (5.5) 0 0 1131 0 6117~ 181501 4(11) 25(69) 7(19) 2 (5.5)
BL N = 36 1 (2.5) 29(74) 1 (2.5) 7(18) 14(36) 3 (8) 5(131 0 25(69) 1 12.51 15(38) 4110) 11 (28) 6 115.51 0 2 (5) 1 (2.5) 1 (2.5) 1 (2.5) 19149) 2 (2.5) 29(74) 101261 2 (2.5)
Mild N = 39 2 (6) 24(73) 2 (6) 7(21 ) 13(391 2 (6) 2 (6) I (3) 22(67) 0 111331 4112) 7(21 ) 41121 0 4(121 0 0 2 (6) 211641 41121 30(90) 6118) 0
Mod N = 33 3(141 11150) 41181 4118) 17(77) 0 0 0 16(721 0 111501 2 (9) 0 0 0 1 (4.5) 0 0 0 131591 0 17177) 3(141 I (4.5)
Sev/PF N = 22 3 (7.5) 24(60) 0 4( l 0) 11(27) 0 0 0 25 (62.5) 0 5 112.51 2 (5) 4(10) 2 (5) 0 1 (2.5) 11 0 2 (5) 11 (27.5) 0 24(60) 5 (12.51 1 (2.5)
Unsp N = 40 4 (6) 40(63) 4 (6) 9(14) 21(33) 0 2 (3) 1 11.51 45(71 ) 0 18 (28.5) 7(11 ) 10(16) 11(171 2 (3) 6 (9.5) 2 (3) 0 2 (3) 28(44) 4 (6) 5t1811 161161 7(11)
Average N = 63 3.922 5.836 1.755 8.928 20.832 11.652 10.330 3.409 1.178 4.260 13.764 5.893 12.058 9.208 5.444 6.872 2.859 4.996 11.105 I 1.395 7.873 11.233 3.931 6.389
X2
0.654* 0.361 0.088* O. 121 0.000 0.042 0.071 0.754* 1.000 0.592* 0.018 0.354 0.036 0.109 0.410* 0.254 0.820* 0.473* 0.052 tl.047 0.178" 0.050 1/.652 0.300
p
BL: borderline MR; Mod: moderate MR; Sev/Pf: se~ere/prolk)und MR; UJ~sp: unspecified MR; average IQ; SIB: self-injurious behavior; Delusions/thought: delusions/thought disorder: Psychomotor retard: psychomotor retardation; Obsessions/compul: obsessitm/compulsion. *Fisher test nonsignificant.
Drugs and alcohol Sexual problems Aggression Anti-social lmpulsivity Social withdrawal Dependent
4
14 (6) 154 (66) 13 (5.5) 31 (13) 84 (36) 5 (2) 10 (4) 21<11 158 (68) 2(<1) 76 (32.5) 27 (12) 42 (18) 25 (10) 2(< 1) 14 (6)
Impaired sensorium Poor concentration Self-neglect Bizarre behavior SIB Delusion/thought Hallucinations Elation Hyperactivity Psychomotor retard Sleep disturbances Eating disturbances Sadness Anxiety Phobias Obsessions/Compul
Somatization
Total N = 233
Target Symptoms
TABLE 3 Target Symptoms Across Functioning Levels (%)
2"
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dysthymia (N = 6). There was a significant difference in depressive disorders with these diagnoses given more to higher functioning individual, specifically borderline and mild MR (X2 = 21.267, df = 5, p < 0.001). The full range of anxiety disorders were diagnosed: overanxious disorder (N = 4), anxiety disorder, NOS (N = 3), posttraumatic stress disorder (PTSD) (N = 4), separation anxiety disorder (N = 1), and obsessive compulsive disorder (N = 2). On Axis II, developmental speech/language disorder and autistic disorder were the most frequent diagnoses made (Table 2). The breakdown of the different levels of mental retardation in our sample was as follows: borderline 15.5% (N =26), mild 17%(N = 39), moderate 14% (N = 33), severe/profound 9% (N = 22), and unspecified 17% (N = 40). Sixty-three subjects (27%) had an average IQ and were included in the study because of other developmental disabilities. Pervasive developmental disorders were observed in all degrees of cognitive ability. There was a significant difference in proportions of diagnosed autistic children, with the severe/profound group being diagnosed more often than other groups with mental retardation (X2 = 19.366, df= 5; p < 0.005). Also there was a significant difference in proportions for which developmental speech/language disorders were given with the severe/profound group being diagnosed less frequently (X2 = 40.061; df= 5; p < 0.001). When this group was excluded, differences in proportions remained significant (X2 = 27.957, df = 4, p < 0.0001). No significant differences were found in the proportions of boys and girls with autistic disorder in this clinical sample. Among the 63 subjects with average intelligence, 20 (32%) were diagnosed either with autistic disorder or pervasive developmental disorder, not otherwise specified (PDD, NOS). Symptom inventory and target behaviors were also examined (Table 3). The most frequent were: impulsivity, hyperactivity, poor attention, span/distractibility, aggression, and self-abusive behavior. Psychotic symptoms, phobias, somatization, alcohol/drug abuse, elation, and psycho-motor retardation were found infrequently. Poor concentration and aggression were two target symptoms that were more often observed in boys than in girls (poor concentration: ×2 = 11.813, df= 1, p < 0.001; and aggression ×2 = 7.213, df= 1, p < 0.01). Pica occurred more frequently in females than in males, but this finding showed only a trend toward significance (X2 = 3.816, df= 1, p = 0.51). There were some significant differences in the percentages of target symptoms across different functioning levels. Whereas sadness and delusions/thought disorder were more likely to be identified in children with higher cognitive levels, self-injurious behavior (SIB) and sleep disturbances were more often observed in subjects with lower cognitive abilities. DISCUSSION To our knowledge this is the first study that examined the psychopatholgy and diagnosis exclusively in children and adolescents with all level of MR/DD using DSM-R. This investigation provides a descriptive account of the psychiatric
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diagnoses of 233 subjects with MR/DD admitted to a tertiary care setting. The sample was composed of a larger percentage of boys, which is consistent with other studies reporting the percentages of males and females (Eaton & Menolascino, 1982; Einfeld, 1984; Johnson et al., 1995; Kolko, 1992; Menolascino, 1969). The distribution of race in our sample represents the catchment area of the program where the study was conducted. Most subjects (80%) had been mentally ill for more than 1 year before coming for psychiatric treatment. Several factors contributing to this finding include the tendency to attribute psychopathology to cognitive deficiency, the difficulty identifying early signs of psychiatric illness in this population, the high level of tolerance of the environment for individuals with MR/DD and considering treatment only when symptoms are severe and unremitting. The rate of individuals coming from a single-parent family (45.5%) is higher than the one found in the population of all families with dependent children. Quine (1986) reported on a similar finding. Eighteen percent of his sample of behaviorally disordered mentally handicapped children were from single-parent families, a figure that is higher (12.1%) than the reported for all families with dependent children. Bradshaw (1979) warned against tracing the link between child disability and relational/marital breakdown, mainly because it is impossible to draw conclusions from cross-sectional data. It is controversial whether some factors associated with growing up in a single-parent family contributes to the genesis of emotional disorders or whether the difficulties of looking after a disabled individual with behavioral problems contribute to the breakdown of parental relationships (Quine, 1986). Only 12% of our sample was without a family history of psychiatric illness. This information is limited since it was obtained from chart review with inability to ascertain its reliability and validity. These high rates could be explained by the tendency to be over inclusive during the clinical assessment and considering more than first degree relatives when gathering the psychiatric family history. Dosen (1984) found that 55% of his sample of depressed children with developmental disabilities had one or both parents with marked "neurotic behavior." He also reported that 29% of his sample had one or more relatives suffering from depressive, manic-depressive, or other psychotic conditions who had received psychiatric treatment. This rate is similar to our finding of 39% of our sample with family history of affective and or psychotic disorders. High rates of drug and alcohol abuse/dependence among family members were found in our sample. Emotional disturbances may have resulted from the poor parenting that is often associated with substance abuse. This fact may shed light not only on the genesis of the emotional disturbances but also on the possible etiological factors of the developmental disabilities with in utero exposure to drugs. The frequencies of the diagnoses encountered in our sample differed from those observed in similar studies looking at psychopathology in children and adolescents with MR/DD (Chess & Hassibi, 1970, Eaton & Menolascino, 1982, Irving & Williams, 1975, Menolascino, 1969), even though almost all of them
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examined referred samples. Five (2%) individuals in our sample had a psychotic diagnosis compared with 38 (44%) in the report of Irving and Williams (1975), and 8 (14%) in the study of Eaton and Menolascino (1982). Also, 10% of our sample were diagnosed with OMD compared with 69% in the study of Menolascino (1969), 32% in Chess and Hassibi (1970), and 48% in Eaton and Menolascino (1982). The use of different terminology and classification may explain these differences, with the tendency of older studies to be overinclusive in their diagnostic categories. For example, in the study by Irving and Williams (1975), psychotic maldevelopment included infantile autism, childhood schizophrenia, and chronic brain syndrome. A more recent study looking at diagnosis in severely and profoundly retarded individuals using DSM-III-R indicated the relative infrequency of the diagnosis of psychosis (King, DeAntonio, McCraaken, Forness, & Ackerland, 1994). Almost all diagnoses were encountered at different levels of cognitive functioning. However, some were identified more frequently in individuals with mild and moderate levels of mental retardation, and others more in the severe/ profound group. OMD was diagnosed more frequently in the latter. Johnson et al. (1995) reported that preschoolers with severe/profound mental retardation were more likely to be diagnosed with organic brain syndromes. These syndromes are more likely to be identified in individuals with low IQ since structural and functional abnormalities are more evident in this group when compared with individuals with mild and moderate level of cognitive functioning (Kirman, 1985). In accordance with the literature, self-injurious behavior occurred more often in the lower functioning individuals since there is evidence of an inverse relationship between the incidence or prevalence of self-injury and level of functioning (Johnson & Day, 1992; Matson, 1989). Also, autistic disorder was more often observed in children and adolescents with low IQ. This was anticipated given that 70% of children with Autistic disorder fall into the mental retardation range and 40% of these children have IQs of 50 or below (Rutter & Lockyer, 1967). Depressive disorders, PTSD, and intermittent explosive disorder were diagnosed more in the higher functioning group. The fact that certain symptoms were found only in the high functioning individuals could be explained by either their absence in the lower functioning group, their difficulties to be identified in this subgroup, or clinicians not searching for them. Most diagnostic categories were represented in our sample. However, some were not encountered in any subject, such as somatoform disorders, depersonalization disorders, and sexual disorders. The lack of use of structured interviews and symptom/behavior checklists may explain this finding. Thirty-two subjects (12.5%) were identified as having an affective disorder. All types of depressive disorders were reported in our sample. Subjects who received the diagnosis of bipolar disorder were classified under the not otherwise specified subtype. It may difficult to diagnose the bipolar disorder in this population and the expression of bipolarity may be different due to the underlying biologic and cognitive factors. In fact, Reid (1972) and Adams, Kivowitz,
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and Ziskind (1970) observed that mentally retarded adults do not display classic manic symptoms of euphoria and flight of ideas. Bipolar disorders were not diagnosed or considered in the old studies mentioned above (Chess & Hassibi, 1970; Eaton & Menolascino, 1982; Irving et al., 1975; Menolascino, 1969). By contrast, the more recent study of King et al. (1994) diagnosed bipolar disorder in 7% of all referred patients with severe and profound mental retardation. The low rate of drug and/or alcohol abuse and dependence was also reported by Reiss (1982). Edgerton (1986) obtained similar findings in adults with mental retardation. However, Rychkova (1986) noted that mildly mentally retarded adolescents are at risk of abusing alcohol. He found that these individuals develop a unique clinical picture of alcoholism with marked personality changes and more rapid onset of symptomatology than in the normal youth population. The retrospective collection of the data, in addition to the lack of using structured interviews may explain our findings here. Fifty-four percent of our sample were diagnosed with a developmental speech/language disorder. This rate is indeed higher than the 3% estimated for the general population (Grossman & Begab, 1983). However, this is not surprising since mental retardation (57% of our sample) may be the single largest cause of delayed language development (Rutter & Martin, 1972). There was no difference in the incidence of developmental speech/language disorders between boys and girls. This finding is inconsistent with the literature suggesting an association between sex and the presence of language disorders. Speech and language disorders prevalence rates typically are higher in boys than in girls (Beitchman, Nair, Clegg, Ferguson, & Patel, 1986; Calnan & Richardson, 1976). A possible explanation for the discrepancy could be that our sample is a clinical one, whereas most of the other studies included community and/or nonpsychiatric samples. Quine (1986) reported on the prevalence of behavioral problems in children with severe mental retardation. Hyperactivity was significantly more likely to be reported in boys than in girls, 25% and 14% respectively. King et al. (1994) found no difference in the percentage of hyperactivity in severely mentally retarded male and female patients. In the same study, 19c~ of the males and 11% of the females were diagnosed with ADHD, with a ratio of 1.7 favoring males. In our cohort, there was no difference between the incidence of hyperactivity in boys and girls, but a significant difference was found for poor concentration. However, a gender difference in the incidence of ADHD showed a trend toward significance (X2 = 0.268, df= 1, p = 0.07). This finding is somewhat consistent with what has been reported in the literature with higher incidence of ADHD in boys than in girls in children and adolescents of average intellectual functioning (Szatmari, Offord, & Boyle, 1989). Menolascino (1969) studied 256 emotionally disturbed outpatient children and adolescents with MR. Their symptoms included: hyperkinesia, impulsivity, stereotyped movements, withdrawal, emotional lability, and panic reactions. All of these symptoms were reported in the present study. However, aggression was
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frequently encountered in our sample but not in Menolascino's. The differences in patient population may explain this finding, since our sample included both inpatients and outpatients. This target symptom was identified in almost half of our sample (47%), and it is similar to the rate of 44.4% reported by Irving and Williams (1975) in their sample of 62 nonpsychotic mentally retarded children. In fact, aggression has often been identified as one of the maladaptive behaviors interfering most with functioning and leading to more restrictive educational placements in school-aged children with MR/DD (Bruininks, Hill, & Morreau, 1988; Quine, 1986). Sleep disturbances were observed in 32.5% of the sample. This is consistent with the literature with reports of sleep problems ranging from 34% (Clements, Wing, & Dunn, 1986) to over 80% (Barlett, Rooney, & Spedding, 1985) in children and adolescents with developmental disabilities. The relative low rates reported here may be attributable to the fact that 62% of our sample were on psychotropic medications. The data presented here were collected retrospectively from a program that specializes in the assessment and treatment of children and adolescents with psychiatric disorders and developmental disabilities. This characteristic limits significantly the generalizability of the results. The sample is by no means representative of the population of children and adolescents with MR/DD who are suffering from emotional difficulties. The absence of a community sample of patients with developmental disorders is expected to lead to a higher rate of psychiatric illness and to a predominance of externalizing disorders. It was also impossible to establish diagnostic reliability or validity taking into consideration the involvement of different treatment teams and the fact that diagnoses were made for clinical purposes using DSM-III-R criteria. Several clinical implications emerge from our study. Despite its limitations, the descriptive data provide a real world perspective on the nature of psychiatric illness in children and adolescents with MR/DD in an inpatient and outpatient setting. These individuals suffer from a wide range of psychopathology, and almost all psychiatric disorders can be diagnosed, externalizing as well as internalizing disorders. Therefore, D S M criteria should be used, whenever possible. It is imperative that clinicians working with this population assess for all types of psychopathology and avoid the overshadowing phenomena. Careful addressing symptoms of psychosis, depression, anxiety, and alcohol/drug abuse may have value in the diagnostic process. This first step is essential in the formulation of a treatment plan and its implementation since children and adolescents with MR/DD should be considered candidates for all types of interventions available, including pharmacotherapy and psychotherapy. In conclusion, the results reported are useful in identifying research issues and in exemplifying the types of problems frequently encountered when working with children and adolescents with MR/DD. This paper points to the need for rigorous examination of current diagnostic concepts and the developmental of diagnostic methods to identify pathology unique to developmental disorders.
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Prospective studies should be conducted with community and clinics samples using multiple sources of information from patients and informants derived from experimental analyses, direct observations, rating scales and standardized clinical instruments to provide more information on psychiatric disorders in this population.
REFERENCES Adams, G. L., Kivowitz, J., & Ziskind, E. (1970). Manic depressive psychosis, mental retardation, and chromosomal rearrangement. Archives of General Psyehiatm', 23, 305-309. Baker, L., & Cantwell, D. P. (1987). A Prospective psychiatric follow-up of children with speech/ language disorders. Journal of the American Academy of Child and Adolescem Psychiatry, 26, 546-553. Balthazar, E. E., & Stevens, H. A. (1975). The emotionally d&turbed mentally retarded. Englewood Cliffs, N J: Prentice-Hall. Barlett, L. B., Rooney, V., & Spedding, S. (1985). Nocturnal difficulties in a population of mentally handicapped children. British Journal of Mental Subnormali~,, 31, 54-59. Beitchman, J. H., Nair, R., Clegg, M., Ferguson, B., & Patel, P. G. (1986). Prevalence of psychiatric disorders in children with speech and language disorders. Journal of the American Academy qfChiM and Adolescent Psychiatry, 25, 528-535. Bemstein, N. R. (1970). Diminished people: Problems and care ~f the mentally retarded. Boston: Little, Brown and Co. Bradshaw, J. (1979). Handicap: bond or burden? One Parent ~mes, 1, 12-14. Bruininks, R. H., Hill, B. K., & Morreau, L. E. (1988). Prevalence and implications of maladaptive behaviors and dual diagnosis in residential and other service programs. In J. A. Stard, F. J. Menolascino, M. H. Albarelli, & V. C. Gray (Eds.), Mental retardation and mental health: Classification, diagnosis, treatment, services (pp. 3-29). New York: Springer-Verlag. Calnan, M., & Richardson, K. (1976). Speech problems in a national survey: Assessment and prevalences. ChiM Care Health Development, 2, 181-202. Chess, S, & Hassibi, M. (1970). Behavior deviations in the mentally retarded children. Journal ~fthe American Academy of Child Psychiatry, 9, 282-297. Clements, J., Wing, L., & Dunn, G. (1986). Sleep problems in handicapped children: A preliminary study. Journal of Child Psychology and Psvchiat~, 27, 399-407. Collins, D. T. (1971). Head-banging: Its meaning and management in the severely retarded adult. In E J. Menolacino (Ed.), Psychiatric aspects of the diagnosis and treatment of mental retardation (pp. 220-221) Seattle, WA: Special Child Publications. Dosen, A. (1984). Depressive conditions in mentally handicapped children. Acta Paedopsychiatrica, 50, 29-40. Eaton, L. E, & Menolascino, E J. (1982). Psychiatric disorders in the mentally retarded: Types, problems, and challenges. American Journal of P~Fehiat~, 138, 1297-303. Edgerton, R. B. (1986). ALcohol and drug abuse by mentally retarded adults. American Jourtu~l~?fMental Deficiency, 90, 602-609. Einfeld, S. L. (1982). Clinical assessments of psychiatrics symptoms in mentally retarded individuals. Australian and New Zealand Journal of Psychiatry, 26, 48-453. Einfield, S. L. (1984). Clinical assessment of 4500 developmentally delayed individuals. Journal e?f Mental Deficiency Research, 28, 129-142. Grossman, H. J., & Begab, M. J. (1983). Classification in mental retardatitm. Washington, DC: American Association on Mental Deficiency. Irving, P., & Williams, N. (1975). Psychopathology and mental retardation: A study of 100 mentally retarded children: I. Psychopathology. American Journal of Psychiatry, 132, 1265-1270.
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Johnson, W. L., & Day, R. M. (1992). The incidence and prevalence of self-injurious behavior. In K. L. LuiseUi, J. L. Matson, & N. N. Singh (Eds.), Self injurious behavior." Analysis, assessment, and treatment (pp. 43-46). New York: Springler-Verlag. Johnson, C. R., Lubetsky, M. J., & Sacco, K. (1995). Psychiatric and behavioral disorders in preschoolers with developmental disorders. Journal of Autism and Development Disorders, 2, 169-182. King, B. H., DeAntonio, C., McCraaken, J. T., Fomess, S. R., & Ackerland, V. A. (1994). Psychiatric consultation in severe and profound mental retardation. American Journal of Psvchiatr3', 151, 1802-1808. Kirman, B. H. (1985). Mental retardation: Medical aspects. In M. Rutter & L. Hersov (Eds.), Child and adolescent psychiatry: Modern approaches (pp. 650-660). Boston: Blackwell Scientific Publications. Kolko, D. J. (1992). Short-term follow-up of child psychiatric hospitalization: Clinical description, predictors, and correlates. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 719-727. Matson, J. L. (1989). Self-injury and stereotypies. In T. H. Ollendick & M. Hersen, (Eds.), Handbook of child psychopathology (2nd ed., pp. 265-275). New York: Plenum Press. Menolascino, E J. (1969). Emotional disturbances in mentally retarded children. American Journal of Psychiatry, 126, 168-176. Parsons, J. A., May, J. G., & Menolascino, E J. (1984). The nature and incidence of mental illness in mentally retarded individuals. In E J. Menolascino & J. A. Starks (Eds.). Handbook of mental illness in the mentally retarded (pp. 3-43). New York: Plenum Press. Philips, I., & Williams, N. (1975). Psychopathology and mental retardation, a study of 100 mentally retarded children: I. Psychopathology. American Journal of Psychiatry, 132, 1265-1271. Quine, L. (1986). Behaviour problems in sevedy mentally handicapped children. Psychological Medicine, 16, 895-907. Reid, A. H. (1972). Psychosis in adult mental defectives: I. Manic depressive psychosis. British Journal of Psychiatry., 120, 205-212. Reid, A. H. (1980). Psychiatric disorders in mentally handicapped children: A clinical and follow-up study. Journal of Mental Deficiency Research, 24, 287-298. Reiss, S. (1982). Psychopathology and mental retardation: Survey of developmental disabilities mental health program. American Journal of Mental Retardation, 20, 128-132. Reiss, S., Levitan, G., & Szyszko, J. (1986). Emotional disturbance and mental retardation: Diagnostic overshadowing. American Journal of Mental Deficiency, 86, 567-574. Ruedrich, S., & Menolascino, E J. (1984). Dual diagnosis of mental retardation and mental illness: An overview. In E J. Menolascino & J. A. Starlcs (Eds.), Handbook of mental illness in the mentally retarded (pp. 45-81). New York: Plenum Press. Rutter, M., Graham, P., & Yule, W. (1970). A neuropsychiatric study of childhood. London: Heinemann. Rutter, M., & Lockyer, L. (1967). A five to fifteen year follow-up study of infantile psychosis: I. Description of the sample. British Journal of Psychiatry, 113, 1169-1182. Rutter, M., & Martin, J. A. M. (1972). The child with delayed speech. London: Heinemann. Rutter, M., Tizzard, J., Yule, W., Graham, O., & Whitemore, K. (1976). Isle of Wight studies, 1964-1974. Psychological Medicine, 6, 313-332. Rychkova, L. S. (1986). Clinical characteristics of early alcoholism in adolescents with slight mental retardation of exogenous etiology. Soviet Neurology and Psychiatry, 20, 55--63. Singh, N. N., Sood, A., Sonenklar, N., & Ellis, C. R. (1991). Assessment and diagnosis of mental illness in persons with mental retardation: Methods and measures. Behavior Modification, 15, 419--443. Szatmari, P., Offord, D. R., & Boyle, M. H. (1989). Ontario Health Child Study: Prevalence of attention deficit disorder with hyperactivity. Journal of ChiM Po'chology and Psychiatry, 30, 219-230. Szymanski L. S. (1994). Mental retardation and mental health: Concepts, aetiology and incidence. In N. Bouras (Ed.), Mental health and mental retardation: Recent advances and practises (pp. 27-28). Cambridge, England: Cambridge University Press. Vitiello, B., & Behar, D. (1992). Mental retardation and psychiatric illness. Hospital and Community Psychiat~, 43, 494-49.
Research in Developmental Disabilities, Vol. 18, No. 5, pp. 369-382, 1997 Copyright © 1997 Elsevier Science Ltd Printed in the USA. All rights reserved 0891-4222/97 $17.00 + .00
PII S0891-4222(97)00016-4
Psychopathology in Children and Adolescents with Developmental Disorders Antonio Hardan and Robert Sahl Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
Children and adolescents with developmental disorders suffer from a wide range of psychopathology. However, there are no published studies examining this subject exclusively in this population using recent diagnostic criteria. The primary purpose of this paper is to report on the diagnosis encountered in a clinical setting using DSM-III-R. The medical records of all individuals assessed in a specialized program during a l-year period were reviewed looking at their demographic features, diagnoses, and target behaviors. Our sample consisted of 233 subjects and contained significantly more boys than girls. The most common psychiatric diagnoses were oppositional defiant disorder and attention deficit hyperactivi O, disorder. Pica, organic mental disorder NOS, and Autistic Disorder were more qften encountered in individuals with low intellectual functioning. Depressive disorders, posttraumatic stress disorder, and developmental speech/language disorders were diagnosed more in high functioning subjects. The most common symptom was impulsivi~. This retrospective study highlights the need for more rigorous examination of current diagnostic concepts and criteria in children and adolescents with developmental disorders. Prospective studies should be conducted with standardized instruments in clinics and community samples to provide more information on psychiatric disorders in this population. © 1997 Elsevier Science Ltd
The authors thank Cynthia Johnson, PhD, Michael DeBellis, MD, and Boris Birmaher, MD for their helpful comments during manuscript preparation. Requests for reprints should be sent to Antonio Hardan, 3811 O'Hara Street, Room 688, Pittsburgh, PA 15213; E-mail: [email protected].
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INTRODUCTION It has been increasingly recognized that individuals with mental retardation and/or developmental disabilities (MR/DD) suffer from a wide range of psychopathology similar to persons with normal cognitive abilities (Bernstein, 1970; Philips & Williams, 1975), although manifestations may differ depending on the degree of cognitive impairment (Balthazer & Stevens, 1975; Collins, 1971). The prevalence rates of psychiatric disorders in children and adolescents with MR/DD have been reported at 15% to 52% (Baker & Cantwell, 1987; Eaton & Menolascino, 1982; Parsons, May, & Menolascino, 1984; Ruedrich & Menolascino, 1984, Rutter, Tizzard, Yule, Graham, & Whitmore, 1976). In Rutter's early Isle of Wight study, 30.4% of the children with IQs less than 70 were found to have a psychiatric disorder on the parent questionnaire, and 41.8% on the teacher questionnaire (Rutter, Graham, & Yule, 1970). Comparable rates for persons without MR/DD were 7.7% and 9.5%, respectively. Children and adolescents with MR/DD have an increased rate of psychiatric disorders (Baker & Cantwell, 1987; Rutter et al., 1976), and they are at higher risk for emotional disturbances when compared with individuals with normal intelligence (Reid, 1980). However, limited information and research exist about psychiatric diagnoses in this population (Einfeld, 1982; Singh, Sood, Sonenklar, & Ellis, 1991; Vitiello & Behar, 1992). In an early study, Menolascino (1969) examined the emotional disturbances in 256 children with MR/DD. He found 134 to have Chronic Brain Syndrome (CBS) with behavioral reactions, 43 with CBS with psychotic reactions, 8 with functional psychoses, 4 with personality disorders, 58 with adjustment reaction and 15 with a psychiatric disorder not further specified.In another early study, Chess and Hassibi (1970) examined the psychiatric disorders of 52 children with mental retardation (MR). They found that 21 had no diagnosis, 18 had reactive behavior disorder, 1 had neurotic behavior disorder, 11 had cerebral dysfunction, and 1 had psychosis. Irving and Williams (1975) studied 100 children with MR referred to a psychiatric outpatient clinic. They found 38 with psychoses, 5 with neuroses, 16 with personality disorders, 26 with behavioral disorders, 2 with transient situational disorders, and 13 had no evidence of psychiatric disorder. Recently, Eaton and Menolascino (1982) assessed, from 1976 to 1979, a community-based sample of 114 individuals with MR, 56 of which were children and adolescents. They found that 8 were diagnosed with schizophrenia, 5 with personality disorders, 16 with adjustment reaction, and 27 with organic brain syndrome. More recently, Szymanski (unpublished data, 1994) conducted a detailed diagnostic assessment in a developmental disabilities' clinic, on 277 children and 123 adults with only mild/moderate MR. A DSM-III Axis I diagnosis of a mental disorder was made in 70% of children. The most common diagnoses were pervasive developmental disorders 22%, affective disorders 12%, and adjustment disorders 10%. Johnson, Lubetsky, and Sacco (1995) reported on the psychiatric and behavioral disorders in hospitalized preschoolers
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with developmental disabilities. The sample consisted of 169 children assessed on an inpatient unit. The most common diagnoses were attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). These researchers used recent diagnostic criteria, but they were not conducted in outpatient and inpatient settings, and the samples studied did not include exclusively children and adolescent with all levels of intellectual functioning. The paucity of information in the literature on the psychiatric diagnoses in children and adolescents with MR/DD may at least be partially explained by diagnostic overshadowing. It refers to the tendency of clinicians to attribute psychopathology to cognitive deficiency rather than to a diagnosable psychiatric disorder. The existence of this phenomenon was validated by Reiss, Levitan, and Szyszko (1986) leading to an increased awareness of this problem among mental health professionals working with individuals with MR/DD. In an attempt to provide more information about this topic, we conducted a retrospective, descriptive investigation of the psychopathology of a sample of children and adolescents with MR/DD. The aims of the present study were three folds: (a) to identify the psychiatric symptoms and diagnoses of children and adolescents with MR/DD assessed in a tertiary clinical setting, (b) to examine the demographic features of this population, and (c) to determine the relationships between identified target symptoms, psychiatric diagnosis, gender and cognitive level of functioning.
METHOD Subjects The study was conducted in a specialized program for developmental disorders that serves the needs of children and adolescents with MR/DD, and their families. It offers an afterschool program, a summer school, a school-based partial program, a 24-bed inpatient unit, and an outpatient clinic. The latter two programs are the port of entry of all patients. Patients' referral sources include other clinics within the university, pediatricians, child psychiatrists in the community, family members, various schools, and community mental health agencies.
Procedure The medical charts of all individuals who entered the program over a 12-month period were reviewed. The following variables were collected from each patient's record: age, race, sex, living situation, family psychiatric history, most recent cognitive testing (IQ), duration of present episode of the illness, symptom inventory/target behaviors, number of previous hospitalizations, inpatient versus outpatient status, psychotropic treatment and diagnoses (axes I, II, and IV). This information was gathered from the psychiatric evaluation forms, the discharge
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summaries, and the progress notes available in the medical record. Psychiatric diagnoses were made by a treatment team headed by a child psychiatrist or neurologist with several years of experience with the population studied. The other members of the team usually include one social worker, a child psychiatry fellow, a psychiatry resident, or a senior clinician, a developmental specialist, a master level behavioral specialist, a psychiatric nurse, and a faculty psychologist. Diagnoses were based on DSM-III-R criteria. The IQ was measured by a developmental psychologist using either the WISC-R or the Stanford-Binet (4th ed.). Patients who were not diagnosed with a developmental disorder were excluded. Patients with borderline intellectual functioning were included. Individuals with severe and profound mental retardation were combined in one group. When a patient had multiple hospitalization or outpatient assessments during the study period, only the last evaluation was considered.
Data Analysis The frequencies and percentages of different variables were calculated across gender, and level of cognitive functioning. The corrected chi-square test was conducted to determine statistical significance across gender, and level of cognitive functioning. The Fisher Exact test was used when the cell size was less than five. RESULTS The charts of 298 individuals were reviewed. One chart was not available. Eighteen were not included because the subjects were found not to have any developmental disorder or any level of mental retardation. Forty-six other charts were excluded. These subjects had multiple assessments during the study period, and only the data form from the last contact was considered. The study population consisted of 233 patients. Their ages ranged from 3.2 to 19.4 years with a mean of 9. Table 1 shows the demographics of the sample. The mean age for boys was 8.8 years (range 3.2-19.1), and 9.4 years for girls (range 3.8-19.4). There were significantly more boys than girls (X2 = 289.305, df= 1, p < 0.001), with a ratio of 2.5. Significantly more children came from a single-parent home (45.5%) than from any other living situation (X2 = 327.979, df= 6, p < 0.001). Among the patients assessed in the outpatient clinic, 14% (N = 16) had a history of one or more hospitalizations. The subjects had significantly more chronic ( > 12 months) than acute emotional problems (×2 = 340.236, df= 1, p < 0.001). Subjects had a significantly higher family history of drug and alcohol abuse/dependence (43%) as compared with other psychiattic disorders (X2 = 124.278, df = 6, p < 0.001). Sixty-two percent of our sample was treated with psychotropic medications. Table 2 presents the frequencies and percentages of the diagnoses across functioning levels. There are more than 233 because multiple diagnoses were
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373
TABLE 1 Demographic Features of the Population Feature Number of children Gender Boys Girls
N 233
i00
168 65
72 28
168 56 9 120 113
72 24 4 51.5 48,5
Race White Black Other
Inpatients Outpatients Stressors None Mild
Moderate Severe Extreme Catastrophic Unspecified Duration of illness < 12 months > 12 months
Family psych history None Affective disorders Psychotic disorders
Drugs and alcohol ADHD MR/autism Other
Living situation Biologic parents Single parent Biologic relative Foster parent Adoptive parents Group home Other
18 62 92 37 9 0 15
8 27 39 16 4 0 6
47 186
20 80
29 70 22 101 31 63 75
12 30 9 43 12 27 32
72 106 12 17 10 12 4
3I 45.5 5 7 4 5 1.5
used. The most common diagnoses for Axis I were: ODD, ADHD, other specified family circumstances, and organic mental disorder (OMD). The latter diagnosis, which includes organic mood disorder, organic personality disorder, organic anxiety disorder, and organic mental disorder, NOS, was significantly more encountered in the severe/profound group (×2 = 21.808, df= 5, p < 0.001). Pica also followed the same t r e n d (X 2 = 11.056, df= 5, p = 0.053), in occurring in the severe/profound group. Almost all subtypes of depressive disorders were reported in our sample: Major depression, single episode, unspecified (N = 5); Major depression, recurrent (N = 2); Depressive disorder, NOS (N = 8); and
105(45) 99(42) 62(26) 25(11) 23(10) 20 (8.5) 19 (8) 24(10) 10(10) 9 (4) 8 (3) 8 (3) 5 (2) 4 (1.5) 4 (1.5) 4 (1.5) 4 (1.5) 3 (1) 2 (1) 126(54) 36 (15.5) 27 (11.5) 7 (3) 10 (4) 5 (2)
ODD ADHD OSFC Enuresis OMD PCP Adjustment Depressive Pica Encopresis Bipolar Anxiety Tic PTSD IED Stereotypy Psychotic Conduct OCD Dev Sp/Lang Autistic PDD, NOS Dev read Dev D, NOS Other Dev D
16(44) 16(44) 13(36) 2 (5.5) 0 7(19) 6(17) 6(17) 0 1 (3) 1 (3) 0 0 3 (8) 0 0 1 (3) 2 (5.5) 0 32(89) 1 (3) 2 (5.5) 1 (3) 2 (5.5) O
BL N = 36
19(49) 16(41) 11(28) 5(13) 0 5(13) 5(13) 11(28) 0 0 0 2 (5) 3 (8) 1 (2.5) 1 (2.5) 0 2 (5) 0 1 (2.5) 14(36) 3 (8) 7(18) l (2.5) 1 (2.5) 1 (2.5)
Mild N = 39 18 (54.5) 14(42) 5(15) 2 (6) 3 (9) 2 (6) 1 (3) 2 (6) 0 0 4(12) 1 (3) 0 0 3 (9) 0 1 (3) 0 1 (3) 19 (57.5) 8(24) 6(18) 0 0 0
Mod N = 33 9(41) 8(36) 2 (9) 0 8(36) 0 0 1 (4.5) 3(14) 1 (4.5) 1 (4.5) 2 (9) 0 0 0 1 (4.5) 0 0 0 4(18) 9(41) 2 (9) 0 0 0
Sev/Pf N = 22 13 (32.5) 15 (37.5) 8(20) 4(10) 7 (17.5) 2 (5) 1 (2.5) 1 (2.5) 3 (7.5) 2 (5) 0 0 0 0 0 1 (2.5) 0 0 0 28(70) 5 (12.5) 0 0 1 (2.5) 0
Unsp N = 40 30(48) 30(48) 23 (36.5) 12(19) 5 (8) 4 (6) 6 (9.5) 3 (5) 4 (6) 5 (8) 2 (3) 3 (5) 2 (3) 0 0 2 (3) 0 1 (1.5) 0 29(46) 10(16) 10(16) 5 (8) 6 (9.5) 4 (6)
Average N = 63 4.782 1.514 11.447 0.111 21.808 9.693 9.592 21.267 11.056 5.925 10.463 5.515 8.904 12.267 13.614 3.785 5.451 6.952 4.557 40.061 19.366 10.725 8.234 7.401 8.206
X2 0.506 1.000 0.046 '9.152 0.000 0.090 0.094 0.000 0.053 0.350 0.067 0.401 0.122 0.032 0.019 0.680 0.409* 0.247* 0.542* 0.000 0.002 0.061 0.156 0.156 0.158
P
BL: borderline mental retardation (MR); Mod: moderate MR; Sev/Pf: severe/profound MR; Unsp: unspecified MR; average IQ; OSFC: other specified family circumstances; OMD: organic mental disorders; PCP: parent child problem; Depressive: major depressive disorder, recurrent, depressive disorder, NOS, and dysthymia; Anxiety: overanxious disorder, seperation anxiety disorder, anxiety disorder, NOS, phobias, and panic disorder; IED: intermittent explosive disorder; PDD, NOS: pervasive developmental disorder; Dev Sp/Lang: developmental speech/language disorder; Dev Read: developmental reading disorder; Dev D, NOS: developmental disorder, NOS; other; Dev D: Dev arithmetic disorder and developmental coordination disorder. *Fisher test nonsignificant.
Total N = 233
Diagnosis
TABLE 2 Diagnosis Across Functioning Levels (%)
(2)
I(< I) 13 15.5~ 110 (47) 14 (6) 176 (75) 47 (20) 13 (5.5)
1 (3) 26(74) 2 (5.5) 0 8(22) 0 1 (3) 0 25(69) 1 (3) 16 (7) 8(22) 10 (4) 2 (5.5) 0 0 1131 0 6117~ 181501 4(11) 25(69) 7(19) 2 (5.5)
BL N = 36 1 (2.5) 29(74) 1 (2.5) 7(18) 14(36) 3 (8) 5(131 0 25(69) 1 12.51 15(38) 4110) 11 (28) 6 115.51 0 2 (5) 1 (2.5) 1 (2.5) 1 (2.5) 19149) 2 (2.5) 29(74) 101261 2 (2.5)
Mild N = 39 2 (6) 24(73) 2 (6) 7(21 ) 13(391 2 (6) 2 (6) I (3) 22(67) 0 111331 4112) 7(21 ) 41121 0 4(121 0 0 2 (6) 211641 41121 30(90) 6118) 0
Mod N = 33 3(141 11150) 41181 4118) 17(77) 0 0 0 16(721 0 111501 2 (9) 0 0 0 1 (4.5) 0 0 0 131591 0 17177) 3(141 I (4.5)
Sev/PF N = 22 3 (7.5) 24(60) 0 4( l 0) 11(27) 0 0 0 25 (62.5) 0 5 112.51 2 (5) 4(10) 2 (5) 0 1 (2.5) 11 0 2 (5) 11 (27.5) 0 24(60) 5 (12.51 1 (2.5)
Unsp N = 40 4 (6) 40(63) 4 (6) 9(14) 21(33) 0 2 (3) 1 11.51 45(71 ) 0 18 (28.5) 7(11 ) 10(16) 11(171 2 (3) 6 (9.5) 2 (3) 0 2 (3) 28(44) 4 (6) 5t1811 161161 7(11)
Average N = 63 3.922 5.836 1.755 8.928 20.832 11.652 10.330 3.409 1.178 4.260 13.764 5.893 12.058 9.208 5.444 6.872 2.859 4.996 11.105 I 1.395 7.873 11.233 3.931 6.389
X2
0.654* 0.361 0.088* O. 121 0.000 0.042 0.071 0.754* 1.000 0.592* 0.018 0.354 0.036 0.109 0.410* 0.254 0.820* 0.473* 0.052 tl.047 0.178" 0.050 1/.652 0.300
p
BL: borderline MR; Mod: moderate MR; Sev/Pf: se~ere/prolk)und MR; UJ~sp: unspecified MR; average IQ; SIB: self-injurious behavior; Delusions/thought: delusions/thought disorder: Psychomotor retard: psychomotor retardation; Obsessions/compul: obsessitm/compulsion. *Fisher test nonsignificant.
Drugs and alcohol Sexual problems Aggression Anti-social lmpulsivity Social withdrawal Dependent
4
14 (6) 154 (66) 13 (5.5) 31 (13) 84 (36) 5 (2) 10 (4) 21<11 158 (68) 2(<1) 76 (32.5) 27 (12) 42 (18) 25 (10) 2(< 1) 14 (6)
Impaired sensorium Poor concentration Self-neglect Bizarre behavior SIB Delusion/thought Hallucinations Elation Hyperactivity Psychomotor retard Sleep disturbances Eating disturbances Sadness Anxiety Phobias Obsessions/Compul
Somatization
Total N = 233
Target Symptoms
TABLE 3 Target Symptoms Across Functioning Levels (%)
2"
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A. Hardan and R. Sahl
dysthymia (N = 6). There was a significant difference in depressive disorders with these diagnoses given more to higher functioning individual, specifically borderline and mild MR (X2 = 21.267, df = 5, p < 0.001). The full range of anxiety disorders were diagnosed: overanxious disorder (N = 4), anxiety disorder, NOS (N = 3), posttraumatic stress disorder (PTSD) (N = 4), separation anxiety disorder (N = 1), and obsessive compulsive disorder (N = 2). On Axis II, developmental speech/language disorder and autistic disorder were the most frequent diagnoses made (Table 2). The breakdown of the different levels of mental retardation in our sample was as follows: borderline 15.5% (N =26), mild 17%(N = 39), moderate 14% (N = 33), severe/profound 9% (N = 22), and unspecified 17% (N = 40). Sixty-three subjects (27%) had an average IQ and were included in the study because of other developmental disabilities. Pervasive developmental disorders were observed in all degrees of cognitive ability. There was a significant difference in proportions of diagnosed autistic children, with the severe/profound group being diagnosed more often than other groups with mental retardation (X2 = 19.366, df= 5; p < 0.005). Also there was a significant difference in proportions for which developmental speech/language disorders were given with the severe/profound group being diagnosed less frequently (X2 = 40.061; df= 5; p < 0.001). When this group was excluded, differences in proportions remained significant (X2 = 27.957, df = 4, p < 0.0001). No significant differences were found in the proportions of boys and girls with autistic disorder in this clinical sample. Among the 63 subjects with average intelligence, 20 (32%) were diagnosed either with autistic disorder or pervasive developmental disorder, not otherwise specified (PDD, NOS). Symptom inventory and target behaviors were also examined (Table 3). The most frequent were: impulsivity, hyperactivity, poor attention, span/distractibility, aggression, and self-abusive behavior. Psychotic symptoms, phobias, somatization, alcohol/drug abuse, elation, and psycho-motor retardation were found infrequently. Poor concentration and aggression were two target symptoms that were more often observed in boys than in girls (poor concentration: ×2 = 11.813, df= 1, p < 0.001; and aggression ×2 = 7.213, df= 1, p < 0.01). Pica occurred more frequently in females than in males, but this finding showed only a trend toward significance (X2 = 3.816, df= 1, p = 0.51). There were some significant differences in the percentages of target symptoms across different functioning levels. Whereas sadness and delusions/thought disorder were more likely to be identified in children with higher cognitive levels, self-injurious behavior (SIB) and sleep disturbances were more often observed in subjects with lower cognitive abilities. DISCUSSION To our knowledge this is the first study that examined the psychopatholgy and diagnosis exclusively in children and adolescents with all level of MR/DD using DSM-R. This investigation provides a descriptive account of the psychiatric
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377
diagnoses of 233 subjects with MR/DD admitted to a tertiary care setting. The sample was composed of a larger percentage of boys, which is consistent with other studies reporting the percentages of males and females (Eaton & Menolascino, 1982; Einfeld, 1984; Johnson et al., 1995; Kolko, 1992; Menolascino, 1969). The distribution of race in our sample represents the catchment area of the program where the study was conducted. Most subjects (80%) had been mentally ill for more than 1 year before coming for psychiatric treatment. Several factors contributing to this finding include the tendency to attribute psychopathology to cognitive deficiency, the difficulty identifying early signs of psychiatric illness in this population, the high level of tolerance of the environment for individuals with MR/DD and considering treatment only when symptoms are severe and unremitting. The rate of individuals coming from a single-parent family (45.5%) is higher than the one found in the population of all families with dependent children. Quine (1986) reported on a similar finding. Eighteen percent of his sample of behaviorally disordered mentally handicapped children were from single-parent families, a figure that is higher (12.1%) than the reported for all families with dependent children. Bradshaw (1979) warned against tracing the link between child disability and relational/marital breakdown, mainly because it is impossible to draw conclusions from cross-sectional data. It is controversial whether some factors associated with growing up in a single-parent family contributes to the genesis of emotional disorders or whether the difficulties of looking after a disabled individual with behavioral problems contribute to the breakdown of parental relationships (Quine, 1986). Only 12% of our sample was without a family history of psychiatric illness. This information is limited since it was obtained from chart review with inability to ascertain its reliability and validity. These high rates could be explained by the tendency to be over inclusive during the clinical assessment and considering more than first degree relatives when gathering the psychiatric family history. Dosen (1984) found that 55% of his sample of depressed children with developmental disabilities had one or both parents with marked "neurotic behavior." He also reported that 29% of his sample had one or more relatives suffering from depressive, manic-depressive, or other psychotic conditions who had received psychiatric treatment. This rate is similar to our finding of 39% of our sample with family history of affective and or psychotic disorders. High rates of drug and alcohol abuse/dependence among family members were found in our sample. Emotional disturbances may have resulted from the poor parenting that is often associated with substance abuse. This fact may shed light not only on the genesis of the emotional disturbances but also on the possible etiological factors of the developmental disabilities with in utero exposure to drugs. The frequencies of the diagnoses encountered in our sample differed from those observed in similar studies looking at psychopathology in children and adolescents with MR/DD (Chess & Hassibi, 1970, Eaton & Menolascino, 1982, Irving & Williams, 1975, Menolascino, 1969), even though almost all of them
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examined referred samples. Five (2%) individuals in our sample had a psychotic diagnosis compared with 38 (44%) in the report of Irving and Williams (1975), and 8 (14%) in the study of Eaton and Menolascino (1982). Also, 10% of our sample were diagnosed with OMD compared with 69% in the study of Menolascino (1969), 32% in Chess and Hassibi (1970), and 48% in Eaton and Menolascino (1982). The use of different terminology and classification may explain these differences, with the tendency of older studies to be overinclusive in their diagnostic categories. For example, in the study by Irving and Williams (1975), psychotic maldevelopment included infantile autism, childhood schizophrenia, and chronic brain syndrome. A more recent study looking at diagnosis in severely and profoundly retarded individuals using DSM-III-R indicated the relative infrequency of the diagnosis of psychosis (King, DeAntonio, McCraaken, Forness, & Ackerland, 1994). Almost all diagnoses were encountered at different levels of cognitive functioning. However, some were identified more frequently in individuals with mild and moderate levels of mental retardation, and others more in the severe/ profound group. OMD was diagnosed more frequently in the latter. Johnson et al. (1995) reported that preschoolers with severe/profound mental retardation were more likely to be diagnosed with organic brain syndromes. These syndromes are more likely to be identified in individuals with low IQ since structural and functional abnormalities are more evident in this group when compared with individuals with mild and moderate level of cognitive functioning (Kirman, 1985). In accordance with the literature, self-injurious behavior occurred more often in the lower functioning individuals since there is evidence of an inverse relationship between the incidence or prevalence of self-injury and level of functioning (Johnson & Day, 1992; Matson, 1989). Also, autistic disorder was more often observed in children and adolescents with low IQ. This was anticipated given that 70% of children with Autistic disorder fall into the mental retardation range and 40% of these children have IQs of 50 or below (Rutter & Lockyer, 1967). Depressive disorders, PTSD, and intermittent explosive disorder were diagnosed more in the higher functioning group. The fact that certain symptoms were found only in the high functioning individuals could be explained by either their absence in the lower functioning group, their difficulties to be identified in this subgroup, or clinicians not searching for them. Most diagnostic categories were represented in our sample. However, some were not encountered in any subject, such as somatoform disorders, depersonalization disorders, and sexual disorders. The lack of use of structured interviews and symptom/behavior checklists may explain this finding. Thirty-two subjects (12.5%) were identified as having an affective disorder. All types of depressive disorders were reported in our sample. Subjects who received the diagnosis of bipolar disorder were classified under the not otherwise specified subtype. It may difficult to diagnose the bipolar disorder in this population and the expression of bipolarity may be different due to the underlying biologic and cognitive factors. In fact, Reid (1972) and Adams, Kivowitz,
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and Ziskind (1970) observed that mentally retarded adults do not display classic manic symptoms of euphoria and flight of ideas. Bipolar disorders were not diagnosed or considered in the old studies mentioned above (Chess & Hassibi, 1970; Eaton & Menolascino, 1982; Irving et al., 1975; Menolascino, 1969). By contrast, the more recent study of King et al. (1994) diagnosed bipolar disorder in 7% of all referred patients with severe and profound mental retardation. The low rate of drug and/or alcohol abuse and dependence was also reported by Reiss (1982). Edgerton (1986) obtained similar findings in adults with mental retardation. However, Rychkova (1986) noted that mildly mentally retarded adolescents are at risk of abusing alcohol. He found that these individuals develop a unique clinical picture of alcoholism with marked personality changes and more rapid onset of symptomatology than in the normal youth population. The retrospective collection of the data, in addition to the lack of using structured interviews may explain our findings here. Fifty-four percent of our sample were diagnosed with a developmental speech/language disorder. This rate is indeed higher than the 3% estimated for the general population (Grossman & Begab, 1983). However, this is not surprising since mental retardation (57% of our sample) may be the single largest cause of delayed language development (Rutter & Martin, 1972). There was no difference in the incidence of developmental speech/language disorders between boys and girls. This finding is inconsistent with the literature suggesting an association between sex and the presence of language disorders. Speech and language disorders prevalence rates typically are higher in boys than in girls (Beitchman, Nair, Clegg, Ferguson, & Patel, 1986; Calnan & Richardson, 1976). A possible explanation for the discrepancy could be that our sample is a clinical one, whereas most of the other studies included community and/or nonpsychiatric samples. Quine (1986) reported on the prevalence of behavioral problems in children with severe mental retardation. Hyperactivity was significantly more likely to be reported in boys than in girls, 25% and 14% respectively. King et al. (1994) found no difference in the percentage of hyperactivity in severely mentally retarded male and female patients. In the same study, 19c~ of the males and 11% of the females were diagnosed with ADHD, with a ratio of 1.7 favoring males. In our cohort, there was no difference between the incidence of hyperactivity in boys and girls, but a significant difference was found for poor concentration. However, a gender difference in the incidence of ADHD showed a trend toward significance (X2 = 0.268, df= 1, p = 0.07). This finding is somewhat consistent with what has been reported in the literature with higher incidence of ADHD in boys than in girls in children and adolescents of average intellectual functioning (Szatmari, Offord, & Boyle, 1989). Menolascino (1969) studied 256 emotionally disturbed outpatient children and adolescents with MR. Their symptoms included: hyperkinesia, impulsivity, stereotyped movements, withdrawal, emotional lability, and panic reactions. All of these symptoms were reported in the present study. However, aggression was
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frequently encountered in our sample but not in Menolascino's. The differences in patient population may explain this finding, since our sample included both inpatients and outpatients. This target symptom was identified in almost half of our sample (47%), and it is similar to the rate of 44.4% reported by Irving and Williams (1975) in their sample of 62 nonpsychotic mentally retarded children. In fact, aggression has often been identified as one of the maladaptive behaviors interfering most with functioning and leading to more restrictive educational placements in school-aged children with MR/DD (Bruininks, Hill, & Morreau, 1988; Quine, 1986). Sleep disturbances were observed in 32.5% of the sample. This is consistent with the literature with reports of sleep problems ranging from 34% (Clements, Wing, & Dunn, 1986) to over 80% (Barlett, Rooney, & Spedding, 1985) in children and adolescents with developmental disabilities. The relative low rates reported here may be attributable to the fact that 62% of our sample were on psychotropic medications. The data presented here were collected retrospectively from a program that specializes in the assessment and treatment of children and adolescents with psychiatric disorders and developmental disabilities. This characteristic limits significantly the generalizability of the results. The sample is by no means representative of the population of children and adolescents with MR/DD who are suffering from emotional difficulties. The absence of a community sample of patients with developmental disorders is expected to lead to a higher rate of psychiatric illness and to a predominance of externalizing disorders. It was also impossible to establish diagnostic reliability or validity taking into consideration the involvement of different treatment teams and the fact that diagnoses were made for clinical purposes using DSM-III-R criteria. Several clinical implications emerge from our study. Despite its limitations, the descriptive data provide a real world perspective on the nature of psychiatric illness in children and adolescents with MR/DD in an inpatient and outpatient setting. These individuals suffer from a wide range of psychopathology, and almost all psychiatric disorders can be diagnosed, externalizing as well as internalizing disorders. Therefore, D S M criteria should be used, whenever possible. It is imperative that clinicians working with this population assess for all types of psychopathology and avoid the overshadowing phenomena. Careful addressing symptoms of psychosis, depression, anxiety, and alcohol/drug abuse may have value in the diagnostic process. This first step is essential in the formulation of a treatment plan and its implementation since children and adolescents with MR/DD should be considered candidates for all types of interventions available, including pharmacotherapy and psychotherapy. In conclusion, the results reported are useful in identifying research issues and in exemplifying the types of problems frequently encountered when working with children and adolescents with MR/DD. This paper points to the need for rigorous examination of current diagnostic concepts and the developmental of diagnostic methods to identify pathology unique to developmental disorders.
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Prospective studies should be conducted with community and clinics samples using multiple sources of information from patients and informants derived from experimental analyses, direct observations, rating scales and standardized clinical instruments to provide more information on psychiatric disorders in this population.
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