Journal of Intellectual Disability Research(JIDR)

Description about the Journal

Journal of Intellectual Disability Research (JIDR),is published on behalf of mencap (which is the largest voluntary organisation in U.K. promoting the interests of people with intellectual disability/learning disability and their families)in association with IASSID (International Association for the Scientific Study of Intellectual Disabilities-the first and only world-wide group dedicated to the scientific study of intellectual disability) Devoted exclusively to the scientific study of intellectual disability and publishes papers reporting original observations in this field. Published monthly, Editor : A.J. Holland ; Mental Health Special Issue Editor: Sally-Ann Cooper Impact Factor is 1.596

Long Presentation :

Authors:

Research Centre :

J. A. Tsiouris, George A. Jervis Clinic S.Y. Kim, Department of Psychology W.T. Brown, Department of Human Genetics I. L. Cohen, Department of Psychology NewYork State Institute for Basic Research in Developmental Disabilities, Staten Island, NY, USA

Journal of Intellectual Disability Research Vol.55, Part 7, pp 636-649, July 2011.

Relevance for Selection

Introduction
The link between violence or aggression and mental disorders has been the focus of diverse studies in persons with intellectual disabilities (ID).
Aggressive behaviours towards others, objects and self, which constitute the core of challenging behaviours, are major intractable problems reported in 30% to 60% of persons with intellectual disabilities (ID) (Sigafoos et al. 1994; Smith et al. 1996; Crocker et al. 2006; Lowe et al. 2007; Cohen et al. 2010)

Introduction con
and in 15% when severe aggressive behaviours associated with psychiatric disorders, physical illness and pervasive developmental disorders are not included (Cooper et al. 2009a,b).

Aggressive behaviours in people with ID have been reported to be associated with the depressive and manic phases of mood disorders (Lowry & Sovner 1992; Sovner et al. 1993; King et al. 1994; Moss et al. 2000; Tsiouris 2001; Tsiouris et al. 2003b; Hemmings et al. 2006; Crocker et al. 2007; Hurley 2008),

Introduction con
Anxiety and psychotic disorders (Holden & Gitlesen 2003; Crocker et al. 2007), impulse control disorders and conduct disorders (King et al. 1994; Rojahn et al. 2004). Crocker et al. (2007) In a study of 296 adults with mild to moderate ID, found that persons categorised (according to the MacArthur scale) in the violent and aggressive groups were associated with higher ratings on autism, psychosis, paranoia, depression and dependent personality disorder.

Introduction con
According to Myrbakk & von Tetzchner (2008). although no overall direct associations were found between individual problem behaviours and psychiatric disorders, aggressive behaviours were associated with psychosis, anxiety and mania independently of degree of ID, whereas depression was associated with aggression against others in those with severe/profound ID and with self-injury in those with mild/moderate ID. Finally, physical aggression against self and tantrums were correlated with mild to moderate degree of ID, but not with psychiatric disorders.

Introduction con
Aggressive behaviours were reported to be associated with attention deficit hyperactivity disorder(ADHD),but no such association was reported for psychotic, depressive, or bipolar disorders(Jones et al.2008;Cooper et al.2009a,b).

Aim of the Study

To find out any significant associations among certain psychiatric disorders and specific types of aggressive behaviours, controlling for sex, age, autism and degree of severity of the ID

Hypothesis
There will not be any significant relationship in terms of aggressive behaviours with psychiatric disorders, age, sex and degree of intellectual disability of patients.

Methodology
Participants: The sample consisted of individuals with ID living in the community and receiving services from the New York State Office for People with Developmental Disabilities (OPWDD) between 2006 and 2007. They were recruited through the direct assistance of the Directors and Chief Psychologists of the various Developmental Disability Service Offices (DDSOs) in New York State.

Methodology con
Based on these communications regarding the numbers of potential participants(n = 9894),10,000 survey forms [Institute for Basic Research Modified Overt Aggression Scale (IBRMOAS), described below; Cohen et al. 2010] were sent to 14 agencies and 4675 were returned for a response rate of approximately 47%. Returned forms with missing information on the aggression items and demographics were excluded, leaving an n of 4069 participants for the current analysis.

Methodology con
Table 1 Demographic characteristics of the sample & the overall population

Methodology con
60%of the sample and 52% of the POP were men. 100%of the sample and 99% of the POP were over 18 years of age and mean ages were similar (sample M = 49.6, POP M = 51.8). The range of ID was similar across groups with slightly more cases in the mild (28%) and less in the moderate (16%) and severe (19%) range of ID in study sample.

Methodology con
The overall percentage of cases identified as having an autism spectrum disorder was also slightly higher (9.7%) in the sample relative to the POP (8.2%).

Methodology con
Measure Used: The Institute for Basic Research Modified Overt Aggression Scale IBR-MOAS (Cohen et al. 2010) was designed specifically for this survey. It was divided into several parts including : Demographic Information, Aggression Scale, Communication Skills, Setting Events(antecedents and consequences of the aggressive behaviours),

Methodology con
Behavior Control Issues (how staff manage outbursts), Prevention Issues (how staff try to prevent outbursts), Developmental Disability Diagnosis (diagnosis of an autism spectrum disorder and level of ID), Sensory Skills (vision and hearing), Medical Issues (e.g. ear infections, reflux, etc.), Developmental Disability Cause (aetiology, if known),

Methodology con
Psychiatric Issues (depression, psychosis, etc.) and Effective Treatments (staff judgement of most efficacious intervention). Aggression Scale measures 5 domains:
1. 2. 3. 4. 5. Verbal Aggression Toward Others (VAOTH) Physical Aggression Against Other People (PAOTH) Physical Aggression Against Objects (PAOBJ) Physical Aggression Against Self (PASLF) Verbal Aggression Toward Self (VASLF)

Methodology con
Based on consultation with the chief psychologists, a Likert measure of the frequency of occurrence of each of the aggression items during the past year was developed .

Methodology con
Diagnoses of psychiatric disorders Psychiatric disorder diagnoses reported on the IBR-MOAS were obtained from the files of persons with ID that were surveyed. The diagnoses on file were clinical diagnoses made by psychiatrists using the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSMIV) or Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision (DSM-IVTR)(American Psychiatric Association 1994, 2000).

Methodology con
Diagnoses of psychiatric disorders(procedure) A description of the process how the diagnoses are made follows: Persons exhibiting psychiatric symptoms, challenging behaviours or both are referred by the treatment team to a psychiatrist for evaluation and medication recommendation, if medical workup, behaviour modification plans and/or environmental changes are not effective in reducing the psychiatric symptoms or the challenging behaviours.

Methodology con
Diagnoses of psychiatric disorders(procedure) The next step involves the psychiatrist meeting with the treatment team, consisting of a psychologist, nurse, social worker and manager of the group home as well as the parent/guardian of the subject, where an agreement is made regarding the evaluation and the recommendations of the treatment.

Methodology con
Diagnoses of psychiatric disorders(procedure) Degree of ID was obtained from the files of each participant, which included medical, psychiatric, psychosocial and psychological evaluations (most recent updated)were used.

Data analyses
The R (R Development Core Team 2010) software package was used for the analyses. Because the aggression domain scores showed a skewed and overdispersed distribution.

Data analyses
The R (R Development Core Team 2010) software package was used for the analyses. Because the aggression domain scores showed a skewed and overdispersed distribution.

Results

Figure shows the percentage of participants who showed aggressive behaviours at any degree of frequency greater than zero across the five aggression domains.

Results con
The domain of VAOTH had the highest percentage 72%( 2922/4069) and the domain of PASLF the lowest 40% (1632/4069). 17% (701/4069) of participants did not show any aggressive behaviours.

Results con

Results con
Psychiatric disorders were diagnosed in 59% of the population surveyed, of whom 31% were diagnosed with only one psychiatric disorder, 17% with two, 10% with three to five and 0.5% with more than five psychiatric disorders. Impulse control disorder was the most frequent diagnosis 21% (862/4069), and personality disorder was the least frequent 8% (337/4069).

Results con
A larger percentage of consumers with mild and moderate degrees of ID had one or more psychiatric disorders compared to those with severe and profound ID (74% vs. 47%). Those in the range of mild and moderate ID were diagnosed with anxiety and impulse control disorders slightly more often than those with severe and profound ID.

Results con

Results con
In addition, 7% of participants who had psychiatric disorders (n = 2401) showed no aggressive behaviour, and 34% of participants with aggressive behaviours (n = 3368) were not diagnosed with any psychiatric disorders (Table 3).

Results con

Results con
Table 4 shows the summary of the associations between the predictor variables and the aggression domain scores. The regression coefficients and their signs indicate the size and direction of the association for each of the predictor measures. Bipolar, psychosis, impulse control and personality disorders were all highly associated with each of the five aggression domains.

Results con
Participants with personality disorder were about 26% more likely to show VAOTH than those without the diagnosis, holding all other variables constant. Participants with impulse control disorder were 84% more likely to engage in PAOBJ than those without the disorder.

Results con
Bipolar disorder was associated with increased frequencies of aggressive behaviour, on average about 45% (ranging from 29% to 56%) more for all aggressive domains compared to those without the disorder, controlling all other variables. Participants with diagnoses of psychosis or personality disorders were about 37% (ranging from 26% to 60%) more likely to show aggressive behaviours in each of the domains.

Results con
The only exception was the association of psychosis with PASLF, whose 18% increase barely reached significance. The largest percentage increase was seen in participants with impulse control disorder, who on average were 64% (ranging from 40% to 84%) more likely to show aggressive behaviours than those without impulse control disorder.

Results con
Depression was most associated with an increase in verbal aggression towards self (27%) Whereas anxiety was most strongly associated with both verbal and physical aggression against self (21% and 34%, respectively), holding all other variables constant.

Results con
The diagnosis of autism was most strongly associated with all three domains of physical aggression (PAOTH, PAOBJ, PASLF), showing about a 31% increase overall, but no significant associations with verbal aggression. The only significant association for participants with OCD was a 21% increase in PAOBJ compared to those without OCD.

Results con
Female participants showed 16% more frequent self-deprecating remarks and about 14% less frequent physical aggression against others and objects than male consumers. Sex was not significantly associated with VAOTH and PASLF when all other variables were controlled.

Results con
Age was not related to verbal aggression towards others, but had an effect on all other kinds of aggression; there were 8%, 9%, 12% and 14% decreases for VASLF, PAOTH,PAOBJ and PASLF, respectively, as age increased about one standard deviation (14 years). Lastly, the level of ID was negatively associated with most measures of aggression; the frequency of aggressive behaviour decreased with increasing ID.

Results con
Verbal aggression towards others decreased by 23% at each level of ID from the previous (less severe) level, and verbal aggression towards self and physical aggression against objects decreased by 10%. However, the frequency of self-injurious behaviour (PASLF) increased by 38% at each level of ID from the previous (less severe) level, controlling all other variables.

Discussion
Impulse control disorder and bipolar disorder are the two psychiatric diagnoses strongly associated in this study with all five domains of aggressive behaviours assessed by the IBR-MOAS in people with ID free of alcohol and drug abuse.

Discussion con
This association in people with ID between aggressive behaviours and impulse control and/or bipolar disorder may be because they have neurobiological characteristics that are similar to those linked to violence in people without ID (i.e. overarousal, impulsivity, mood dysregulation and impaired cortical control of an amygdala hypersensitive to stimuli) (Siever 2008).

Discussion con
Psychotic disorder was most associated with the first four domains, the association with physical aggression against self much weaker. The study found that psychotic, impulse control, or bipolar disorders, as well as younger age and more severe ID, were associated with the domain of physical aggression against other persons.

Discussion con
Depressive disorder was most associated with verbal aggression towards self (i.e. making self deprecating statements). This behaviour was more prevalent in those with less severe ID and was more prevalent in women. The results indicated that anxiety, impulse control and bipolar disorders as well as young age and having severe ID or an autism diagnosis were associated with physical aggression against self.

Discussion con
Physical aggression against self and its overall association with depression in persons with severe ID have been previously reported (Marston et al. 1997; Tsiouris et al. 2003a,b; Hemmings et al. 2006). The physical aggression against self has been reported to be associated with affective disorders in women (Cooper et al. 2007a), and its reversal after treatment with antidepressants has been reported (Sovner et al. 1993; Tsiouris et al. 2003b).

Discussion con
In this study, only impulse control and bipolar disorder, not depression or gender, were associated with physical aggression towards self. Physical aggression against self and its association with women diagnosed with autism and severe ID have been a common finding (Crocker et al. 2006; Cohen et al. 2010).

Discussion con
It is interesting to note that in Cohen et al. (2010), women with autism had the highest self-destructive behaviour scores (i.e. both verbal and physical), and the same group had an increased rate of anxiety or mood disorders compared to non-autistic women Verbal aggression towards self was associated with being female and with depression, but not with autism in the current study.

Discussion con
Depression in adults with severe to profound ID who exhibit physical aggression against self is under-diagnosed by psychiatrists who do not have training and experience in the mental health issues of the ID population (Beasley 2004),although five of the nine characteristics of major depression as per DSM-IV are observed in this population (Tsiouris 2001; Tsiouris et al. 2003a).

Discussion con
Previous studies have found no association between aggressive behaviours and major psychiatric disorders except for ADHD ( Jones et al. 2008; Cooper et al. 2009a). This is due to the exclusion of aggressive behaviours that were part of psychiatric disorders, physical illness and pervasive developmental disorders as per.

Discussion con
Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (Royal College of Psychiatrists 2001), the diagnostic instrument used in these studies, from the analyses the mental age of adults with ID is estimated to be between 2 and 9 years of age.

Discussion con
Most of these people have been separated from their families or have been victimised, and their lower ability level likely predisposed them for increased risk for major psychiatric disorders (Cooper et al. 2009b; Koenen et al. 2009) as well as increased prevalence of aggressive behaviours (Nihira et al. 1980; Emerson et al. 1999; Jones et al. 2008; Tsiouris 2010).

Discussion con
An association of anxiety disorder with tantrums (Myrbakk & von Tetzchner 2008) and with overall challenging behaviours in adults with more severe ID has been reported in two studies (King et al. 1994; Holden & Gitlesen 2006).

Limitations
Participants were living in community group homes and only 10% were living at home and attending state programmes daily .This sample cannot be considered as representing the entire population within NewYork State, other US states or other countries. The prevalence rates found in this study are much higher than reported in other studies of persons with ID, especially psychotic disorder

Limitations con
(Deb et al. 2001; Whitaker & Read 2006; Cooper et al. 2007b; Morgan et al. 2008). There are several possible explanations for this. It is possible that the psychiatric diagnoses were the clinical diagnoses on file made by the treating psychiatrist who associated aggressive behaviours with psychosis in persons with ID (Morgan et al. 2008).

Limitations con
It is possible that some of the psychiatric diagnoses were given without in-depth evaluation of the persons with ID and aggressive behaviours in order to match the categories of psychotropics prescribed for control of aggressive behaviours. The possibility also exists that persons with ID under the care of New York State and not by private agencies or families have higher rates of psychopathology.

Limitations con
Inter-rater reliability of psychiatric diagnoses on a subsample of persons surveyed with an independent psychiatrist trained in issues of ID would have strengthened the results of the study, but because of financial issues, this option was not available to us. The purpose of this study was to investigate any associations between certain psychiatric diagnoses and the type of aggressive behaviours in persons with ID, not the factors aetiologically associated with aggressive behaviours

Evaluation of the study

Future Studies
The purpose of this study was to delineate any significant association between certain psychiatric disorders and specific domains of aggressive behaviours in a large sample of persons with ID controlling for sex, age, autism and degree of ID. Future studies should obtain psychiatric diagnosis from psychiatrists trained in issues of ID who will follow the individuals and treat their diagnosable psychiatric disorders,

Future Studies con

while obtaining baseline measures and subsequently collecting information on aggressive behaviours using the IBR-MOAS or previous versions. Exacerbation, initiation or elimination of aggressive behaviours in association with changes in mental status or with control of signs and symptoms of psychiatric disorders will enable us to answer the question of these associations in a more precise manner.

Future Studies con

Whether behavioural withdrawal by temperament(i.e. behavioural inhibition shyness) which is associated with social anxiety and predisposition to mood disorder, is the phenotype predisposing to physical aggression against self in response to aversive, internal or external stimuli and setting events is an area which has to be investigated further.

Conclusion
Impulse control and bipolar disorder (characterised by arousability, low frustration tolerance and impulsivity or disinhibition, as well as mood dysregulation) appear to be the psychiatric diagnoses associated with all the domains of aggressive behaviours. When dealing with aggressive behaviours, impulse control disorder is the first diagnosis to be considered for treatment with appropriate medication

Conclusion con
(i.e. a2 adrenergic agonists, beta-blockers and selective serotonin reuptake inhibitors) in combination with the corresponding psychotropics for treatment of other comorbid psychiatric disorders. This study supports the notion that specific aggressive behaviours in persons with ID are associated with more than one psychiatric diagnosis, with certain exceptions,

Conclusion con
and also supports the notion that specific aggressive behaviours cannot be considered as characteristic of certain psychiatric disorders (Tsiouris et al. 2003b). Age, gender and degree of ID, along with a diagnosis of autism, predispose these individuals towards engaging in certain domains of aggressive behaviours.

Conclusion con
Treatment of the diagnosable psychiatric disorders in persons with ID and aggressive behaviours often decreases the behaviours frequency and severity.

Conclusion con
Psychotic disorder is only one of the many psychiatric diagnoses associated with aggressive behaviours (but not with physical aggression against self). Considering the high prevalence of impulse control, anxiety and mood disorders in the general and ID populations and the low prevalence of psychotic disorders in persons with and without ID and their association with all the domains of aggressive behaviours,

Conclusion con
Treatment of the diagnosable psychiatric disorders in persons with ID and aggressive behaviours often decreases the behaviours frequency and severity. In case the aggressive behaviours are chronic and they are exacerbated by psychiatric disorders, a combination of behavioural psychosocial interventions and the corresponding psychotropics should be applied.

Conclusion con
It is our hope that, in the future, there will be a decrease in the overreliance of psychotropics, and especially antipsychotics, for the treatment of aggressive behaviours in persons with ID.