Elsevier

Research in Developmental Disabilities

Volume 33, Issue 5, September–October 2012, Pages 1574-1580
Research in Developmental Disabilities

Behaviour profile of Hungarian adolescent outpatients with a dual diagnosis

https://doi.org/10.1016/j.ridd.2012.03.001Get rights and content

Abstract

The behaviour dimensions of 244 Hungarian adolescent psychiatric outpatients with a dual diagnosis (intellectual disability and psychiatric diagnosis) were examined by means of the adapted version of the Behaviour Problem Inventory (BPI, Rojahn, Matson, Lott, Esbensen, & Smalls, 2001). Four IQ subgroups were created: borderline, mild, moderate and profound ID subsamples. Significantly higher means were found in the self-injury/stereotyped behaviour/summarized scale categories both in the frequency and severity of symptoms in the more disabled groups against the samples having milder IQ impairment. Adolescents with a dual diagnosis showed much higher BPI scale means than an adult residential ID sample. ADHD and emotional disorders were the most frequent psychiatric diagnostic comorbidities of ID (20.67% and 11.73%). Academic achievement disorder, depression and psychosis had low occurrences (3.35, 2.23 and 1.17%, respectively) but showed convergency with other authors’ data. The comorbid emotional disorders may create challenges for the care of the mildly intellectually disabled group.

Highlights

► Differences in BPI characteristics within intellectual impairment levels in adolescent outpatients with a dual diagnosis. ► Frequencies of the psychiatric comorbid diagnoses of ID adolescents treated in child psychiatric services. ► Child psychiatrists, psychologists, special needs teachers and other professionals working in the field of disability practice and research may be interested.

Introduction

Despite the diagnostic difficulties and the frequent lack of symptom criteria, it is widely estimated that the rate of psychiatric problems is equally frequent or even higher in intellectually disabled samples than in the normative population (Gustafsson and Sonnander, 2004, King et al., 2005, Nota et al., 2008, White et al., 2005). However, White et al. (2005) stress that dual diagnosis (i.e. Matson & Bamburg, 1998) is “often overlooked due to difficulties associated with establishing a diagnosis of a mental disorder in people with intellectual disability” which may result in a seemingly lower prevalence of psychiatric problems than really exists. In Rojahn's view, prevalence reports of psychiatric symptoms in ID population vary greatly (16–49%, Rojahn, Rowe, Kasdan, Moore, & van Ingen, 2011) and depend on “a host of variables, including sampling strategies, case definition and the type of diagnostic system used”. Gustaffson's Swedish study estimates an incidence of 34–64% mental health problems in adults with ID within the general psychiatric care system. Community sample studies indicate 1.25–1.8% (Morgan et al., 2008, White et al., 2005) of people with a psychiatric illness having a concurrent ID. The Lundby study showed the relative risk of mental disorder as 1.34 in subjects suffering from ID as compared with 1 of the normative group (Nettelbladt, Goth, Bogren, & Mattisson, 2009).

This part of the intellectually disabled population, namely the members who suffer not only from various degrees of intellectual disability, but from any form of psychiatric diagnosis as well (having dual or even multiple diagnoses), that requires therapy, education or care finds itself in a midposition regarding competencies between two disciplines: special needs education and psychiatry. The psychiatric problems of people requiring special care may reformulate the tasks and the efforts of corrective therapy performed by special needs educators and all those involved face more difficulties compared to the therapy aims of “pure” clients suffering “only” from intellectual disability. On the other hand, if the intellectual positions are diminished or a definite IQ loss exists, that is, the psychiatric patient has a low normal or a borderline intellectual status, the situation is complicated, as most psychiatrists do not have sufficient training in the field of ID. In a regional study of ID persons requiring residential treatment we found (Csorba, Radvanyi, Regenyi, & Dinya, 2011) no strong connections between the medical diagnosis of ID impairment (ICD-10 F 70–79 diagnoses) and the estimated IQ range performed by the Hungarian Hamburg–Wechsler test (MAWI). The situation is often worse regarding comorbid diagnoses influencing intellectual abilities (including specific academic and non-academic achievement disorders and speech disorders) and physicians are not infrequently inattentive to the special needs of the patient. Intellectual disability (ID) not only makes people more likely to accumulate health complaints and psychological-psychiatric problems, but hinders their abilities to articulate them and to procure suitable treatment. The situation may become even more complicated if the mental health service (struggling with its own organisational difficulties) aims to provide efficient care for multiproblem adolescents (for instance: adolescent with borderline IQ and comorbid alcohol-drug abuse accompanied with conduct disorder).

The literature indicates a full awareness of the related problems. Contradictions between the relatively low number of ID people having psychiatric problems in psychiatric care and the strikingly much higher frequency of mental health problems health staff face in residential homes for intellectually disabled individuals (or how family members and guardians overcome related problems at home) contribute to the debate as to whether the dual diagnosis population should be provided support by general, specialised or liaison services (i.e. Chaplin, 2009).

In the case of comorbid pathology to ID, observing psychiatrists have to document the additional problems carefully, although contributors in the health service express different points of view regarding multiproblem or multidiagnostic patients. Special needs teachers and psychologists try to understand each psychopathological symptom or challenging behaviour of ID individuals from an individual motivational and/or finalistic aspect looking at the needs of the patient, considering the beneficial aspects of the environment or looking for the meaning and aims of the behaviour, while psychiatrists and physicians form diagnoses if the symptoms fit certain criteria and give psychopathological labels even if no definite but only subthreshold, ongoing or “form fruste” syndromes are observed. More research is wanted for this “dual diagnosis” population as it has a greater risk of acquiring and accumulating psychopathological and life management problems while having less chance of making their problems understandable and so receiving appropriate services.

Because of the difficulties of exploring the emotional and internalizing symptoms in ID people, special emphasis is made on behavioural dimensions reflecting the global adjustment level of the patient in care to the local community. Our study focuses on behaviour symptoms, draws consequences regarding the IQ accomplishment differences including the low normal IQ and borderline level (HAWIK-MAWI 85-70 IQ) patients, presents comorbid medical diagnoses of the study population and reports some reliability data on the Hungarian version of the BPI.

Section snippets

Aims

The aims of the study were as follows:

  • (a)

    to measure 3 behavioural dimensions in double diagnosis clinical adolescent participants,

  • (b)

    to compare the sums of behavioural symptoms in 4 different groups according to IQ levels,

  • (c)

    to present a varying profile of comorbid illnesses per IQ range and

  • (d)

    to report some preliminary data from the Hungarian pilot version of the Behaviour Problem Inventory (BPI, Rojahn et al., 2001).

The following hypotheses were made: increased self-injurious and stereotyped behaviour,

Sample

A clinical sample of adolescent patients (10–19 years) was recruited from 12 regional Child Psychiatric Centres of Hungary (based partly on former working relationships with colleagues see the Pannonia Survey, Csorba, Dinya, Plener, Nagy, & Pali, 2009), with every region of the country represented. Treated outpatients and recent admissions were included in the study if they fulfilled the abovementioned preadolescent–adolescent age criteria and the double diagnosis of a psychiatric disorder with

Results

The age distribution of the sample is seen in the Graph, the age subsamples were nearly equalized, with 23–35 individuals per category.

Table 1 displays the means of frequency sums followed by those of severity sums in four-grouped blocks in 3 BPI scales: self-injurious behaviour (SI), stereotyped behaviour (St), and aggressive-destructive behaviour (Aggr). Regarding the frequency and severity of SI behaviour, differences did not reach significant levels differentiating the borderline from the

Discussion

When interpreting the behavioural dimensions of the IQ subgroups, special attention should be focused on the dual diagnosis or double pathology, that is, any increase or decrease of means are influenced not only by the level of intellectual disability but also by various psychopathological conditions, especially ill-adjusted behaviour and conduct disorder. Comparing our results with the means of identical BPI scales of adult ID individuals in residential homes (Csorba et al., 2011), further

Acknowledgement

We would like to thank the collaboration of numerous colleagues from the 12 regional child psychiatric centres participating in the study

References (19)

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