[Electroconvulsive therapy in people with intellectual disability]. / Elektrokonvulsionstherapie bei Menschen mit Intelligenzminderung.

Electroconvulsive therapy (ECT) is a highly effective treatment option for severe mental illness. Although people with intellectual disability (ID) have similar prevalence rates of mental disorders in comparison to the general population their access to ECT remains challenging. A systematic literature review was carried out on treatment with ECT in patients with ID and a case report on a patient with ID who underwent ECT is presented, to highlight a typical clinical routine. A total of 100 articles with 208 different case reports were retrieved. In summary, the results underline the effectiveness of ECT in people with ID, with side effects comparable to those in the general population. The ECT is effective in the treatment of severe affective and psychotic disorders and particularly in people with catatonia. The use of ECT can improve the patient's mental health and quality of life and is often a life-saving treatment option. The prophylaxis of relapses should be included as early as possible in the planning process. Providing an easy access to ECT treatment for people with ID is corroborated by its effectiveness and is in line with the right to equal treatment in accordance with article 25 of the United Nations Convention on the Rights of Persons with Disabilities.

Impact of the emotional development approach on psychotropic medication in adults with intellectual and developmental disabilities: a retrospective clinical analysis.

BACKGROUND: Compared with the general population, adults with an intellectual developmental disorder (IDD) are more likely to develop mental health problems and to receive high levels of psychotropic medication, particularly antipsychotics. The emotional development (ED) approach may help to better understand the nature of challenging behaviour (CB) and tailor treatment and support accordingly. The aim of this retrospective study was to investigate the impact of the ED approach on the prescription of psychotropic medication during inpatient psychiatric treatment. METHODS: The clinical data of 1758 patients were analysed within a retrospective study design over a period of 12 years. ED level was assessed (1) for the first time (INITIAL-SEO), (2) during a previous hospital stay (PAST-SEO) or (3) not at all (NO-SEO). The effects of the ED assessment and the respective intervention during the current admission on the number of psychotropics and the number and dosage of antipsychotics were analysed for the total sample, including those with CB, autism spectrum disorders and psychosis. Group differences were analysed by a chi-square test and a one-factorial analysis of variance. For analysing the impact of the application of the ED approach on psychotropic medication, a covariance model was applied. Changes between the subsamples were analysed by t-tests for dependent samples. RESULTS: The ED approach had a significant impact on reducing the overall amount of psychotropic medication and the dosage of antipsychotics in all patients with IDD. These effects were mainly attributable to those showing CB. In patients with autism spectrum disorders, the developmental approach reduced the number of antipsychotics. No effects could be observed in patients with psychosis; in this subsample, both the number and dosage of antipsychotics increased. CONCLUSIONS: The application of the ED approach in the current hospital stay reduced the number of psychotropic drugs and the number and dosage of antipsychotics, especially in those patients with IDD and CB, but also in those with autism spectrum disorders.

A brief version of the Scale of Emotional Development - Short.

BACKGROUND: The Scale of Emotional Development - Short (SED-S) captures the level of emotional development in persons with a disorder of intellectual development (DID) with 200 items on five developmental levels. The study aims to develop a brief version of the SED-S. METHODS: Based on item analysis (proportions, χ2 -test, Spearman's ρ and corrected item-total correlation), a brief version of the SED-S was developed in a sample of 224 adults with a DID (n1 ) and validated in a second independent matched sample (n2  = 223). RESULTS: Item reliability ranged per item set from Cronbach's α = 0.835 to 0.924. Weighted kappa resulted in κω  = 0.743 (P < 0.001, 95% confidence interval = 0.690-0.802). Overall agreement of the brief version with the original SED-S was PO  = 0.7. The brief version of the SED-S showed weaknesses in distinguishing level 2 from the adjacent levels. CONCLUSIONS: The brief version of the SED-S showed good reliability and moderate to good validity results. Items of phase 2 and, to some degree, of phase 5 should be revised to further improve the psychometric properties of the scale.

Scale of Emotional Development - Short: reliability and validity in adults with intellectual disability.

BACKGROUND: Intellectual disability (ID) is often associated with delays in emotional development (ED). The Scale of Emotional Development - Short (SED-S) was developed to assess the level of ED and to adapt treatment and care accordingly. METHODS: In a sample of 724 adults from five study sites in three countries, a confirmatory factor analysis with a one-factor model was conducted on the entire dataset as well as in different subgroups. Furthermore, internal consistency was investigated using Cronbach's alpha. RESULTS: The confirmatory factor analysis indicated that a single-factor model fits the SED-S data well. The subgroup analyses revealed good model fit, regardless of the severity of ID and irrespective of sex or the presence of autism spectrum disorder or psychiatric disorders. Internal consistency was excellent for the entire sample (Cronbach's alpha = 0.93) and various subgroups (0.869-0.938). CONCLUSION: The results of this study suggest that the SED-S is psychometrically sound and can be used to assess the level of ED in adults with ID.

Brief report comparing the Scale of Emotional Development - Short (SED-S) with other scales for emotional development.

BACKGROUND: Different instruments were devised for assessing emotional development (ED) level in persons with an intellectual disability (ID), that is, the Scale of Emotional Development - Short (SED-S), the Scheme for Appraisal of Emotional Development (SAED), the Scale for Emotional Development - Second Revision (SED-R2 ) and the Schaal voor Emotionele Ontwikkeling - Lukas (SEO-Lukas). The aim of this study was to compare the level of emotional functioning as assessed with the SED-S with the SAED, SED-R2 and SEO-Lukas. METHODS: Emotional development was measured in adults with ID with the SED-S (N = 186) and the SAED (n = 85), the SED-R2 (n = 50) and the SEO-Lukas (n = 51). Correlation analysis and Cohen's kappas were calculated between the SED-S and the three respective scales. Internal consistencies (Cronbach's alpha) of the four scales were determined. RESULTS: The SED-S results correlated most with the SEO-Lukas (γ = 1; кω = 0.936) followed by the SAED (γ = 0.809; кω = 0.343) and least by the SED-R2 (γ = 0.665; кω = 0.182). The stage of ED assessed with the SED-S was lower than the ED results measured with the SAED, but higher than with the SED-R2 and most similar to the SEO-Lukas. Cronbach's alphas were high, ranging from 0.853 to 0.975. CONCLUSIONS: Given the respective differences between the scales, the SED-S may equalise the results as compared with previous versions.

Social individuation: Extending the scale of emotional development - Short (SED-S) for adolescent reference ages.

BACKGROUND: The SED-S is a standardized diagnostic instrument for assessing emotional development (ED) in people with a disorder of intellectual development. The SED-S defines five ED stages covering emotional reference ages up to 12 years in eight domains (5 items per domain). Stage 6 will extend the scale for early adolescent reference ages. AIMS: The aim of this study is to define the SED-S items for stage 6 ('Social Individuation'). METHODS AND PROCEDURES: Experts in developmental psychology phrased 56 items (7 items/domain) describing typical behaviors for emotional reference ages 13th-18th year (145th-216th month) in English, German and Dutch. Twenty-eight independent experts assessed the items' content validity and observability on a Likert scale (0 = good to 3 = unacceptable). Two items/domain with the lowest ratings were excluded to finally select 5 items/domain for SED-S stage 6. OUTCOMES AND RESULTS: The ratings were good with results ranging from 0.06 to 0.78 for validity and 0.06-1.78 for observability. After exclusion of the 2 lowest ranking items/domain, a set of 40 items was selected. CONCLUSIONS AND IMPLICATIONS: The SED-S is extended to allow the assessment of emotional reference ages up to 18 years. Further research should evaluate the scale's psychometric properties. WHAT THIS PAPER ADDS?: The current version of the SED-S covers emotional reference ages up to 12 years (144 months). Extending the SED-S for emotional reference ages up to 18 years (145th-216th months of life) in Dutch, German and English allows better differentiation in the higher ED range and expands the applicability of the scale. Specifically, it makes it possible to apply the SED-S in people with borderline intellectual functioning. Accounting for the level of ED may provide valuable information about the behaviors and needs of individuals with higher reference ages and may support targeted treatment options in a population highly vulnerable to behavioral or mental disorders.

Behavioural phenomena in persons with an intellectual developmental disorder according to the level of emotional development.

BACKGROUND: Challenging behaviours in people with an intellectual developmental disorder (IDD) are complex and often difficult to understand. The developmental perspective may provide additional insights into the specific behavioural patterns and underlying motives in different emotional reference ages. METHODS: The behaviours of 185 adults with IDD who were admitted to psychiatry were systematically assessed with the Aberrant Behaviour Checklist (ABC) and the Modified Overt Aggression Scale (MOAS). The association of the different behaviours with various emotional reference age groups as assessed with the Scale of Emotional Development - Short (SED-S) was analysed to deduce behavioural patterns typical for a certain level of functioning. RESULTS: Overall, the severity of challenging behaviours decreases in higher emotional reference age groups. Physical aggression was most prevalent in persons in the second phase of emotional development (7-18 months reference age). In SED-S-1 (reference age 0-6 months), the persons appeared to be searching for physical comfort and showed high scores in social withdrawal, stereotypies and aggression towards the self. Persons functioning in SED-S-2 (reference age 7-18 months) scored highest in irritability and physical aggression (searching for security), while those in SED-S-3 (19-36 months) exhibited the searching for autonomy type characterised by defiant and socially inappropriate behaviours. Persons with an emotional reference age of 4-7 years (SED-S-4) showed inappropriate speech, verbal self-regulation and depressive-like behavioural aspects (searching for identity). CONCLUSIONS: The behavioural phenomena exhibited in a certain emotional reference age may support the clinician to differentiate behavioural problems from psychopathological symptoms to yield the proper diagnosis.

The impact of emotional development in people with autism spectrum disorder and intellectual developmental disability.

BACKGROUND: Intellectual developmental disabilities (IDDs) and autism spectrum disorders (ASDs) are developmental conditions, which may also be associated with impairments in emotional development (ED). ED can be assessed using the Scale of Emotional Development - Short (SED-S), a five-stage model consisting of eight domains, which allows to study the relationship between ASD and ED in people with IDD. METHODS: In this retrospective study, the level of ED was compared in 327 adults with IDD with [n = 83; mean age 38.3 years; level of IDD: mild (6), moderate (21), severe (45) and profound (11)] and without [n = 244, mean age 36.9 years; level of IDD: mild (67), moderate (73), severe (68) and profound (36)] ASD. The discriminative ability of the SED-S was determined by a regression in a training and a validation sample. RESULTS: The level of ED correlated with the severity of IDD (rs  = -.654) and the presence of ASD (rs  = -.316). People with additional ASD showed lower levels of ED compared with those with IDD only (mean reference ages 7-18 vs 19-36 months). The developmental profiles were equally balanced in ASD and IDD-only. A regression analysis revealed three domains ('Relating-to-Peers', 'Differentiating-Emotions', and 'Regulating-Affect') to be useful for ASD assignment (AUC > 0.70, sensitivity 0.76-0.80, specificity 0.62-0.63). CONCLUSIONS: In people with IDD, additional ASD was associated with delays in ED, which may be considered in diagnostics, treatment and care.

[Body weight and mental disorders : Results from a clinical psychiatric cross-sectional study of people with intellectual disabilities]. / Körpergewicht und psychische Erkrankungen : Ergebnisse einer klinisch-psychiatrischen Querschnittsanalyse bei Menschen mit Intelligenzminderung.

BACKGROUND: People with intellectual disabilities (ID) have a shorter life expectancy and higher mortality rate and more often suffer from various physical and mental disorders (WHO: 3-4 times more often than the general population). Obesity is an important risk factor for various disorders. This cross-sectional study examined the body weight and its risk factors in a clinical population of adults with ID. METHODS: The prevalence of underweight, normal weight, and overweight was determined using the body mass index (BMI) for 633 patients of an outpatient clinic for people with ID and mental disorders. A multiple logistic regression analysis was used to assess factors for alterations in body weight. RESULTS: Approximately one out of two men and two out of three women with ID and mental disorders were overweight. Adults with mild and moderate ID, female gender, increasing age, Down's syndrome, behavioral disorders, and a less supported living situation were associated with a higher rate of obesity. People with dementia and autism spectrum disorders showed a lower rate of obesity. CONCLUSION: Young women with ID and mental disorders were particularly at risk for obesity. The respective factors may support the development of specific prevention programs to reduce the risk of overweight and thereby lead to better mental and physical health in people with ID.

Screening for ASD in adults with ID-moving toward a standard using the DiBAS-R and the ACL.

BACKGROUND: Identification of Autism Spectrum Disorder (ASD) in persons with intellectual disability (ID) is challenging but essential to allow adequate treatment to be given. This study examines whether the combination of two ASD screening instruments specifically developed for persons with ID, namely, the Diagnostic Behavioral Assessment for ASD-Revised (DiBAS-R) and the Autism Checklist (ACL), improves diagnostic accuracy when used in combination compared to the application of the single instrument. METHOD: A clinical sample of adults with ID who are suspected of having ASD (N =148) was assessed using two ID specific screening scales (DiBAS-R and ACL). The diagnostic validity of the single instruments and of their combination was assessed. RESULTS: While both instruments showed acceptable diagnostic validity when applied alone (DiBAS-R/ACL: sensitivity: 75%/91%; specificity: 75%/75%; overall agreement: 75%/83%), specificity increased when two positive screening results were used (88%), and sensitivity increased (95%) when at least one positive screening result was used. CONCLUSIONS: Different combinations of the ASD screening instruments DiBAS-R and ACL lead to improvements in sensitivity and specificity. The complementary use of the ACL in addition to the sole use of the DiBAS-R improves overall accuracy.

[The importance of a developmental approach in psychiatric assessment and treatment of adults with intellectual disability]. / Die Bedeutung des emotionalen Entwicklungsniveaus bei der psychiatrischen Behandlung von Menschen mit geistiger Behinderung.

INTRODUCTION: Mental disorders are 3-4 times more frequent in individuals with intellectual disabilities than in those without. From a developmental perspective the reason for this high prevalence could be, besides biological aberrations, a personality development with a difference between cognitive and emotional developmental levels. This discrepancy renders the person being highly vulnerable for the onset of problem behaviour and psychiatric disorders. For a proper insight into processes which have led to the disorder, it is necessary to evaluate the level of emotional development. This can be determined by the "schema of emotional development (SEO)" developed by A. Dosen. METHODS: By means of a case description the authors demonstrate the application of SEO in the assessment and utilization of the concept of the level of emotional development in clinical practice. RESULTS: The knowledge of the level of emotional development contributes to the explaining and understanding of the disorder, and also facilitates the establishment of an integrated diagnosis and the creation of appropriate integrated treatment strategies. Hence, temper tantrums, sleep patterns and mood improved in the case described. CONCLUSION: Besides biopsychosocial aspects, the developmental aspect, and in particular the level of emotional development should be taken into consideration in the diagnostic work-up and treatment of individuals with intellectual disabilities and mental health problems. The data generated by the SEO may help in understanding the disorder and developing a treatment approach for these individuals.

[Autism in adults with intellectual disabilities]. / Autismus bei erwachsenen Menschen mit geistiger Behinderung.

According to the World Health Organization (WHO) the estimated prevalence of intellectual disabilities (ID) is about 1-3% and 1 out of 4 individuals with ID suffer from an additional autistic spectrum disorder (ASD) (arithmetic mean 24.6%, 19 studies, n=9,675) whereby the prevalence increases with the severity of ID (IQ 50-70: 9.9%, IQ<50: 31.7%). Therefore, it is of particular importance for physicians treating individuals with ID who have psychiatric disorders or behavioral problems to take ASD into account as a differential diagnosis so that appropriate treatment can be initiated.Irrespective of the IQ the diagnosis is based on an impairment of social interaction and communication and restricted repetitive interests presenting before the age of 3 (infantile or Kanner autism). ASD can be diagnosed as a separate disorder in adults with ID, however, the social and communicative abilities in respect of the cognitive and developmental level have to be considered.Due to reduced verbal capacity, high prevalence of physical and mental disorders, difficulties in taking the past medical history and presentation of atypical symptoms, the diagnostic assessment for autism in adults with ID is challenging.This article describes the typical symptoms, diagnostic approach, frequent comorbidities, differential diagnoses treatment options and their limitations for adults with ID suspected of having ASD.

[Psychotherapy in intellectual disability. Theoretical background and implementation]. / Psychotherapie bei Menschen mit Intelligenzminderung. Theoretischer Hintergrund und praktische Umsetzung.

BACKGROUND: Every third person with intellectual disability suffers from additional mental health problems, among others phobic disorders. Yet we do not know whether psychotherapeutic methods that are effective in the normal population are applicable to people with intellectual disabilities. PATIENTS AND METHODS: We give a survey of the development and the present state of the art of psychotherapy, particularly with regard to phobic disorders in intellectual disability. Therapeutic recommendations described in the literature will be evaluated in a case study of one patient. RESULTS: The confrontation with the phobic stimulus is the basis of behavior therapy for people with intellectual disability as well. However, with respect to the special needs of these people, some modifications need to be considered in the treatment strategy. In addition to some general rules like simple language or the use of visual materials, some techniques of intervention turned out to be particularly effective, e.g., graduated in vivo exposure, involving significant others, contingency management, and coping strategies. CONCLUSION: Specific phobias in intellectual disability can be treated with behavior therapy as well. However, the special needs of these people need to be considered.

Effects of subthalamic deep brain stimulation on dysarthrophonia in Parkinson's disease.

BACKGROUND: Motor deficits in Parkinson's disease (PD) are reduced by deep brain stimulation (DBS) of the subthalamic nucleus (STN), but the impact of this therapy on dysarthrophonic problems in PD remains controversial. We therefore aimed to disentangle the effects of STN DBS on the speech skills of long-term treated patients. METHODS: Under continued medication, speech and motor functions of 19 patients with PD with bilateral STN DBS were studied when their therapeutic stimulation was active (STIM-ON) versus switched off (STIM-OFF). Per condition, perceptual speech ratings were given by: (i) the patients themselves, (ii) the treating physician, and (iii) professional speech therapists. Furthermore, single speech parameters were measured with a battery of technical exams in both STIM-ON and STIM-OFF. RESULTS: STN DBS significantly worsened speech performance according to all perceptual rating methods applied. In contrast, technical measures showed DBS-induced improvements of single speech dimensions affected by the PD-specific motor disorder. These changes occurred independently of the reduction of motor impairment, which was consistently effectuated by STN DBS. CONCLUSION: In parallel to the beneficial effects on the motor symptoms of PD, STN DBS reduces designated disease-inherent dysarthrophonic symptoms, such as glottic tremor. However, these actions on speech are predominantly outweighed by the general dysarthrogenic effects of STN DBS, probably based on a decline of complex (eg, prosodic) functions. Thus, stimulation-induced speech impairment should be considered a likely problem in the course of this treatment.

Compliance with secondary prevention of ischemic stroke: a prospective evaluation.

BACKGROUND AND PURPOSE: Compliance with pharmacological therapy is essential for the efficiency of secondary prevention of ischemic stroke. Few data exist regarding patient compliance with antithrombotic and risk factor treatment outside of controlled clinical trials. The aim of the present study was to assess the rate of and predictors for compliance with secondary stroke prevention 1 year after cerebral ischemia and to identify reasons for noncompliance. METHODS: Patients with a diagnosis of ischemic stroke or TIA and antithrombotic discharge medication were prospectively recruited. At 1 year, the proportion of patients compliant with antithrombotic treatment and with medication for risk factors (eg, hypertension, diabetes, hyperlipidemia) was evaluated through structured telephone interviews. In addition, the reasons for nontreatment with antithrombotic and risk factor medication were determined. Independent predictors for compliance were analyzed by logistic regression analyses. RESULTS: Of 588 consecutive patients admitted to our stroke unit, 470 had a discharge diagnosis of cerebral ischemia (TIA 26.2%, cerebral infarct 73.8%) and recommendations for antithrombotic therapy. At 1 year, 63 patients (13.4%) had died and 21 (4.5%) were lost to follow-up, thus, 386 could finally be evaluated. Of the patients, 87.6% were still on antithrombotic medication, and 70.2% were treated with the same agent prescribed on discharge. Of the patients with hypertension, diabetes, and hyperlipidemia, 90.8%, 84.9%, and 70.2% were still treated for their respective risk factors. Logistic regression analyses revealed age (OR 1.03, 95% CI 1.00 to 1.06), stroke severity on admission (OR 1.09, 95% CI 1.00 to 1.20), and cardioembolic cause (OR 4.13, 95% CI 1.23 to 13.83) as independent predictors of compliance. CONCLUSIONS: Compliance with secondary prevention in patients with ischemic stroke is rather good in the setting of our study. Higher age, a more severe neurological deficit on admission, and cardioembolic stroke cause are associated with better long-term compliance. Knowledge of these determinants may help to further improve the quality of stroke prevention.

B-50 (GAP-43) in the rat spinal cord caudal to hemisection: lack of intraspinal sprouting by dorsal root axons.

The controversial hypothesis that intraspinal sprouting by dorsal root axons promotes reinnervation of partially denervated neurons caudal to a low thoracic cord hemisection was re-investigated in rats using quantitative immunohistochemical analysis of the neural specific growth-associated protein B-50 (GAP-43) at postoperative survival times of 3, 10, 21, 42, and 90 days. The lack of increase in B-50-immunoreactivity in all segments below the hemisection at all survival times does not support the concept of intraspinal sprouting following the removal of supraspinal descending pathways.

Structural changes of anterior horn neurons and their synaptic input caudal to a low thoracic spinal cord hemisection in the adult rat: a light and electron microscopic study.

Structural changes in lumbosacral ventral horn neurons and their synaptic input were studied at 3, 10, 21, 42, and 90 days following low thoracic cord hemisection in adult rats by light microscopic examination of synaptophysin immunoreactivity (SYN-IR) and by electron microscopy. There was an ipsilateral transient decrease in SYN-IR at the somal and proximal dendritic surfaces of anterior horn neurons which extended caudally from the site of injury over a postoperative (p.o.) period of 42 days. Concomitantly, at 21 days p.o., perineuronal SYN-IR started to recover in upper lumbar segments. By 90 days p.o., a normal staining pattern of SYN was noted in upper and mid lumbar segments, but the perineuronal SYN-IR was still slightly below normal levels in low lumbar and sacral segments. Electron microscopy revealed ultrastructural changes coincident with the alterations in SYN-IR. At 3 days p.o., phagocytosis of degenerating axon terminals by activated microglial cells was observed at the somal and proximal dendritic surfaces of ventral horn neurons. These changes were most prominent up to two segments caudal to the lesion. At 10 days p.o., advanced stages of bouton phagocytosis were still detectable in all lumbosacral motor nuclei. Additionally, abnormal axon terminals, with a few dispersed synaptic vesicles and accumulations of large mitochondria, appeared at the scalloped somal surfaces of anterior horn neurons. At 21 days p.o., several large lumbosacral motoneurons had developed chromatolysis-like ultrastructural alterations and motoneuronal cell bodies had become partially covered by astrocytic lamellae. At 42 days p.o., there was a transient appearance of polyribosomes in some M-type boutons. In addition, at 42 and 90 days p.o., a few degenerating motoneurons were detected in all lumbosacral segments, but most displayed normal neuronal cell bodies contacted by numerous intact synapses as well as by astrocytic processes. In contrast to these striking alterations of synaptic input at somal and proximal dendritic surfaces of motoneurons, relatively few degenerating boutons were detected in the neuropil of motor nuclei at all the p.o. times studied. We suggest that the preferential disturbance of the predominantly inhibitory axosomatic synapses on ventral horn neurons may be involved in the mechanisms which influence the well-established increase in motoneuronal excitability after spinal cord injury.