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Journal of Intellectual Disability Research(JIDR)


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Description about the Journal

Journal of Intellectual Disability Research (JIDR),ispublished on behalf of mencap (which is the largestvoluntary organisation in U.K. promoting the interests ofpeople with intellectual disability/learning disability andtheir families)in association with IASSID (International

Association for the Scientific Study of IntellectualDisabilities-the first and only world-wide group dedicatedto the scientific study of intellectual disability)

Devoted exclusively to the scientific study of intellectual

disability and publishes papers reporting originalobservations in this field.

Published monthly, Editor :A.J. Holland ; Mental HealthSpecial Issue Editor: Sally-Ann Cooper

Impact Factor is 1.596


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Authors: J. A. Tsiouris, George A. Jervis ClinicS.Y. Kim, Department of PsychologyW.T. Brown, Department of Human GeneticsI. L. Cohen,Department of Psychology

Research Centre : NewYork State Institute for Basic Research inDevelopmental Disabilities, Staten Island, NY, USA

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

Long Presentation :


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Relevance for Selection


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The link between violence or aggressionand mental disorders has been the focus ofdiverse studies in persons with intellectual

disabilities (ID).

Aggressive behaviours towards others, objectsand self, which constitute the core of

challenging behaviours, are major intractableproblems reported in 30% to 60% of persons withintellectual disabilities (ID) (Sigafoos et al. 1994;Smith et al. 1996; Crocker et al. 2006; Lowe et al.2007; Cohen et al. 2010)

Introduction


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and in 15% when severe aggressive behavioursassociated with psychiatric disorders, physicalillness and pervasive developmental disordersare not included (Cooper et al. 2009a,b).

Aggressive behaviours in people with ID havebeen reported to be associated with the

depressive and manic phases of mooddisorders (Lowry & Sovner 1992; Sovner et al.1993; King et al. 1994; Moss et al. 2000; Tsiouris2001; Tsiouris et al. 2003b; Hemmings et al.

2006; Crocker et al. 2007; Hurley 2008),

Introduction con


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Anxiety and psychotic disorders (Holden &Gitlesen 2003; Crocker et al. 2007), impulsecontrol 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 theMacArthur scale) in the violent and aggressivegroups were associated with higher ratings onautism, psychosis, paranoia, depression and

dependent personality disorder.

Introduction con


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According to Myrbakk & von Tetzchner (2008).although no overall direct associations werefound between individual problem behavioursand psychiatric disorders, aggressive behaviours

were associated with psychosis, anxiety andmania independently of degree of ID, whereasdepression was associated with aggressionagainst others in those with severe/profound IDand with self-injury in those with mild/moderateID.

Finally, physical aggression against self andtantrums were correlated with mild to moderatedegree of ID, but not with psychiatric disorders.

Introduction con


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Aggressive behaviours were reported to beassociated with attention deficit hyperactivitydisorder(ADHD),but no such association wasreported for psychotic, depressive, or bipolar

disorders(Jones et al.2008;Cooper et al.2009a,b).

Introduction con


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To find out any significant associations amongcertain psychiatric disorders and specific types ofaggressive behaviours, controlling for sex, age,

autism and degree of severity of the ID

Aim of the Study


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There will not be any significant relationship interms of aggressive behaviours with psychiatricdisorders, age, sex and degree of intellectual

disability of patients.

Hypothesis


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Participants:

The sample consisted of individuals with IDliving in the community and receiving services

from the New York State Office for People withDevelopmental Disabilities (OPWDD) between2006 and 2007.

They were recruited through the directassistance of the Directors and ChiefPsychologists of the various DevelopmentalDisability Service Offices (DDSOs) in New York

State.

Methodology


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Based on these communications regarding thenumbers of potential participants(n = 9894),10,000survey forms [Institute for Basic Research

Modified Overt Aggression Scale(IBRMOAS), described below; Cohen et al. 2010]were sent to 14 agencies and 4675 were returnedfor a response rate of approximately 47%.

Returned forms with missing information on theaggression items and demographicswere excluded, leaving an n of 4069 participantsfor the current analysis.

Methodology con


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Table 1 Demographic characteristics of the sample & the overall population

Methodology con


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60%of the sample and 52% of the POP weremen. 100%of the sample and 99% of the POPwere 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 inthe moderate (16%) and severe (19%) range ofID in study sample.

Methodology con


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The overall percentage of cases identified ashaving an autism spectrum disorder was alsoslightly higher (9.7%) in the sample relative to

the POP (8.2%).

Methodology con


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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 partsincluding :

Demographic Information,

Aggression Scale, Communication Skills,

Setting Events(antecedents and consequences ofthe aggressive behaviours),

Methodology con


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Behavior Control Issues (how staff manageoutbursts),

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


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Psychiatric Issues (depression, psychosis, etc.) and

Effective Treatments (staff judgement of mostefficacious intervention).

Aggression Scale measures 5 domains:

1. Verbal Aggression Toward Others (VAOTH)

2. Physical Aggression Against Other People (PAOTH)

3. Physical Aggression Against Objects (PAOBJ)4. Physical Aggression Against Self (PASLF)

5. Verbal Aggression Toward Self (VASLF)

Methodology con


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Based on consultation with the chief psychologists,a Likert measure of the frequency of occurrence ofeach of the aggression items during the past year

was developed .

Methodology con


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Diagnoses of psychiatric disorders

Psychiatric disorder diagnoses reported onthe IBR-MOAS were obtained from the files of

persons with ID that were surveyed. The diagnoseson file were clinical diagnoses made bypsychiatrists using the Diagnostic and StatisticalManual of Mental Disorder, Fourth Edition (DSM-IV) or Diagnostic and Statistical Manual of MentalDisorder, Fourth Edition, Text Revision (DSM-IV-TR)(American Psychiatric Association 1994, 2000).

Methodology con


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Diagnoses of psychiatric disorders(procedure)

A description of the process how the diagnoses aremade follows:

Persons exhibiting psychiatric symptoms,challenging behaviours or both are referred by thetreatment team to a psychiatrist for evaluationand medication recommendation, if medical work-up, behaviour modification plans and/orenvironmental changes are not effective inreducing the psychiatric symptoms or the

challenging behaviours.

Methodology con


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The next step involves the psychiatristmeeting with the treatment team, consisting of a

psychologist, nurse, social worker and manager ofthe group home as well as the parent/guardian ofthe subject, where an agreement is made regardingthe evaluation and the recommendations of thetreatment.

Methodology con


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Degree of ID was obtained from the files ofeach participant, which included medical,

psychiatric, psychosocial and psychologicalevaluations (most recent updated)were used.

Methodology con


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Data analyses The R (R Development Core Team 2010)

software package was used for theanalyses. Because the aggression domainscores showed a skewed and over-

dispersed distribution.


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Data analyses The R (R Development Core Team 2010)

software package was used for theanalyses. Because the aggression domainscores showed a skewed and over-

dispersed distribution.


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Results

Figure shows the percentage of participantswho showed aggressive behaviours at anydegree of frequency greater than zero across thefive aggression domains.


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Results con The domain of VAOTH had the highest

percentage 72%( 2922/4069) and thedomain of PASLF the lowest 40%(1632/4069). 17% (701/4069) of

participants did not show any aggressivebehaviours.


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Results con


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Results con Psychiatric disorders were diagnosed in59% of the population surveyed, of

whom 31% were diagnosed with onlyone psychiatric disorder, 17% with two,

10% with three to five and 0.5% withmore than five psychiatric disorders.

Impulse control disorder was the mostfrequent diagnosis 21% (862/4069), andpersonality disorder was the leastfrequent 8% (337/4069).


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Results con A larger percentage of consumers withmild and moderate degrees of ID had

one or more psychiatric disorderscompared to those with severe

and profound ID (74% vs. 47%).

Those in the range of mild and moderateID were diagnosed with anxiety andimpulse control disorders slightly moreoften than those with severe andprofound ID.


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Results con


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Results con In addition, 7% of participants who hadpsychiatric disorders (n = 2401) showed

no aggressive behaviour, and 34% ofparticipants with aggressive behaviours

(n = 3368) were not diagnosed with anypsychiatric disorders (Table 3).


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Results con


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Results con Table 4 shows the summary of the

associations between the predictorvariables and the aggression domainscores. The regression coefficients and

their signs indicate the size and directionof the association for each of thepredictor measures.

Bipolar, psychosis, impulse control and

personality disorders were all highlyassociated with each of the fiveaggression domains.


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Results con Participants with personality disorder

were about 26% more likely to showVAOTH than those without thediagnosis, holding all other

variables constant. Participants withimpulse control disorder were 84% morelikely to engage in PAOBJ than thosewithout the disorder.


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Results con Bipolar disorder was associated with

increased frequencies of aggressivebehaviour, on average about 45%(ranging from 29% to 56%) more for

all aggressive domains compared tothose without the disorder, controllingall other variables.

Participants with diagnoses of psychosis

or personality disorders were about 37%(ranging from 26% to 60%) more likelyto show aggressive behaviours in each ofthe domains.


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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 controldisorder, who on average were 64%(ranging from 40% to 84%) more likelyto show aggressive behaviours than

those without impulse control disorder.


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Results con Depression was most associated with an

increase in verbal aggression towardsself (27%)

Whereas anxiety was most stronglyassociated with both verbal and physicalaggression against self (21% and 34%,respectively), holding all other

variables constant.


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Results con The diagnosis of autism was most

strongly associated with all threedomains of physical aggression (PAOTH,PAOBJ, PASLF), showing about a

31% increase overall, but no significantassociations with verbal aggression.

The only significant association forparticipants with OCD was a 21%

increase in PAOBJ compared to thosewithout OCD.


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Results con Female participants showed 16% more

frequent self-deprecating remarks andabout 14% less frequent physicalaggression against others and

objects than male consumers. Sex wasnot significantly associated with VAOTHand PASLF when all other variables werecontrolled.


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Results con Age was not related to verbal aggression

towards others, but had an effect on allother kinds of aggression; there were 8%,9%, 12% and 14% decreases for VASLF,

PAOTH,PAOBJ and PASLF, respectively,as age increased about onestandard deviation (14 years).

Lastly, the level of ID was negatively

associated with most measures ofaggression; the frequency of aggressivebehaviour decreased with increasing ID.


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Results con Verbal aggression towards others

decreased by 23% at each level of IDfrom the previous (less severe) level, andverbal aggression towards self and

physical aggression against objectsdecreased by 10%. However, thefrequency of self-injurious behaviour(PASLF) increased by 38% at each

level of ID from the previous (less severe)level, controlling all other variables.


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Impulse control disorder and bipolardisorder are the two psychiatric diagnosesstrongly associated in this study with allfive domains of aggressivebehaviours assessed by the IBR-MOAS inpeople with ID free of alcohol and drug

abuse.

Discussion


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This association in people with IDbetween aggressive behaviours and impulsecontrol and/or bipolar disorder may be

because they have neuro-biological characteristics that are similar tothose linked to violence in people withoutID (i.e. overarousal, impulsivity, mood

dysregulation and impaired cortical controlof an amygdala hypersensitive to stimuli)(Siever 2008).

Discussion con


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Psychotic disorder was most associated withthe first four domains, the association withphysical aggression against self much

weaker. The study found that psychotic,impulse control, or bipolar disorders, aswell as younger age and more severe ID,were associated with the domain of

physical aggression against other persons.

Discussion con


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Depressive disorder was most associatedwith verbal aggression towards self (i.e.making self deprecating statements). This

behaviour was more prevalent in thosewith less severe ID and was more prevalentin women.

The results indicated that anxiety,

impulse control and bipolar disorders aswell as young age and having severe ID oran autism diagnosis were associated withphysical aggression against self.

Discussion con


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Physical aggression against self and itsoverall association with depression inpersons with severe ID have been

previously reported (Marston et al.1997; Tsiouris et al. 2003a,b; Hemmings et al.2006). The physical aggression against selfhas been reported to be associated with

affective disorders in women (Cooper et al.2007a), and its reversal after treatment withantidepressants has been reported (Sovneret al. 1993; Tsiouris et al. 2003b).

Discussion con


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In this study, only impulse control andbipolar disorder, not depression or gender,were associated with physical aggression

towards self. Physical aggression againstself and its association with womendiagnosed with autism and severe ID havebeen a common finding (Crocker et al.

2006; Cohen et al. 2010).

Discussion con


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It is interesting to note that in Cohen et al.(2010), women with autism had the highestself-destructive behaviour scores (i.e.

both verbal and physical), and the samegroup had an increased rate of anxiety ormood disorders compared to non-autisticwomen

Verbal aggression towards self wasassociated with being female and withdepression, but not with autism in thecurrent study.

Discussion con


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Depression in adults with severe toprofound ID who exhibit physicalaggression against self is under-diagnosed

by psychiatrists who do not have trainingand experience in the mental health issuesof the ID population (Beasley 2004),althoughfive of the nine characteristics of

major depression as per DSM-IV areobserved in this population (Tsiouris 2001;Tsiouris et al. 2003a).

Discussion con


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Previous studies have found noassociation between aggressive behavioursand major psychiatric disorders except for

ADHD ( Jones et al. 2008; Cooper et al.2009a).

This is due to the exclusion of aggressivebehaviours that were part of psychiatric

disorders, physical illness and pervasivedevelopmental disorders as per.

Discussion con


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Diagnostic Criteria for Psychiatric Disordersfor Use with Adults with LearningDisabilities/Mental Retardation (Royal

College of Psychiatrists 2001), the diagnosticinstrument used in these studies, from theanalysesthe mental age of adults with ID isestimated to be between 2 and 9 years of

age.

Discussion con


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Most of these people have beenseparated from their families or have beenvictimised, and their lower ability level

likely predisposed them for increased riskfor major psychiatric disorders (Cooper et al.2009b; Koenen et al. 2009) as well asincreased prevalence of aggressive

behaviours (Nihira et al. 1980; Emerson et al.1999; Jones et al. 2008; Tsiouris 2010).

Discussion con


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An association of anxiety disorder withtantrums (Myrbakk & von Tetzchner 2008)and with overall challenging behaviours in

adults with more severe ID hasbeen reported in two studies (King et al.1994; Holden & Gitlesen 2006).

Discussion con


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Participants were living in communitygroup homes and only 10% were living athome and attending state programmes daily

.This sample cannot be considered asrepresenting the entire population withinNewYork State, other US states or othercountries.

The prevalence rates found in this studyare much higher than reported in otherstudies of persons with ID, especiallypsychotic disorder

Limitations


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(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 bythe treating psychiatrist who

associated aggressive behaviours withpsychosis in persons with ID (Morgan et al.2008).

Limitations con


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It is possible that some of the psychiatricdiagnoses were given without in-depthevaluation of the persons with ID and

aggressive behaviours in order to matchthe categories of psychotropics prescribedfor control of aggressive behaviours.

The possibility also exists that persons with

ID under the care of New York State andnot by private agencies or families havehigher rates of psychopathology.

Limitations con


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Inter-rater reliability of psychiatric diagnoseson a subsample of persons surveyed with anindependent psychiatrist trained in issues of

ID would have strengthened the results of thestudy, but because of financial issues, thisoption was not available to us.

The purpose of this study was to investigate

any associations between certain psychiatricdiagnoses and the type of aggressivebehaviours in persons with ID, not the factorsaetiologically associated with aggressive

behaviours

Limitations con


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Evaluation of the study


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The purpose of this study was to delineate anysignificant association betweencertain psychiatric disorders and specific

domains of aggressive behaviours in a largesample of persons with ID controlling for sex,age, autism and degree of ID. Future studiesshould obtain psychiatric diagnosis from

psychiatrists trained in issues of ID whowill follow the individuals and treat theirdiagnosable psychiatric disorders,

Future Studies


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while obtaining baseline measures andsubsequently collecting informationon aggressive behaviours using the IBR-MOAS

or previous versions. Exacerbation, initiation or elimination of

aggressive behaviours in associationwith changes in mental status or with control ofsigns and symptoms of psychiatric disorderswill enable us to answer the question of theseassociations in a more precise manner.

Future Studies con


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Whether behavioural withdrawal bytemperament(i.e. behavioural inhibition shyness)which is associated with social anxiety

and predisposition to mood disorder, is thephenotype predisposing to physical aggressionagainst self in response to aversive, internal orexternal stimuli and setting events is an area

which has to be investigated further.

Future Studies con


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Impulse control and bipolardisorder (characterised by arousability, lowfrustration tolerance and impulsivity or

disinhibition, as well as mood dysregulation)appear to be the psychiatric diagnosesassociated with all the domains ofaggressive behaviours.

When dealing with aggressive behaviours,impulse control disorder is the first diagnosis tobe considered for treatment with appropriate

medication

Conclusion


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(i.e. a2 adrenergic agonists, beta-blockers andselective serotonin reuptake inhibitors) incombination with the corresponding

psychotropics for treatment of other comorbidpsychiatric disorders.

This study supports the notion thatspecific aggressive behaviours in persons withID are associated with more than one psychiatricdiagnosis, with certain exceptions,

Conclusion con


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and also supports the notion that specificaggressive behaviours cannot be considered ascharacteristic of certain psychiatric

disorders (Tsiouris et al. 2003b). Age, gender and degree of ID, along with a

diagnosis of autism, predispose theseindividuals towards engaging incertain domains of aggressive behaviours.

Conclusion con


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Treatment of the diagnosable psychiatricdisorders in persons with ID and aggressivebehaviours often decreases the behaviours

frequency and severity.

Conclusion con


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Psychotic disorder is only one of the manypsychiatric diagnoses associated with aggressivebehaviours (but not with physical aggression

against self). Considering the high prevalence of impulse

control, anxiety and mood disorders in thegeneral and ID populations and the lowprevalence of psychotic disorders in personswith and without ID and their association withall the domains of aggressive behaviours,

Conclusion con


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Treatment of the diagnosable psychiatricdisorders in persons with ID and aggressivebehaviours often decreases the behaviours

frequency and severity. In case the aggressive behaviours are chronic

and they are exacerbated by psychiatricdisorders, a combination ofbehavioural psychosocial interventions and thecorresponding psychotropics should be applied.

Conclusion con


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It is our hope that, in the future, there will be adecrease in the overreliance of psychotropics,and especially antipsychotics, for the treatment

of aggressive behaviours in persons with ID.

Conclusion con


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long aggressive

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