Factors Associated With Restraint Application in Children and Adolescents With Intellectual and Developmental Disabilities Displaying Severe Challenging Behavior.

The goal of this communication is to provide clinicians and behavioral scientists with a scoping perspective on the diverse array of impacts of the COVID-19 pandemic on individuals with intellectual and developmental disabilities (IDD) in the U.S. It is our hope that this will stimulate subsequent scientific and advocacy efforts to ameliorate the disproportionate burden of the pandemic on people with IDD.We begin with the assertion that among non-infected persons in the U.S. few are more adversely affected by COVID-19 than individuals with IDD, given that a vast proportion require in-person care or critical therapeutic support within their living environments, with little back-up or systematic coverage for prolonged interruption of services.Many have temporarily lost access to trained caregivers or community service providers, and now face evolving threats to the return of baseline service, given uncertainties in State and agency budgets.Therefore, a first priority relates to restoration of in-person support services or comparable alternatives.There have been emerging guidelines on the safe care and support of individuals with IDD during the COVID pandemic-see Supplementary Table (ST) 1 which lists resources and documentation of early success of such strategies, however guidance is still evolving, has not permeated all reaches of the community where the information is desperately needed, and is not always presented in ways that can be fully comprehended by those with IDD.It must be

This study examined the reliability of an instrument, portions of which have been used in previous research, to evaluate services provided to people with developmental disabilities. Seven types of variables were analyzed: demographic data, residential arrangements, medical needs, adaptive behavior, severity of challenging behavior, frequency of challenging behavior, and the perceptions that disabled residents have of their living situations. Data resulted from accidentally interviewing residents (and their caregivers) twice in 1991 (N = 49) and 1992 (N = 86) who received services from the Oklahoma Department of Human Services Developmental Disabilities Service Division. High reliabilities were found when interviewing caregivers about demographic data, residents' adaptive behavior, severity of residents' challenging behavior, and frequency of residents' challenging behavior as well as from residents own perceptions of their living situations. High test-retest reliability was also apparent when asking residents about food quality. These results suggest that reasonably reliable information can be obtained from both caregivers and persons with developmental disabilities.

Challenging behaviors are common in those with developmental disabilities (DD) and intellectual disabilities (ID) (Matson, Cooper, Malone, & Moskow, 2008; Matson, Kiely, & Bamburg, 1997; Murphy et al., 2005) and also in typically developing children with emotional and behavioral problems (Brestan & Eyberg, 1998). Estimates suggest that in those with DD, such as Autism Spectrum Disorders (ASD), 8–17% of individuals exhibit challenging behaviors (Emerson & Bromley, 1995; Kiernan et al., 1997; Lowe et al., 2007). These behaviors range from physical aggression (i.e., hitting, kicking, and biting others) to self-injurious behavior (SIB; i.e., hitting self, head banging, skin picking) to property destruction. While severe challenging behaviors are common in those with DD and ID, a similar number of typically developing children also exhibit challenging behaviors that may lead to emotional and behavioral disorders later on (Webster-Stratton, 1997). It has been well established in the literature that the most effective treatments are interventions based on the functions of the behavior (DuPaul & Ervin, 1996; Gettinger & Callan Stoiber, 2006). As such, functional assessments have grown in popularity. One review found that previous to 1985, approximately 35% of studies which used behavioral intervention for aggressive behavior in those with DD or ID used some form of functional assessment. However, this percentage increased to 71% for more recent studies which used functional assessment (Hile & Desrochers, 1993). Functional assessments allow for the identification of the maintaining factor of the behavior so that prevention and intervention strategies can be added to a treatment program, as well as replacement behaviors which allow the person to achieve the goal of the challenging behavior by more appropriate means. Furthermore, functional assessment for each challenging behavior is required as topographically similar behaviors may serve drastically different functions (Iwata et al., 1994).

Challenging behaviour, the application of restrictive measures and psychotropic drug prescription in people with intellectual disabilities

Accessible summary • Many people who show challenging behaviour continue to be tranquilised and physically restrained. • There have been claims that deep pressure touch can be of beneficial in reducing agitation and distress, particularly in people with autism spectrum disorders. • Deep pressure touch is demonstrated to have a beneficial effect on extreme agitation, including lowering increased heart rate and respiration, as well as reducing the need for physical restraint and medication • This paper describes a ‘‘low tech’’ approach to the systematic use of deep pressure touch that can be readily applied in many settings Summary Although there have been claims of significant therapeutic benefits arising from the use of deep touch pressure techniques with children with autistic spectrum disorders, to date there have been few empirical investigations of its use with adults with autistic spectrum disorders and anxiety in clinical practice. This paper reports on the systematic use of deep touch pressure within a structured programme for a man with autism who was presenting with severe challenging behaviour. The programme led to significant reductions in the use of both physical restraint and medication, as well as appropriate physiological changes, with a parallel increase in the person's quality of life. The implications of this approach are discussed with regard to both theory and practice with the aim of increasing the provision of more appropriate forms of support for people who present with challenging behaviour.

Previous research has suggested substantial variation in prevalence rates of psychiatric disorders in individuals with intellectual disability (ID) and also differential patterns of associations between psychiatric disorders and challenging behaviors in people with ID. The aim of this study was to determine the prevalence rate of specific psychiatric disorders and challenging behaviors and the relationship between them in a community-based sample of individuals with ID. A community-based sample of 159 adults primarily with mild and moderate ID was surveyed for the presence of psychiatric disorders and challenging behaviors using the Behavior Problem Inventory and the Psychiatric Assessment Schedule (PAS-ADD). Individuals who met threshold on the PAS-ADD were subsequently evaluated using the Mini PAS-ADD Interview. Screening for psychiatric disorders using the PAS-ADD indicated a prevalence rate of 10%. There was a large discrepancy between the overall rate of challenging behaviors (45%) and the rate of psychiatric disorders identified by the Mini PAS-ADD Interview (6%). However, the rate of more severe behavior problems (8%) was closer to the rate of psychiatric disorders (6%). Thirty-one percent of people with severe challenging behaviors also were rated as having psychiatric disorders and odd ratio analysis indicates that individuals with severe challenging behaviors are substantially more likely to present with a psychiatric disorder. However, the relationship between different topographies of challenging behaviors and discrete diagnostic categories of psychiatric disorders appears to be unclear. This study reports a low prevalence of psychiatric disorders in a community-based population. The presence of severe challenging behaviors appears to have some association with psychiatric disorders but does not appear specific to discrete diagnostic categories. Clinicians and researchers need to debate the validity of considering challenging behaviors atypical manifestations of psychiatric disorders.

Entirely revised and updated, this edition of a very well-received and successful book provides the essentials for all those involved in the fields of intellectual, developmental and learning disabilities and mental retardation, drawing both on clinical experience and the latest research findings. An international, multidisciplinary team of experts cover the available literature in full and bring together the most relevant and useful information on mental health and behavioural problems of people with intellectual, developmental and learning disabilities and mental retardation. In addition, this book highlights the principles behind clinical practice for assessment, management and services. It offers hands-on, practical advice for psychiatrists, psychologists, nurses, therapists, social workers, managers and service providers

Approximately one third of adults with intellectual and developmental disabilities have emotion dysregulation and challenging behaviors (CBs). Although research has not yet confirmed that existing treatments adequately reduce CBs in this population, dialectical behavior therapy (DBT) holds promise, as it has been shown to effectively reduce CBs in other emotionally dysregulated populations. This longitudinal single-group pilot study examined whether individuals with impaired intellectual functioning would show reductions in CBs while receiving standard DBT individual therapy used in conjunction with the Skills System (DBT-SS), a DBT emotion regulation skills curriculum adapted for individuals with cognitive impairment. Forty adults with developmental disabilities (most of whom also had intellectual disabilities) and CBs, including histories of aggression, self-injury, sexual offending, or other CBs, participated in this study. Changes in their behaviors were monitored over 4 years while in DBT-SS. Large reductions in CBs were observed during the 4 years. These findings suggest that modified DBT holds promise for effectively treating individuals with intellectual and developmental disabilities.

FC28-05 - Prevalence of psychiatric diagnoses and challenging behaviours in a community based population of individuals with intellectual disability

On behalf of the Conference Planning Committee, it is my sincere pleasure to welcome you to the "Queen City," Charlotte, North Carolina, and the American Association on Intellectual and Developmental Disabilities (AAIDD) 136th Annual Meeting. The theme of this year's conference is research, practice, policy—and there's no better setting for such a conference than the Carolinas! This year's AAIDD annual conference promises to be a forum where researchers, clinicians, practitioners, educators, policymakers, and advocates will be able to share cutting-edge research, effective practices, and valuable information on important policy initiatives.I want to start my presidential address by thanking all the attendees for joining us for the AAIDD 136th Annual Meeting. This conference could not be the success it is without your presence and participation. I also want to thank all our colleagues from across the United States and the world who traveled to Charlotte to present their work and share their ideas and findings with us. I'll come back to this point in a minute. I would be remise if I did not acknowledge the important contribution to the success of this meeting of all those who provided their time and wisdom on the Conference Planning Committee and the Local Arrangements Committee as well as the large group of volunteers, and of course none of this could happen without the diligent work of the AAIDD staff and Dr. Maggie Nygren, AAIDD executive director and CEO. Please join me in thanking all these individuals in making this annual meeting the success that it is.This year's annual meeting was preceded by a series of exciting and stimulating preconference workshops on topics ranging from findings from the AAIDD Cuba Delegation, the National Task Group on Dementia, DirectCourse's Comprehensive Competency-Based Training Approach, Supports Intensity Scale and Individual Support Planning, and Ethical Issues for Psychologists.We opened our conference with a blue-ribbon plenary panel on research, practice, and policy in the area of autism spectrum disorders. We heard three fantastic presentations from Drs. Joe Piven (University of North Carolina), Connie Kasari (University of California–Los Angeles), and Susan L. Parish (Brandeis University). The opening plenary was an excellent example of the richness and importance of research, intervention, and policy issues and their interplay in the area of autism spectrum disorders. Our other panel presentation had a distinguished group of federal partners, including Drs. Melissa Parisi (Eunice Kennedy Shriver National Institute of Child Health and Human Development; NICHD), Gloria Krahn (National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention; NCBDD CDC), and George Jesien (Association of University Centers on Disabilities). This illustrious federal panel discussed the importance and role played by these agencies in supporting research and practice as well as the importance of policy matters in continued funding of these programs in the area of intellectual and developmental disabilities.Our biggest challenge this year in organizing the conference was reviewing and evaluating the great number of high-quality proposals submitted. We received almost 300 proposal submissions from across the United States and more than a dozen countries around the world. The conference was rich with 24 break-out panel presentations on topics including aging, health, employment, quality of life, transition, cross-cultural issues, end-of-life, forensic, supports, direct support workforce, inclusion, systems change, self-advocacy, spirituality, parenting, funding issues, and postsecondary education. In addition to these rich break-out sessions, we had more than 150 stimulating poster presentations from students, recent graduates, early careers professionals, established professionals, and researchers from around the world.Today and tomorrow, our conference wraps with a series of postconference workshops that will offer continuing education units on a variety of topics, including writing for publication, lessons learned from states using the Supports Intensity Scale, assessment of intellectual disability in capital cases, religion and spirituality, positive behavior supports, trauma-informed care, and dysphagia. These workshops offer some very practical hands-on training from highly respected and skills practitioners. I trust many of you will be taking advantage of these workshops before heading home.This year's conference theme was selected to highlight and remind us of the importance of interdisciplinary and interprofessional collaboration for the field of intellectual and developmental disabilities. Our field has had many accomplishments in research, intervention, and policy that have had significant impacts on improving the lives and outcome for persons with intellectual and developmental disabilities (IDD) and their families.Many years ago, a Norwegian physician by the name of Dr. Asbjorn Folling discovered that a group of individuals with intellectual disability had particular characteristics, and this led to his discovery that these individuals all had inherited a recessive gene that resulted in their bodies' inability to break down an amino acid called phenylalanine. The condition, called phenylketonuria (PKU), if undetected, would result in a build-up of phenylalanine to toxic levels in the individual's central nervous system, resulting in severe cognitive impairments. A relatively simple treatment consisting of a strict diet that eliminates all foods high in protein, which are rich in phenylananine, eliminated the devastating effects of PKU on infant brain development. Infant screening for PKU commenced as early as the 1960s, resulting in the identification and treatment of PKU and thus preventing thousands of children from developing intellectual disability.We should also not forget that the benefits yielded from the work done in our field reach beyond persons with IDD.Another important area of work stimulated by a practitioner in the field of intellectual disability is early childhood education. This was Dr. Maria Montessori, an Italian physician who worked with young children with intellectual disability. Maria Montessori had been influenced by the work of a couple of giants in the field of intellectual disability, including Jean Itard and Edouard Séguin. The Montessori Method stresses the development of initiative and self-reliance by permitting children to do by themselves the things that interest them—self-paced learning under the guidance of a teacher. Montessori's work led to significant gains in learning in children previously thought to have little potential because of their intellectual disability. The Montessori Method demonstrated that this structured learning method and environment can have important beneficial results in children with cognitive delays but also in typically developing children. Today, Maria Montessori's educational approach is used around the world and has become a highly coveted educational strategy used with children of all intellectual abilities.A final example of the richness of the work done in our field is in the area of applied behavior analysis and positive behavior supports. The science of using principles of behavior analysis to understand the function of behavior to promote learning and behavior change has been a critical part of intervention strategies in the field of intellectual and developmental disabilities for decades. We have used the science of applied behavior analysis and, more recently, positive behavior supports to teach new skills, promote pro-social behavior, and understand and reduce problem behavior. These approaches have been instrumental in our field of early intervention to promote inclusion, supported employment, and supported living, to name a few examples. These techniques are being used in all realms of daily life, including and increasingly with people without special needs. More and more preschool programs and school districts have adopted positive behavior support strategies to promote pro-social behaviors and the prevention of all forms of less desirable behaviors such as bullying, disrespectful behavior, aggression, and so forth.So we can see how research and practitioners play key interactive roles in promoting improved research and intervention for persons with IDD. And, at times, these methods also have applications for everyone. Public policy and legislation also play a key role in research and intervention for people with IDD. We, at times, did not appreciate the important role research and intervention findings play in crafting and influencing policies. Their interrelatedness cannot and should not be understated. I want to name but a few important policies that have played a key role in promoting services, programs, and research for persons with IDD. Early in the 1960s the Kennedy administration created important legislation now called the Developmental Disabilities and Bill of Rights Act (DD Act). The DD Act led to the creation of the University Centers for Excellence in Developmental Disabilities, DD planning Councils, and Protection and Advocacy Agencies in every state. During this same period we saw policy work that led to the creation of the National Institute on Child and Human Development (NICHD), which has been an important source of research funding for the field of intellectual and developmental disabilities, including the IDD research centers. Other important legislation for our field has included the Individual with Disabilities Education Act (IDEA), Combating Autism Act, and also Rose's Law. Rose's Law is an interesting piece of legislation but important because it resulted in the removal of stigmatizing language such as "mental retardation" from federal laws, replacing it with "intellectual disability." This aforementioned list is far from comprehensive. We have had a century of ground-breaking policy changes that have illustrated the work between policymakers, stakeholders, practitioners, and researchers. I selected these to make a point—not to identify them as more important than others not mentioned. Suffice it to say, policy, practice, and research are intertwined and interdependent, perhaps more than many really appreciate or admit.Founded in 1876, the American Association on Intellectual and Developmental Disabilities is the oldest professional association concerned with intellectual and developmental disabilities. I am truly honored to have the privilege to serve as president for 2012–2013. We have a great group of board members, a dedicated staff, and a very dynamic executive director/CEO. Despite these difficult economic times, our association is in good financial health. An exciting characteristic of our association that strikes me as indicative of the strength of our membership and leadership is the products that we continue to develop and deliver to the field. The credit for all this is a shared one. It is shared among our board members, our executive director/CEO, the staff in the national office, and especially you! All of our key products (e.g., the terminology and classification manual and user's guide, Positive Behavior Supports Training Curriculum, Supports Intensity Scale, annual meeting—yes, I include this as one of our key products—Good Blood, Bad Blood, online courses, and webinars) are largely the result of the hard work and brain power of our members.I have three basic priorities that I have set for my presidency. Following are my priorities—not necessarily in order of importance.The major functions of AAIDD are to:There are several factors that establish AAIDD as the best place for cutting-edge research, tools, and materials that inform IDD policy and practice. AAIDD has a long history in publishing some of the field's best journals, including Intellectual and Developmental Disabilities as one of the field's leading practice journals and the American Journal on Intellectual and Developmental Disabilities as the oldest and more respected research journal. This is the professional home for thousands of interdisciplinary practitioners, researchers, and leaders within the field of intellectual and developmental disabilities. Whether mentioned in legislation, the U.S. Supreme Court, or among stakeholders, families, or colleagues, AAIDD is seen as the authoritative organization on matters related to IDD. We must keep our focus on evidence-based and data-driven product development and ensure that we, as an organization, continue to deliver high-quality tools and materials that are needed to advance the quality of supports, services, and knowledge.Our association can only sustain its leadership through succession planning and grooming the next generation of educators, researchers, leaders, policymakers, practitioners, and so forth. We must make every effort to include students and early career professionals on our association task forces, committees, and work groups. The vitality of our association can only be ensured by the inclusion of senior leaders and more junior rising stars among our membership. This is a win–win proposal that will benefit all and promote high-quality work and outcome.I am committed to continuing the great work of the last several AAIDD presidents in supporting the students and early career professionals who have recently formed their own special interest group. Below are some suggestions of ways you and I can support AAIDD students or early career professionals:Please e-mail me any suggestions or ideas you have to increase the participation and meaningful involvement of students and early career professionals in our association life and annual meetings.This priority is to make certain that we educate and guide the American Psychiatric Association (APA) as it continues its work in crafting the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Of particular concern is that the DSM-5 revisions of the condition formerly called "mental retardation" currently include APA's proposal to rename the condition "intellectual developmental disorder." As you know, there is a national consensus in the United States, including federal legislation, to replace "mental retardation" with "intellectual disability."In addition to proposing a radically different terminology that lacks all support from the field of intellectual disability, the current version of the DSM-5 diagnostic criteria are the following: (a) significant deficits in intellectual functioning–profile of cognitive abilities; (b) significant deficits in adaptive behavior including daily life, communication, social participation, functioning at school and work, personal independence at home and in community where these limitations result in a need for ongoing support at school, work, or independent life; and (c) that these significant deficits originate during the developmental period.The adoption of a different terminology and the proposed DSM-5 diagnostic criteria are fraught with the potential to harm people with intellectual disability and their families. In a June 14 letter to the APA and the DSM-5 Neurodevelopmental Disorders work group cochairs, AAIDD wrote a detailed letter expressing our concerns and making clear suggested changes. AAIDD's concern regarding the DSM-5 proposal to adopt "intellectual developmental disorder" is that it is regressive and divergent with the currently accepted terminology of "intellectual disability." We have in the United States legislation called Rose's Law that was signed by President Obama that has replaced "mental retardation" with "intellectual disability" in federal law. All professional and disability organizations have adopted "intellectual disability." The DSM-5 adopting a different terminology will lead to confusion, inconsistency, and will hurt people with intellectual disability and their families. Adopting a different terminology, accepted by no one else, could affect federal and state determination of eligibility for benefits and services in schools, social security insurance, Home and Community Based Services (HCBS) waivers, as well as research communication and evaluations in the forensic arena, including capital cases.Other concerns include that the lack of an operational definition of the age of onset could potentially lead to different determinations of the age cutoff across states or even between state agencies. We also suggested the APA make more systematic their definition of adaptive behavior as being represented by conceptual, practical, and social skills. Finally, we cautioned the DSM-5 against deemphasizing individualized standardized testing in favor of clinical assessment and recommended APA strengthen the language regarding measurement error.I want to draw your attention to this important matter and encourage you to familiarize yourself with the AAIDD concerns with the DSM-5 proposal. We also applaud our colleagues in other national and international organizations who have endorsed the AAIDD position, including The Arc [of the United States], Special Olympics International, Inclusion International, American Psychological Association–Division 33, and American Academy of Developmental Medicine and Dentistry. We expect other groups to continue adopting our letter as a model in communicating their concerns to the DSM-5 work group. We should all be extremely concerned about the current direction being taken by the DSM-5.In closing my presidential address, I want to thank you again for joining us in Charlotte for the 136th AAIDD Annual Meeting and for choosing to be a member of AAIDD. I hope to see many of you next year in Pittsburgh, Pennsylvania. Do not hesitate to contact me should you have any questions, concerns, suggestions, and ideas how we can further advance the mission of our association, and let me know how you can become involved in strengthening AAIDD! Thank you.My thanks to the Conference Planning Committee: Lynn Ahlgrim-Delzell, Giulia Balboni, Britt Butler, Melissa DiSipio, Celia Feinstein, Judith Gross, Aaron Kaat, Yves Lachapelle, Laura Lee McIntyre, Loui Lord Nelson, Maggie Nygren, Joanna Pierson, Holly Riddle, Geronimo Robinson, David Rotholz, Peter Smith, Jim Thompson, and Miguel Verdugo; and the Local Arrangements Committee: Lynn Alhgrim-Delzell (co-chair), Holly Riddle (co-chair), Barbara Agnello, Greg Best, Kelly Bohlander, Davan Cloninger, Barton Cutter, Jody Deacon, Kira Fisher, Monica Foster, Melissa Hudson, Kelly Kazukauskas, Angela Lee, Judy Lewis, Mike Mayer, Andrea Misenheimer, Lauren Mullis Borchert, Greg Olley, Scott Paul, Pat Porter, Genny Pugh, Rod Realon, Ron Reeve, David Rotholz, and Deborah Whitfield.

Young persons with intellectual disabilities and challenging behaviour in transition usually have complex needs, which may not be served well within existing resources. In this article, we present a survey of all the young people, between 16 and 18 years of age with intellectual disabilities and challenging behaviour identified in one inner London borough. They were in transition to adult services at the time of the study (between 2006 and 2008). The objective was to examine their socio-demographic and clinical characteristics, pattern of service use and associated costs of care. An assessment toolkit was devised to measure the mental and physical health, challenging behaviour and service use of the sample. Instruments within the toolkit included the Strengths and Difficulties Questionnaire, challenging behaviour scale, Client Service Receipt Inventory (CSRI) and socio-demographic data form. Twenty-seven individuals in transition to adult services had challenging behaviour, 23 of whom had mental health diagnoses and 18 of whom had physical diagnoses. Severity of challenging behaviour did not correlate with cost of care. Informal care accounted for the highest proportion of the total cost of care (66%) with education being the second largest contributor at 22%. Evidence on transition outcomes for young people with complex needs and intellectual disabilities and associated costs is lacking. This article illustrates some of the relevant issues in this area. Further research is required to investigate these aspects and guide commissioning of appropriate services.

To compare the nature and prevalence of use of procedures employed to treat and manage challenging behaviours across two approaches to providing community-based supported accommodation for people with intellectual disabilities (ID) and severe challenging behaviour: noncongregate settings where the minority of residents have challenging behaviour, and congregate settings where the majority of residents have challenging behaviour. Community-based supported accommodation for people with ID and challenging behaviour. Longitudinal matched groups design. The nature and prevalence of use of procedures employed to treat and manage challenging behaviours. Observed and reported severity of challenging behaviours. Both types of settings were associated with low prevalence of use of behavioural technologies for the reduction of challenging behaviour (less than 15% of participants). In contrast, high proportions of participant received antipsychotic medication in both noncongregate (56%) and congregate (80%) settings. Congregate settings were associated with the increased use of physical restraint as a reactive management strategy, with over half of participants being in receipt of physical restraint by two or more members of staff. Changes in reported and observed challenging behaviour over a 10-month period were slight. The use of evidence-based behavioural technologies for the reduction of challenging behaviour may have led to better outcomes.

There has been an increased awareness in the diagnosis of mental disorders in people with intellectual disability (ID). The evidence base has demonstrated that people with ID can display the same mental disorders as the general population and that the prevalence of such disorders varies according to the methods used for their assessment and diagnosis. The diagnosis of mental disorders in people with ID is a highly complex process mostly because of the difficulty or inability of some people with ID to express their feelings and symptoms. Hence, many of the diagnostic criteria for mental disorders used in the general population needed to be modified and adapted for people with ID.The National Association for Persons with Developmental Disabilities and Mental Health Needs (NADD) has been among the leading organizations in the U.S. and internationally in providing educational and training programs, support for research projects, and publicizing important clinical and policy issues regarding people with mental disorders and ID.In 2007, the NADD published the Diagnostic Manual – Intellectual Disability (DM–ID; Fletcher, Loschen, Stavrakaki, & First, 2007) as a companion to the American Psychiatric Association's (APA; 2000) manual for psychiatric diagnosis (i.e., the DSM-IV-TR) to assist clinicians in making more accurate diagnoses for people with ID. Approximately ten years later, with the APA's (2013) publication of their updated manual (i.e., the DSM-5), the NADD published the Diagnostic Manual – Intellectual Disability (DM-ID 2): Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability (DM-ID 2: Fletcher, Barnhill, & Cooper, 2017) for people with ID, having taken into consideration the changes introduced by the DSM-5.The editors of the DM-ID 2 stated that their book is designed to provide state-of-the-art knowledge of mental disorders for people with ID. The DM-ID 2 was compiled by "a multicentered, multicultural, and multifaceted" (p. 9) collaboration of over 100 clinicians, researchers, and practitioners with expertise in mental disorders and ID who worked in 26 working groups over a period of four years. A chairperson was assigned for each working group. A summary of the main points of the DM-ID 2 has also been published separately (Fletcher, Barnhill, McCarthy, & Strydom, 2016).The DM-ID 2 consists of 27 chapters covering the main psychiatric diagnostic categories that correspond closely to the DSM-5 classification system, with modifications to make them more applicable to people with ID. Chapter 1 describes the most commonly used assessment and diagnostic methods "to assist the reader in understanding the biopsychosocial developmental approach when conducting a psychiatric assessment" with people with ID. Chapter 2 describes "behavioral phenotypes that are associated with genetic disorders, which is intended to aid in the understanding of how a disorder's genotype affects its behavioral phenotype". Both chapters 1 and 2 are informative and comprehensive and present an added value to the publication of the DM-ID 2.The authors of the DM-ID-2 relied upon an expert consensus model in much of their work to overcome the poverty of existing relevant research in the field. Each chapter is based on a systematic critical review of the available literature and follows guidelines for clarity and uniformity.The principal elements of the guidelines for the structure of each chapter include both organizational and conceptual elements (e.g., chapter summary, review of diagnostic criteria, general description of the disorder, summary of DSM-5 criteria, diagnosis in people with ID, comorbidity, application of diagnostic criteria to people with ID, etc.)Variations of the suggested guidelines are evident in several chapters of the DM-ID 2, probably due to the different prevalence of mental disorders in people with ID. Therefore, all of the guidelines were not applicable to all mental disorders. All chapters consist of three main parts: (1) summary of the DSM-5 criteria, (2) review of the literature, and (3) suggestions for applying criteria for people with mild/moderate ID and severe/profound ID.There are important changes in the DSM-5 reflecting developments in research of genetics and neuroimaging, and there is a revised organizational structure, taking into consideration that mental disorders do not always fit entirely within the boundaries of a single disorder, but that some symptoms involve multiple diagnostic categories. The changes in DSM-5 relevant to people with ID include a lifespan approach and the abandonment of the multi-axial method. Other important changes in the DSM-5, that have been adopted for the DM-ID-2, include the amalgamation of autistic disorder, Asperger's syndrome, and pervasive developmental disorder, into one diagnostic category - Autism Spectrum Disorder (ASD). Reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorder, and adjustment disorder have been combined in the DSM-5 under the diagnostic category trauma- and stressor-related disorders that has also been adopted by the DM-ID 2. Disorders previously referred to as "dementias" are now designated as major or mild neurocognitive disorders by both the DSM-5 and DM-ID 2.A critical change in DSM-5 is that intellectual disability (ID) is included as "a discrete syndrome" with the term Intellectual Development Disorder (IDD) within the diagnostic category of Neurodevelopmental Disorders. The DM-ID 2 adopts the term IDD (in the disability field this abbreviation stands for intellectual and developmental disabilities) but makes a central point that IDD can coexist with other mental disorders. This emphasis of the coexistence of IDD with other mental disorders is an important distinction of the DM-ID 2 from DSM-5, where IDD is frequently an exclusion criterion from the diagnosis of other mental disorders.The inclusion of IDD as a separate category, under the neurodevelopmental disorders of the DSM-5, to affirm that it is a health condition, remains controversial (Bertelli, Salvador-Carulla, & Harris, 2016). The American Association for Intellectual and Developmental Disorders (AAIDD) defines ID as a "disability" and not as a "health condition." The AAIDD definition states that ID is "characterized by significant limitations, both in intellectual functioning and adaptive behavior as expressed in conceptual, social, and practical adaptive skills," and that the disability originates before age 18. (Schalock et al., 2010, p. 1).Another important change in the DSM-5 for the diagnosis of IDD is that it shifts the emphasis from IQ scores to the necessity that the onset should occur "during the developmental period and to include both intellectual and adaptive functioning deficits in conceptual, social and practical domains" (American Psychiatric Association, 2013, p. 33).The DM-ID 2 retains IDD as a separate diagnosis, and in Chapter 4, the complex conceptual issues involved with the diagnostic criteria of Neurodevelopmental Disorders. These issues include a number of overlapping symptoms from other, co-existing, neurodevelopmental syndromes or/and other mental disorders. DM-ID 2 allows some flexibility by stating that clinicians will have to judge how best to modify inclusion, specifiers, and exclusion criteria to apply these diagnostic criteria to people with IDD.Additional changes in the diagnostic criteria covered in the DSM-5 and adopted by DM-ID-2 include the exclusion of Attention Deficit Hyperactivity Disorder (ADHD) from Autism Spectrum Disorder (ASD); the realignment of impulse control and disruptive behavior disorders to the category of Disruptive Mood Dysregulation Disorder (DMD) for people with affect dysregulation and ADHD (previously diagnosed as bipolar disorder) and the creation of trauma- and stressor-related disorders.The DSM-5 diagnostic criteria for major neurocognitive disorder and mild neurocognitive disorder to aid in the diagnosis of dementia have also been modified for people with ID in the DM-ID 2, but some caution is given for the validity of mild neurocognitive disorder in people with ID.The DM-ID 2 aims to assist in the diagnosis of mental disorders for people with ID based on adaptation and modification of the diagnostic criteria of the DSM-5. It is written in a well-organized and methodological style in a field characterized by very difficult and complex issues and concepts. Individual chapters include wide-ranging discussions based on a systematic review of the literature and the extant research evidence on mental disorders among people with ID to support the suggested adaptive diagnostic criteria for people with ID. The term IDD as used in the DSM-5, has been adopted by the DM-ID 2 throughout the publication. The process of developing the DM-ID 2 does not include field trials and does not mention the association with the APA, as was the case with the development of the DM-ID.The acceptance of a psychiatric diagnosis and classification for those with mental disorders, including for people with IDD, serves several purposes, including "medical record keeping, data collection, retrieval and compilation of statistical information, communicating with third parties, such as insurers and governmental agencies, and is the basis for eligibility and reimbursement for psychiatric services" (Sturmey, 1999, p. 4). Standardized diagnosis can also serve as the basis for communication between different professional groups and non-professionals as well as in research contexts. Diagnosis also serves the purpose of providing a summary for multiple presenting symptoms, etiology, and prognosis, and can inform therapeutic interventions. The provision of mental health services for those with ID has undergone profound transformations since the implementation of community care programs (Bouras, Ikkos, & Craig, 2017). Accurate diagnosis is of utmost importance for planning, provision, and delivery of services, monitoring, and evaluation (Bouras, 2017).The publication of the DM-ID 2 is an important resource toward advancing our knowledge of mental disorders in people with ID. Discussion on the relationship of problem behavior known as "challenging behavior" not included in the DSM-5, would have been helpful in the DM-ID 2. The value of the DM-ID 2 remains to be confirmed in clinical practice and research studies that apply the suggested diagnostic criteria. In the future, the publication of an "operational guide" for the DM-ID 2 will serve as a user-friendly tool facilitating diagnosis and treatment for people with ID and mental disorders.

Individuals with intellectual and developmental disabilities who engage in severe challenging behavior may comprise 5%–10% of the clinical population. Unfortunately, challenging behavior literature tends to underrepresent adult participants and emphasize efficacy (Does the intervention work?) more often than effectiveness (Does the intervention work in real world settings?). We conducted a systematic program evaluation to examine the effectiveness of a comprehensive behavioral treatment package using a hybrid quasi‐experimental consecutive case series design featuring eight adults who experienced the treatment package. The results depicted a substantial decrease in challenging behavior and increase in adaptive behavior across sessions for most participants. Impressive treatment integrity outcomes (M = 84%, range, 82%–90%) showcased that the intervention was implemented as intended. Social validity surveys administered to participants, caregivers, and case managers provide support for the acceptability of the treatment package. Project limitations, clinical considerations, and future directions are discussed.

BackgroundFew studies have explored the relationship between challenging behaviour and mental health symptoms in autistic individuals with intellectual disabilities, and findings have been mixed. While the prevalence of mental health disorder in this population is high, recognition and identification of these disorders may be challenging. No previous study of the relationship with challenging behaviour has used mental health measures specifically developed for this population. MethodUsing a standardised tool for challenging behaviour (Aberrant Behavior Checklist, ABC), differences between participants were explored according to whether they were diagnosed with a mental health disorder, in a clinical sample of 175 autistic individuals with co-occurring intellectual disabilities (ages 14–68) referred for mental health assessment. The relationship between severity of challenging behaviour and severity of mental health symptoms reported on the Psychopathology in Autism Checklist (PAC) was also explored. ResultsFew group differences were identified for challenging behaviour according to diagnosis, but clear associations were identified between PAC and ABC scales. These included general/non-specific associations and more specific associations that remained significant when controlling for the underlying conditions. Potential interactions were found involving different PAC scales and age, gender, autism-related characteristics, level of intellectual disability, and communication skills, respectively, but these varied for each ABC scale. ConclusionsThe relationship between challenging behaviour and mental health disorder appears to be complex and multifaceted. The lack of specificity of challenging behaviour indicates that these cannot reliably be used to identify specific mental health disorders, even if these behaviours may constitute atypical expressions of mental health symptoms.