Mild To Borderline Intellectual Disability Research Articles

The prospective associations between autonomy support, basic psychological needs, motivation and well-being among people with a mild to borderline intellectual disability: a two-wave study.

This study, grounded in self-determination theory, examined how satisfaction of the needs for autonomy, relatedness and competence in people with mild to borderline intellectual disability (MBID) changed over a 4.5-year period. Additionally, it explored the association between life events across various domains (i.e. health, support and living situation, crime, relationships and freedom and finance) and these changes and explored the prospective associations between these needs, perceptions of support from direct support staff and the well-being and ill-being of people with MBID. Based on a sample of 117 adults with MBID, multiple regression analyses were conducted to determine correlations between constructs at both time points and the impact of autonomy support on need satisfaction and motivation, taking into account life events. The analyses showed that, at both time points, most constructs were statistically significantly correlated and remained so despite a time lag of 4.5 years. Autonomy support emerged as a significant positive predictor, of medium size, for satisfying autonomy and relatedness needs. Its association with competence need satisfaction was not statistically significant after Bonferroni correction. For type of motivation, autonomy support statistically predicted increased autonomous motivation, irrespective of life events. Findings underline the potential of autonomy supportive direct support in the lives of individuals with MBID. Some unexpected null findings underscore the need for further study into the interplay between autonomy support, life events and the well-being of people with MBID.

Factors influencing the oral health behaviour of Dutch adolescents with mild to borderline intellectual disabilities living in residential care: A qualitative study.

Toothbrushing, limiting intake frequency, and scheduled visits to an oral healthcare professional (OHP) are key for good oral health. We aimed to explore factors influencing these oral health behaviours in Dutch adolescents with mild to borderline intellectual disabilities (MBID) in residential care. Using a qualitative, descriptive approach, we conducted focus groups and interviews with 12 adolescents, 9 counsellors, and 6 OHPs. Thematic analysis mapped factors influencing adolescents' knowledge, attitude, planning, and execution of oral health behaviours to oral care stakeholders. Of nine identified influencing factors, three were pivotal: Structure (influencing toothbrushing and intake frequency), Anxiety (impeding dental visits), and Support (provided by counsellors). Counsellors should provide structured daily guidance on oral hygiene and diet for adolescents with MBID, while respecting the adolescents' autonomy. As intermediaries between adolescents and OHPs, counsellors are key in reducing dental anxiety. Counsellors need clear oral health policies within care facilities to address competing priorities.

Virtual Reality Aggression Prevention Training for People with Mild Intellectual Disabilities: A Feasibility Study

ABSTRACT Introduction Problems with adequately regulating aggression are comon in people with mild to borderline intellectual disabilities (MBID). Learning through experience has been shown to be effective in MBID. Therefore, we adapted an aggression prevention training that uses virtual reality (VR), which was initially made for a forensic psychiatric population. We aimed to assess the feasibility of this VR aggression training for MBID. Methods Nine people with MBID attended the 12-session VR aggression training. Both quantitative (on session satisfaction, well-being and observed aggression), and qualitative measures (feasibility workbook evaluations and focus groups with participants and therapists) were obtained. Results Six participants completed all sessions, and three participants dropped out because of a lack of motivation. Session satisfaction scores were high. Thematic analyses identified that participants learned coping strategies, and gained insights into emotions and triggers. Suggestions for improvement of the training included more personalization, practicing longer in VR, and more involvement of the social network in training sessions. Aggression observation measures were not feasible and no reliable results could be obtained. Conclusion Although the dropout was substantial, the training seems feasible and acceptable for participants and therapists. However, improvements should be made to the intervention to increase efficacy, and enable better fits with participants’ specific needs.

Effectiveness of the mentalisation-based serious game 'You & I' for adults with mild to borderline intellectual disabilities: A randomised controlled trial.

Mentalising and stress regulation pose challenges for adults with mild to borderline intellectual disabilities (MBID), emphasising the importance of an intervention program. The study examined the effectiveness and social validity of the serious game 'You & I' in enhancing mentalising and stress regulation among adults with MBID. A randomised controlled superiority trial with experimental and waitlist-control groups was conducted with 159 adults with MBID (Mage = 36) at baseline, post-test, and follow-up. Analyses investigated the effects on aspects of mentalising, stress regulation, and social validity. The experimental group showed decreased stress from negative interpersonal relations, while the control group experienced increased stress (d = 0.26). There were no significant effects on mentalising, but positive user expectations and experiences were reported. This initial study on 'You & I' provides limited evidence of its effectiveness for people with MBID, warranting further examination of the potential of serious games.

Basic Psychological Needs and Mental Health in Adolescents with a Mild to Borderline Intellectual Disability

ABSTRACT Introduction Emotional and behavioral problems are common in adolescents with mild to borderline intellectual disabilities (MBID). Basic Psychological Needs Theory connects fulfillment of basic psychological needs (autonomy, relatedness, competence) to ill-being (mental health problems). The associations between the frustration and satisfaction of basic psychological needs and indicators of mental health problems are the subject of this study. Method Adolescents with MBID (N = 324, mean age 15.2 years), filled out questionnaires on basic psychological needs (BPNSFS-ID) and on anxiety (SCARED), depression (CDI) and aggression (Externalizing Problems scale of YSR). A subgroup of adolescents with MBID and severe behavioral problems (MBID-SBP) was compared to a general subgroup (MBID-G). Results Outcomes for adolescents with MBID-SBP were worse than for adolescents with MBID-G on most measures. BPNSFS-ID frustration was positively associated with mental health problems. Correlations for the BPNSFS-ID satisfaction scales were positive but weaker. Associations within the MBID-SBP subgroup were stronger than for the MBID-G subgroup. Discussion Frustration of BPN in particular is associated with mental health problems. Attending basic psychological needs may potentially help to counter ill-being.

Lessons learned from the adaptation of the Reflective Functioning Questionnaire (RFQ) for Dutch people with mild to borderline intellectual disabilities.

People with mild to borderline intellectual disabilities (MBIDs) face challenges in social functioning, possibly as a result of limited mentalising abilities such as reflecting on the behaviour of themselves and others. Reflective functioning in people with MBIDs has not yet been investigated due to a lack of instruments. The Reflective Functioning Questionnaire (RFQ) is a seemingly easy adaptable, short self-report questionnaire. The aim of the present, explorative study was to adapt the RFQ for people with MBIDs and investigate the psychometric properties and correlations with other mentalising related constructs. The formulation of the items was adapted to the target group and items were added to broaden the scope towards reflection on both the self and other. Participants were 159 adults with MBIDs who completed a Dutch-translated and easy-to-read RFQ with five supplemental items, a questionnaire for autistic traits, a self-report questionnaire assessing perspective taking and two performance-based measures assessing emotion recognition and Theory of Mind. Confirmatory factor analysis confirmed the factor structure of the RFQ and revealed a two-factor structure with a Self and Other subscale. Generally satisfactory internal consistency and test-retest reliability were found. Explorative results showed correlations of the RFQ-8 and RFQ subscales with autistic traits and between the RFQ Other and perspective taking. This explorative study is the first testing psychometric properties of the RFQ as a self-report questionnaire for assessing reflective functioning in adults with MBIDs. This step is relevant in gaining more scientific knowledge on assessing mentalising in people with MBIDs.

Explaining Risk Factors for Successful Family Supervision Orders: Families with Intellectual Disabilities in Child Protection in the Netherlands.

Families with mild to borderline intellectual disabilities (MBID) are overrepresented in child protection, and are at higher risk for long and unsuccessful family supervision orders (FSOs). This is worrisome, as many children apparently are exposed to unsafe parenting situations for longer periods of time. Therefore, the present study examined which child and parental factors and child maltreatment are related to the duration and success of an FSO in families with MBID in the Netherlands. Casefile data were analysed of 140 children with an ended FSO. Results from binary logistic regression analyses showed that in families with MBID, young children, children with psychiatric problems, and children with MBID were at higher risk for a longer duration of FSOs. Furthermore, young children, children with MBID and children who were sexually abused had a lower chance of a successful FSO. Unexpectedly, children who witnessed domestic violence or whose parents were divorced, had a higher chance of a successful FSO. The discussion focuses on implications of these results for treatment and care of families with MBID from the perspective of child protection.

Exploring the predictive properties of the Hayes Ability Screening Index subtest background information in identifying individuals with MBID among in-patients with SUD.

For individuals with substance use disorder (SUD), mild to borderline intellectual disability (MBID) goes undetected in treatment clinics. The Hayes Ability Screening Index (HASI) has been found to be a valid, time-saving screening instrument for MBID in SUD treatment. MBID can have significant implications for treatment planning and outcomes. Therefore, it is important to have methods for the early recognition of these comorbid conditions. Because of less sensitivity to recent or ongoing substance use, the HASI subtest background information may be particularly valuable as an early screening of MBID. The main aim was to investigate the convergent, predictive, and discriminant validity of the HASI subtest background information in identifying in-patients with SUD as MBID or non-MBID. Eighty-four in-patients with SUD aged 19-64 participated in this multicentre study. MBID was diagnosed according to the ICD-10 using WAIS-IV, Vineland II, and self-reported childhood learning difficulties. The main finding was that, among the HASI subtests, background information was the strongest predictor. A HASI background information cut between 6 and 7 showed a sensitivity of 78% and a specificity of 72%. The HASI subtest background information has acceptable convergent, predictive, and discriminant validity as a screening for MBID among in-patients in SUD treatment.

Susceptibility to peer influence in adolescents with mild-to-borderline intellectual disability: Investigating links with inhibition, Theory of Mind and negative interpretation bias

ABSTRACT Background This preregistered study compares adolescents with mild-to-borderline intellectual disability (MBID) and typically developing (TD) adolescents on their susceptibility to peer influence. To understand why adolescents with MBID are susceptible to peer influence, links with inhibition, Theory of Mind (ToM) and negative interpretation bias are investigated. Method We assessed 163 adolescents (111 MBID, 52 TD 14–19 years; 63% boys) using experimental tasks and self- and/or teacher-reports. Results Adolescents with MBID and TD adolescents did not differ in their susceptibility to peer influence, inhibition, and negative interpretations. On two ToM instruments, adolescents with MBID performed weaker than TD adolescents. In a structural equation model, tested in the MBID group, inhibition, ToM and negative interpretation bias were not related to susceptibility to peer influence. Conclusions This study revealed new insights by strong methods such as the multimethod approach, a full theoretical model testing relations between all constructs simultaneously, and the large sample.

Neurocognitive functioning of children with mild to borderline intellectual disabilities and psychiatric disorders: profile characteristics and predictors of behavioural problems.

BackgroundThe aim of the current study was twofold: first, to uncover a neurocognitive profile of normative and relative strengths and weaknesses that characterises an extremely vulnerable group of children with mild to borderline intellectual disabilities (MBID) and co‐morbid psychiatric disorders, and second, to investigate the relevance of these neurocognitive functions explaining internalising and externalising symptoms.MethodWe recruited 45 children (M age = 9.5, SD age = 1.7; range 6–13 years) with MBID (Full‐Scale IQ 50–85) and at least one psychiatric disorder. Neurocognitive functioning was examined utilising the Wechsler Intelligence Scale for Children – Fifth Edition (WISC‐V) indices and the Cognitive Task Application (COTAPP), a comprehensive computerised self‐paced task designed in such a manner that ‘g’ (an overall tendency of children with MBID to execute tasks with a slower reaction time and a higher error rate) has been corrected for in the administration of the task (i.e. completely self‐paced) and in the operationalisation of outcome measures. Behavioural problems were measured using the CBCL and TRF. One‐sample t‐tests and binomial tests were carried out to compare performance with normative data. Regression analyses were used to examine the relationship between neurocognitive parameters and mental health.ResultsCompared with normative data, very small to very large effect sizes were found, indicating clear heterogeneity amongst neurocognitive domains relevant for children with MBID. Two prominent neurocognitive weaknesses emerged: processing speed – characterised by slowness and unstableness combined with a high drift rate and delayed processing of the previous trial, particularly under higher cognitive demands – and working memory – in terms of a weaker central executive and ‘slave’ systems to temporarily store information. Both domains were not clearly predictive of internalising or externalising problems.ConclusionChildren with MBID and psychiatric disorders are hampered by a strongly diminished processing speed and working memory capacity, together resulting in an overall limited processing capacity that may underlie the general developmental delays on domains that depend on fast and parallel processing of information (i.e. language, reading, mathematics and more complex forms of social cognition). Neurocognitive vulnerabilities are neither necessary nor sufficient to explain internalising and externalising problems; rather, a mismatch between the support needs and adaptations these children need, arising from their diminished processing capacity, and the inadequacy of the environment to compensate for this vulnerability may be of relevance.

Intellectual Disability among Violent Repeat Offenders and Its Relation with Psychopathology and Self-Sufficiency

Despite the recognized importance of mild to borderline intellectual disability (MBID) among offender populations, there is insufficient understanding of its prevalence and associations with other social-psychiatric problems. Therefore this study investigated MBID prevalence and its relation with psychopathology and self-sufficiency problems (SSPs) in important life-domains among young adult violent repeat offenders (N = 432) enrolled in a focused deterrence program in Amsterdam. Offenders participated voluntarily in a social psychiatric screening which included the Screener for Intellectual Disability and Learning Disorders (SCIL) to assess MBID, the Dutch version of the self-sufficiency matrix (SSM-D) to assess SSPs, and an assessment of the presence of psychiatric disorders according to DSM methodology. Results showed an MBID prevalence of 51.1%. Nearly all offenders presented with at least one psychiatric disorder (95.0%) and SSPs in multiple life-domains. Among MBID offenders, symptoms of mood- and anxiety disorders, substance dependency and higher variety in SSPs were more frequently observed than among non MBID offenders. These results indicate the importance of adapting communication and treatment programs to increase their responsivity to MBID offenders. Self-sufficiency problems, that may reflect shortcomings in adaptive functioning specifically among MBID offenders, can be considered criminogenic needs and should be targeted accordingly to reduce recidivism.

Effectiveness of a mindfulness-oriented substance use prevention program for boys with mild to borderline intellectual disabilities: study protocol for a randomised controlled trial

BackgroundBoys with mild to borderline intellectual disabilities (MBID) are at particular risk to drink in harmful ways once they start to consume alcohol. Interventions based on mindfulness have been proven to be effective in preventing substance use, but mostly for adults with MBID. A mindfulness oriented intervention targeting 11–17 years old boys will be tested in a randomised controlled trial. Study aim is to investigate the benefits of this new intervention compared to an active control condition within a 12 months follow-up.MethodsIn this randomised controlled proof of concept study, 82 boys with MBID who consumed any alcohol during the last year will be randomised either to the 6 week mindfulness oriented intervention or the control group receiving a control intervention equal in dose and length. The intervention group undergoes mindfulness training combined with interactive drug education, while the control group completes a health training combined with the same education. In the intention-to-treat analysis the primary outcome is the self-reported delay of first post-intervention drunkeness within a 12 months follow-up time span, measured weekly with a short app-based questionnaire. Secondary outcome is the use of alcohol, tobacco and other drugs within 30 days post-intervention. Changes in neurobiological behavioural parameters, such as impulse control, reward anticipation, and decision making, are also investigated. Other secondary outcomes regard trait mindfulness, emotion regulation, psychopathological symptoms, peer networks, perceived stress, and quality of life. In addition, a prospective registry will be established to record specific data on the population of 11–17 year old boys with MBID without any alcohol experience.DiscussionThis study offers the opportunity to gain first evidence of the effectiveness of a mindfulness-oriented program for the prevention of substance use for boys with MBID.Trial registrationGerman Clinical Trials Register, DRKS00014042. Registered on March 19th 2018.

Feasibility and reliability of screening on mild to borderline intellectual disabilities using SCIL through video-administration

Purpose In the Netherlands, the Screener for Intelligence and Learning Disabilities (SCIL) was developed to aid recognition of mild to borderline intellectual disability (MBID) early in the criminal justice system or health-care trajectory. In situations where physically meeting the suspect or client is not feasible, administration of the SCIL using a video-link might be a solution. This paper aims to examine whether the SCIL is still reliable when administered remotely instead of face-to-face. Design/methodology/approach The SCIL was administered twice to a total of 89 respondents: once face-to-face, once using a video link, in varying order and with an interval of at least six weeks. A laptop with a Skype connection was used for the remote administration, while an assistant was present to make sure the respondents did not have to perform technical actions. After the second SCIL administration, respondents were asked to answer a series of evaluation questions. Findings Respondents were generally satisfied with both methods of administration of the SCIL. However, they were in general more positive about face-to-face administration. Nevertheless, most respondents would be willing to undergo administration through video-link in future. On average, respondents scored slightly lower on the SCIL when administered remotely (µ = 16.31, SE = 0 0.77) than with face-to-face administration (µ = 16.94, SE = 0.78), t(88) = 2.47, p = 0 0.015. Calculation of the reliability of the assessment “suspected MBID” showed a (linear weighted) Kappa of 0.77, p = 0.000, 95% RI: 0.64-0.90. Originality/value The results of this study show that with some caution, the SCIL can be administered remotely. When doing this, the SCIL will only lead to a small number of respondents being wrongly labelled as “suspected MBID”.

When Do those \u201cRisk-Taking Adolescents\u201d Take Risks? The Combined Effects of Risk Encouragement by Peers, Mild-to-Borderline Intellectual Disability and Sex

Adolescents with mild to borderline intellectual disability (MBID) show more daily life risk taking than typically developing adolescents. To obtain insight in when these “risk-taking adolescents” especially take risks, we investigated main and interaction effects of (a) MBID, (b) sex, and (c) type of peer influence on risk taking. The Balloon Analogue Risk Task (BART) was used as a proxy of real-life risk taking. 356 adolescents (12–19 years, 51.7% MBID, 63.4% boys) were randomly assigned to one of three BART peer-influence conditions: solo (no peers), positive risk encouragement (e.g., ‘You are cool if you continue’) or negative risk encouragement (e.g., ‘You are a softy if you do not continue’). The main finding was that boys with MBID took more risks than typically developing boys in the negative risk encouragement condition. Boys with MBID also took more risks in the negative risk encouragement condition compared to the solo condition, whereas typically developing boys did not. There were no such effects for girls. Surprisingly, boys with MBID took less risks in the solo condition than typically developing boys. We conclude that boys with MBID especially show high risk taking when peers belittle or threat with exclusion from the peer group. Prevention and intervention programs should specifically target boys with MBID to teach them to resist negative risk encouragement by peers.

Psychometric Properties of the Basic Psychological Need Satisfaction and Frustration Scale – Intellectual Disability (BPNSFS-ID)

Abstract. The Basic Psychological Need Satisfaction and Frustration Scale – Intellectual Disability (BPNSFS-ID), an adapted version of the original BPNSFS ( Chen, Vansteenkiste, et al., 2015 ), operationalizes satisfaction and frustration with the three basic psychological needs according to self-determination theory (SDT): autonomy, relatedness, and competence. The current study examined the psychometric properties of the BPNSFS-ID in a group of 186 adults with mild to borderline intellectual disability (MBID). The results indicated an adequate factorial structure of the BPNSFS-ID, comprising the satisfaction and frustration of each of the three needs. The associations between BPNSFS-ID subscales autonomy, relatedness, and competence and the self-determination subscale of the Personal Outcome Scale (POS), the De Jong Gierveld Loneliness Scale, and the General Self-Efficacy Scale – 12 (GSES-12), supported the construct validity. In addition, the BPNSFS-ID demonstrated high internal consistency (α = .92) and 2-week test-retest reliability ( r = .81 for the composite subscale autonomy, r = .69 for the composite subscale relatedness, and r = .85 for the composite subscale competence). Overall, the BPNSFS-ID proved to be a valid and reliable measure of basic psychological need satisfaction and need frustration among people with MBID.

Peer-Influence on Risk-Taking in Male Adolescents with Mild to Borderline Intellectual Disabilities and/or Behavior Disorders

This study aimed to disentangle the effects of Mild-to-Borderline Intellectual Disability (MBID) and Behavior Disorders (BD)on risk taking in circumstances where peer influence was absent or present. We studied 319 adolescents in four groups: MBID-only, MBID+BD, BD-only, and typically developing controls. The Balloon Analogue Risk-Task (BART), in a solo or peer condition, was used as a proxy of real-life risk-taking. Results show a significant main effect of BART condition. Post-hoc tests indicated higher risk-taking in the peer compared to the solo condition in all groups except BD-only. Moreover, risk taking was increased in adolescents with MBID compared to adolescents without MBID, but only under peer-influence. No main or interaction effects with BD were observed. Model based decomposition of BART performance in underlying processes showed that the MBID related increase in risk-taking under peer-influence was mainly related to increased risk-taking propensity, and in the MBID-only group also to increased safety estimates and increased confidence in these safety estimates. The present study shows that risk-taking in MBID may be better explained by low intellectual functioning than by comorbid BD, and may not originate in increased risk taking per se, but may rather be related to risk-taking under peer-influence, which is a complex, multifaceted risk-taking context. Therefore, interventions to decrease risk-taking by adolescents with MBID that specifically target peer-influence may be successful.

Differences between self- and peer-rated likability in relation to social anxiety and depression in adolescents with mild intellectual disabilities

BackgroundSocial anxiety and depressive symptoms are relatively common in adolescents with Mild to Borderline Intellectual Disabilities (MBID). Unfortunately, there are only a few studies that focus on examining processes underlying social anxiety and depression in these adolescents. AimsThe aim was to examine the differences between self- and peer-rated likability in relation to social anxiety and depression in the classroom environment. Methods and Procedures631 normative non-clinical adolescents with MBID completed questionnaires to measure social anxiety, depression, and the estimation of their own likability by peers. Peer-reported likability was derived from peer-rating scales on likability. Outcomes and ResultsAdolescents with higher levels of social anxiety significantly rated their own likability as lower than their non-anxious peers. However, socially adolescents were equally liked by their peers. Adolescents with higher levels of depression were significantly less liked by their peers, but still underestimated their own likability than adolescents with lower levels of depression. Conclusions and ImplicationsSocial anxiety and depression are linked to a biased interpretation of likability, but only depression is linked to actually being less liked by peers. Social anxiety and depression are partly based on similar underlying cognitive biases.

Intelligentie, executieve functies en licht verstandelijke beperking in justitiecontext

Individuals with a mild to borderline intellectual disability (MBID) are thought to be over-represented in the criminal justice system. The current article reviews research on the associations between executive functioning with antisocial behavior and MBID. Associations with executive functions such as working memory, inhibition, planning and cognitive flexibility, as well as punishment and reward sensitivity, are described. Working memory appears particularly strongly associated with antisocial behavior as well as with MBID. Research on MBID to date, however, almost exclusively focused on children and adolescents. More research on these issues could provide practical information for supervision as well as aid the adaptation or development of interventions for this population, and provide tools to allocate individuals to interventions tailored to their specific needs.

The relationship between drinking motives and interpretation bias in problematic drinkers with mild to borderline intellectual disability

ABSTRACTBackground The goal of this study was to examine the relationship between drinking motives and interpretation bias (interpreting ambiguous stimuli in an alcohol-related way) in problematic drinkers with and without mild to borderline intellectual disability (MBID).Method Participants (N = 178) were divided into 4 groups based on severity of alcohol use–related problems and full-scale IQ. They completed a word-association task and the Drinking Motives Questionnaire Revised (DMQ-R).Results Problematic drinkers showed an interpretation bias towards alcohol. Participants with MBID had a relatively strong interpretation bias. The DMQ-R coping motive predicted the strength of the bias in negative scenarios, whereas the DMQ-R coping and social motives predicted the strength of the bias in positive scenarios.Conclusions The activation of this bias might depend on individual differences in drinking motives, which provides implications for the assessment and treatment of problematic alcohol use in individuals with and without MBID.

The Usefulness of Implicit Measures for the Screening, Assessment and Treatment of Problematic Alcohol Use in Individuals with Mild to Borderline Intellectual Disability

Although the neuropsychological underpinnings of problematic alcohol use have been studied extensively, this research has not yet been generalised to individuals with mild to borderline intellectual disability (MBID). In this paper, we present the main findings of a research project aimed at studying the deficiencies in information processing associated with problematic alcohol use in problematic drinkers with and without MBID. The objectives were to develop and test indirect measures of cognitive biases and executive dysfunctioning of problematic drinkers with MBID and studying the extent and nature of the influence of IQ and executive control on these deficiencies. In addition to extending the fundamental knowledge about problematic alcohol use, the research findings provide practical implications that can be translated into the screening, assessment and treatment of problematic drinkers—both with and without MBID. Based on our results, we discourage the use of indirect, reaction time-based measures for cognitive biases for clinical purposes. The word association task, on the other hand, provides better opportunities, for example as a way to identify high-risk situations for alcohol use. With regard to cognitive and executive functioning, we advise practitioners to conduct a thorough assessment in an early phase of the treatment but withhold from incorporating neurocognitive treatment protocols in the treatment of problematic alcohol use.