Mini PAS-ADD Research Articles

Assessing Psychiatric Symptomatology in Adults with Intellectual Disabilities: Psychometric Properties of German Versions of the PAS-ADD Checklist and the Mini PAS-ADD

ABSTRACT Introduction Adults with intellectual disabilities (ID) face a high risk of developing psychiatric disorders, yet there is a lack of valid instruments measuring psychopathology in this population. Two existing instruments are the PAS-ADD Checklist questionnaire and the Mini PAS-ADD interview, two third-party assessments that can be used for the purpose of screening. Methods German versions of the PAS-ADD Checklist and the Mini PAS-ADD were performed on 78 and 55 adults with ID, respectively. Internal consistency, sensitivity, and specificity were calculated for both instruments and the convergent validity of the two tools was tested. Results Cronbach’s alphas of the Checklist’s scales and the total score were questionable (alpha over 0.6), except for a very low alpha for Organic Condition (0.34). For the scales of the Mini PAS-ADD, Cronbach’s alpha varied between 0.34 (Unspecified Disorder) and 0.72 (Psychosis). Using current clinical diagnoses as a reference, sensitivity was rather poor in both instruments, with a case identification of 52% each. Specificity was 70% for the Checklist and 100% for the Mini PAS-ADD. The correlation between the tools was low to moderate (Spearman’s ρ = 0.32, Kendall’s τ = 0.22). Applying the available thresholds, the instruments resulted in the same conclusion about the possible occurrence of psychopathology in only 52.7% of the cases. Discussion The PAS-ADD Checklist and the Mini PAS-ADD are feasible third-party instruments for the assessment of psychiatric disorders in people with ID. Professionals must be aware of the low sensitivity of both tools, meaning that a referral to further assessment should not be based on the thresholds alone. More research is needed as to the adjustment of the thresholds, the suitability of the unusual scoring system and the additional development of self-report instruments.

EHMT1 mosaicism in apparently unaffected parents is associated with autism spectrum disorder and neurocognitive dysfunction

BackgroundGenetic mosaicism is only detected occasionally when there are no obvious health or developmental issues. Most cases concern healthy parents in whom mosaicism is identified upon targeted testing of a genetic defect that was initially detected in their children. A germline genetic defect affecting the euchromatin histone methyltransferase 1 (EHMT1) gene causes Kleefstra syndrome, which is associated with the typical triad of distinct facial appearance, (childhood) hypotonia, and intellectual disability. A high degree of psychopathology is associated with this syndrome. A few parents with a mosaic EHMT1 mutation have been detected upon testing after a child was diagnosed with a germline EHMT1 defect. At first glance, carriers of a mosaic EHMT1 mutation appeared to function normally. However, recent studies have shown that de novo, postzygotic mutations in important developmental genes significantly contribute to autism spectrum disorder (ASD). Therefore, we hypothesized that EHMT1 mosaicism could cause neuropsychiatric defects. To investigate this, we performed a detailed investigation of cognitive neuropsychiatric parameters in parents identified with EHMT1 mosaicism.MethodsThree adults (two males, one female) with a genetically confirmed diagnosis of EHMT1 mosaicism were examined by means of a battery of tests and observational instruments covering both neurocognitive and psychiatric features. The battery included the following instruments: the Autism Diagnostic Observation Schedule (ADOS), the mini Psychiatric Assessment Schedules for Adults with Developmental Disabilities (mini PAS-ADD), the Vineland Adaptive Behavior Scales (VABS), and the Cambridge Neuropsychological Test Automated Battery (CANTAB). These measures were compared with our previously reported data from Kleefstra syndrome patients with confirmed (germline) EHMT1 defects.ResultsAll three subjects achieved maximum total scores on the VABS, indicative of adequate (adaptive) functioning. In all, scores above cutoff were found on the ADOS for ASD and on the mini PAS-ADD for major depressive disorder (lifetime). Finally, results on the CANTAB showed impaired cognitive flexibility in all subjects.ConclusionIndividuals with EHMT1 mosaicism seem to have increased vulnerability for developing severe psychopathology, especially ASD and mood disorders. Although at first glance they appear to be well-adapted in their daily functioning, they may experience significant psychiatric symptoms and show reduced cognitive flexibility in comparison to the general population.

Adaptive and maladaptive functioning in Kleefstra syndrome compared to other rare genetic disorders with intellectual disabilities.

Detailed neurobehavioural profiles are of major value for specific clinical management, but have remained underexposed in the population with intellectual disabilities (ID). This was traditionally classified based on IQ level only. Rapid advances in genetics enable etiology based stratification in the majority of patients, which reduces clinical heterogeneity. This paper illustrates that specific profiles can be obtained for rare syndromes with ID. Our main aim was to study (mal)adaptive functioning in Kleefstra Syndrome (KS) by comparing and contrasting our findings to three other subgroups: Koolen-de Vries Syndrome, GATAD2B-related syndrome, and a mixed control group of individuals with ID. In total, we studied 58 individuals (28 males, 30 females) with ID; 24 were diagnosed with KS, 13 with Koolen-de Vries Syndrome, 6 with the GATAD2B-related syndrome, and 15 individuals with undefined neurodevelopmental disorders. All individuals were examined with a Vineland Adaptive Behavior Scale, mini PAS-ADD interview, and an Autism Diagnostic Observation Schedule to obtain measures of adaptive and maladaptive functioning. Each of the three distinctive genetic disorders showed its own specific profile of adaptive and maladaptive functioning, while being contrasted mutually. However, when data of the subgroups altogether are contrasted to the data of KS, such differences could not be demonstrated. Based on our findings, specific management recommendations were discussed for each of the three syndromes. It is strongly suggested to consider the genetic origin in individuals with congenital neurodevelopmental disorders for individual based psychiatric and behavioral management.

PSYCHOPATHOLOGY IN ADULTS WITH INTELLECTUAL DISABILITIES WITH OR WITHOUT EPILEPSY: A CASE CONTROL STUDY

AimsEpilepsy-related factors may increase the risk of developing psychopathology in adults with intellectual disabilities (ID). We examined the patterns of problem behaviours and psychiatric disorders among adults with ID and...

Manualised Individual Cognitive Behavioural Therapy for mood disorders in people with mild to moderate intellectual disability: A feasibility randomised controlled trial

BackgroundEvaluation of complex interventions, including standardisation of the intervention, types of outcomes selected and measures of change, is a fairly novel concept in the field of intellectual disabilities. Our aim was to explore these issues in a feasibility study of Manualised Individual Cognitive Behaviour Treatment (M-iCBT) compared to the treatment as usual alone (TAU). MethodsService users with mild to moderate intellectual disability experiencing a mood disorder or symptoms of depression and/or anxiety (mini PAS-ADD total score >10 or 7 respectively) were randomly assigned to either. ResultsIn total, 32 participants were randomly assigned to 16 sessions of M-iCBT (n=16) in addition to TAU or TAU alone (n=16). We explored recruitment and accrual rates, willingness to participate, acceptability of the intervention and suitability of assessment tools. Mean change (95% CI) in the Beck Depression Inventory-Youth (BDI-Y) score from baseline to the 16 week endpoint (primary variable) was 0.10 (95% CI: −8.56, 8.76) and in the Beck Anxiety Inventory-Youth (BAI-Y) 2.42 (95% CI: −5.27, 10.12) in favour of TAU. However, there was a clear trend in favour of CBT in depressed participants with or without anxiety. LimitationsThe intervention targeted both depression and anxiety following a transdiagnostic model. This may have impacted the anticipated size of change in the primary outcome. The precise impact of cognitive limitations on ability to use therapy effectively is not fully understood. ConclusionsThis study demonstrates that it is feasible to carry out a pragmatic randomised controlled trial of M-iCBT for people with mild to moderate intellectual disability. However, uncertainties about its clinical and cost effectiveness can only be fully answered by further examination of its superiority against other treatments.

Psychometric evaluation of a Dutch version of the Mini PAS‐ADD for assessing psychiatric disorders in adults with different levels of intellectual disability

People with intellectual disabilities (ID) have an increased vulnerability to develop psychiatric problems. Moreover, the early recognition and the accurate diagnosis of psychiatric disorders in the population of persons with ID are challenging. A Dutch version of the Mini PAS-ADD, which is a screening instrument for identification of mental health problems in people with ID, was evaluated in terms of internal consistency, interinformant reliability, item grouping and criterion validity based on a large-scale random sample (n = 377) and a clinical sample (n = 99) of adults with ID. The Dutch version of the Mini PAS-ADD showed moderate internal consistency, and moderate concordance among informants. Both aspects of the reliability were comparable for different levels of ID. A factor analysis largely confirmed the scale structure. Concurrent validity with the Reiss Screen for Maladaptive Behavior was high for the Depression, Psychosis and Autism scale. The outcome of the criterion-validity analysis indicated high specificity. The sensitivity for specific psychiatric disorders by the corresponding scales was moderate, but the general sensitivity for the presence of psychopathology on the basis of any of the scales was satisfying. The present research reconfirmed the use of the Mini PAS-ADD as a primary screening device for the identification of mental health problems among people with ID.

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

IntroductionPrevious research has suggested substantial variation in prevalence rates of psychiatric disorders in individuals with intellectual disability and also differential patterns of associations between psychiatric disorders and challenging behaviours in people with intellectual disabilities. The aim of this study was to determine with the prevalence rate of specific psychiatric disorders and challenging behaviours and the relationship between them in a community based sample of individuals with intellectual disability.MethodA community based sample of 159 adults primarily with mild and moderate intellectual disabilities was surveyed for the presence of psychiatric disorders and challenging behaviour using the Behaviour Problem Inventory (BPI) and the Psychiatric Assessment Schedule (PAS-ADD). Individuals who met threshold on the PAS-ADD were subsequently evaluated using the Mini- PAS-ADD Interview.ResultsScreening for psychiatric disorder using the PAS-ADD indicated a prevalence rate of 10%. There was a large discrepancy between the overall rate of challenging behaviour (45%) and the rate of psychiatric disorders identified by the Mini PAS-ADD Interview (6%). However, the rate of more severe behaviour problems (8%) was closer to the rate of psychiatric disorders (6%). Thirty one percent of people with severe challenging behaviours also were rated as having psychiatric disorders and odd ratio analysis indicates that individuals with severe challenging behaviour are substantially more likely to present with a psychiatric disorder. However, there does not appear to be a relationship between different topographies of challenging behaviour and discrete diagnostic categories of psychiatric disorder.

Prevalence of Psychiatric Diagnoses and Challenging Behaviors in a Community-Based Population of Adults With Intellectual Disability

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.

Screening Individuals With Intellectual Disability for Psychiatric Disorders: Comparison of Four Measures

Convergences and divergences between four of the most commonly used checklists for psychiatric disorders (the Reiss Screen, The Mini PAS-ADD, the DASH-II, and the ADD) were examined. We screened 181 individuals with intellectual disability for psychiatric disorders with the four checklists and compared the results on the checklists. The concordance of the overall scores on the four checklists was high; but the agreement on specific psychiatric disorders was limited. The results indicate that the checklists are useful as general indicators of psychiatric disorders, but are of less value for specifying the nature of the disorders in individuals with intellectual disability.

Psychiatric disorders and behavior problems in people with intellectual disability

The relationship between behavior problems and psychiatric disorders in individuals with intellectual disability is still unresolved. The present study compares the prevalence and pattern of psychiatric disorders in individuals with intellectual disability who were assessed on the ABC to have moderate and severe behavior problems and a matched group of individuals without such problems. Both groups were living in community settings and had their intellectual disability varied from mild to profound degrees. The participants were screened for psychiatric disorders using four different instruments; the Reiss Screen, the Mini PAS-ADD, the DASH-II and the ADD. The group with moderate and severe behavior problems showed significantly more symptoms of psychiatric disorders than the group without such problems when items related to behavior disorders were omitted, and the majority of the participants with behavior problems had symptoms of the main psychiatric disorders. The participants with mild and moderate intellectual disability showed more symptoms of psychosis and depression than the participants with severe and profound intellectual disability. There were no direct associations between individual behavior problems and psychiatric disorders, but the group with mild/moderate intellectual disability showed a somewhat different pattern of associations than the group with severe/profound intellectual disability. Depression was associated with screaming and aggression in the participants with severe and profound intellectual disability, and with self-injury in the participants with mild and moderate intellectual disability. The finding that the majority of the participants with behavior problems showed symptoms of psychiatric disorders suggests that many behavior problems may be (unconventional) symptoms of psychiatric disorders or reflect a difficult life situation caused by a psychiatric disorders, or that a difficult life situation may contribute to both psychiatric disorders and behavior problems in individuals with intellectual disability.

The association between severity of intellectual disability and psychiatric symptomatology.

Mental illness is more prevalent in people with intellectual disabilities (ID) than in the normal population. The association between mental illness and severity of ID is also of importance in the understanding and treatment of maladaptive and challenging behaviours. The aim of this study was to investigate the association between severity of ID and prevalence of mental illness. Using the Mini PAS-ADD, an instrument designed to identify psychiatric symptoms in people with ID, informants were interviewed about the presence of symptoms in 96 participants with moderate, severe and profound ID, and asked about the use of psychotropic medication. Mental illness, particularly anxiety, depression and psychosis, was far more prevalent in participants with moderate ID than in people with severe and profound ID. The use of psychotropic medication was not significantly different between the groups. The prevalence of psychiatric illness decreases with severity of ID. The usefulness of psychiatric illness models, in explaining maladaptive and challenging behaviours, also decreases with severity of ID. Drug treatment may become more complicated, and behavioural and environmental interventions may become relatively more important, as severity of ID increases.

Mental disorder in adults with intellectual disability. 1: Prevalence of functional psychiatric illness among a community-based population aged between 16 and 64 years.

The reported prevalence of psychiatric illness among adults with intellectual disability (ID) varies widely between 10 and 39%; however, many methodological problems exist. The aims of the present study were to establish the prevalence of functional psychiatric illness among adults with ID who live in the community, in order to compare the overall rate and types of psychiatric illness between the population with ID and the general population without ID, and to establish the risk factors associated with psychiatric illness in adults with ID. The study was done in two stages. In the first part, a trained psychiatrist interviewed 101 randomly selected adults with ID and their carers using the Mini Psychiatric Assessment Schedule for adults with Developmental Disability (Mini PAS-ADD) to screen for psychiatric caseness. Out of these 101 adults, 90 had sufficient communicative abilities that made the administration of Mini PAS-ADD possible. A second trained psychiatrist interviewed 19 out of the 20 adults who were diagnosed as psychiatric cases according to the initial Mini PAS-ADD interview. This psychiatrist interviewed patients and their carers in line with the full PAS-ADD interview. The second psychiatrist was blind to the initial diagnoses made according to the Mini PAS-ADD questionnaire. A final psychiatric diagnosis was made according to International Classification of Diseases - 10th Revision (ICD-10) criteria. Some 14.4% (95% confidence interval = 7.4-21.4%) of the cohort had a psychiatric diagnosis according to ICD-10 criteria: 4.4% had schizophrenia, 2.2% depressive disorder, 2.2% generalized anxiety disorder, 4.4% phobic disorder and 1% delusional disorder. The overall rate of functional psychiatric illness (point prevalence) was similar to that found in the general population (16%). However, the rates of schizophrenic illness and phobic disorder were significantly higher in the study cohort compared with those in the general population (0.4% and 1.1%, respectively). Increasing age and the presence of physical disability were significantly associated with the occurrence of psychiatric illness. Out of the 11 remaining adults with severe ID, two (18%) had a diagnosis of a psychiatric illness (one mania and one anxiety disorder) according to the Diagnostic Assessment for the Severely Handicapped (DASH) questionnaire.

Staff Knowledge about Symptoms of Mental Health Problems in People with Learning Disabilities

The present study examined the knowledge of 116 health and social care staff working in learning disability services about the symptoms of mental health problems in this client group, using the Mini PAS-ADD as a comparator. Seventy-one percent of participants currently supported a client with mental health problems and learning disabilities; however, only 47 percent had received any training in this area. The health staff scored significantly higher than the residential and day care staff in relation to knowledge of symptoms for anxiety, depression and psychosis, but overall levels were low for all three groups. Those individuals who had received training in the area had significantly greater knowledge about symptoms, and higher confidence levels in supporting this client group, than those who had not. The staff also reported a range of behavioural symptoms, which were not included in the Mini PAS-ADD. Implications of the study are discussed.

Reliability and validity of the Mini PAS-ADD for assessing psychiatric disorders in adults with intellectual disability.

The Mini PAS-ADD is an assessment schedule for psychiatric disorders in people with an intellectual disability. It is designed to provide a link between the mental health expertise of psychiatrists and psychologists, and the detailed knowledge of individual service users possessed by support staff. In broad terms, the aim of the Mini PAS-ADD is to enable non-psychiatrists accurately to recognize clinically significant psychiatric disorders in the people who they care for, so that they can make informed referral decisions. The instrument comprises 86 psychiatric symptoms and generates a series of subscores on: depression, anxiety and phobias, mania, obsessive-compulsive disorder, psychosis, unspecified disorder (including dementia), and pervasive developmental disorder (autism). The present paper reports the results of a study investigating internal consistency, inter-rater agreement and validity in relation to clinical opinion, using a sample of 68 people with intellectual disability who were in contact with psychiatric services. In terms of the instrument fulfilling its main intended function, i.e. accurate case recognition, the crucial question was whether the support workers, with their lesser knowledge of psychopathology, were also able to correctly identify cases identified by expert clinicians. The validity results in this respect (81% agreement on case recognition) were sufficiently good that it is to be anticipated that the Mini PAS-ADD should have a significant impact on the identification of psychiatric disorders in the community of people with intellectual disability.