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Psychiatric disorders in children with

intellectual disability
TERHI KOSKENTAUSTA, MATTI IIVANAINEN, FREDRIK ALMQVIST

Koskentausta T, Iivanainen M, Almqvist F. Psychiatric disorders in children with intellectual


disability. Nord J Psychiatry 2002;56:126 131. Oslo. ISSN 0803-9488 .
We investigated psychiatric disorders in intellectually disabled children; the prevalence rate
and types of psychiatric disorders, and the association of psychiatric disorders with sex,
residence type, level of disability, and epilepsy were examined. The population comprised 155
intellectually disabled children. Medical information was obtained from case les, which
indicated that a psychiatric disorder had previously been diagnosed for 11% of patients. A
careful re-examination of the case les revealed a psychiatric disorder for 33%. The criteria
of a psychiatric ICD-10 diagnosis were ful lled by 23%, and a further 10% had an unspeci ed mental disorder. The most common diagnoses were pervasive developmental disorders
and hyperkinetic disorders. The former were less common among children with mild intellectual disability. In conclusion, about one-third of children with intellectual disability have a
psychiatric disorder which needs to be taken into account in treatment.
Children, Epidemiology, Intellectual disability, Mental disorders, Psychopathology.
Fredrik Almqvist, Professor, Department of Child Psychiatry, Hospital for Children and
Adolescents, University of Helsinki, Lastenlinnantie 2, FI-00250 Helsinki, Finland. E-mail:
fredrik.almqvist@hus. ; Accepted: 4 June 2001.

ndividuals with intellectual disability are vulnerable


to behavioural problems and psychiatric disorders.
These problems result in part from intellectual disability itself sub-average intellectual functioning with
tested IQ B 70 and associated de cits in social-adaptive
behaviour which limits coping skills in daily life. In
addition, several other factors may contribute to psychopathology in intellectually disabled children.
Dykens (1) has recently discussed factors mediating
the expression of psychopathology in intellectually disabled children, including psychological, familial and
social issues, as well as biological vulnerabilities such as
genetic status. According to Dykens, psychological factors include poor self-image, repeated experiences of
failure, learned helplessness and certain personality features such as outer-directed orientation whereby children look to others for solutions to dif cult problems,
aberrant social styles and low expectancy or enjoyment
of success. Dykens speculates that the intellectually
disabled childs genetic predisposition to certain types
of psychopathologie s sets in motion a series of parental
responses that may, in turn, ameliorate or worsen these
problems. In addition, environmental factors, such as
marital discord or parental psychiatric disorder, may be
triggers for child psychopathology . Social factors described by Dykens include exploitation, physical and
sexual abuse, disability as a social stigma, compromised
social intelligence and peer rejection. Biological factors

126

consist of seizures, self-injurious behaviours, and sensory and motor impairments. Moreover, speci c aetiologies, such as foetal alcohol, fragile X, Williams,
Prader-Willi, Smith-Magenis, Down and 5p-syndromes,
have been linked with certain behavioural and psychiatric problems.
Estimates about the prevalence of psychiatric disorders among adults with intellectual disability are highly
variable, ranging from about 10% to 70% (2, 3). The
lowest rates have generally been obtained in large population surveys of case les, whereas higher rates have
been reported in surveys in which the psychiatric diagnosis has been identi ed using behaviour rating scales
or structured interviews (3). The prevalence of psychiatric disorders among children and adolescents with
intellectual disability has also varied between 10% and
60% (4 12).
Types of psychiatric disorders have been investigated
in a few studies. Koller et al. (7) found that 29% of
children with intellectual disability had emotional disturbance, 12% hyperactive behaviour, 33% aggressive
conduct disorder and 27% antisocial behaviour. Gillberg et al. (6) reported the following frequencies of
psychiatric disorders in children with mild (IQ 50 70)
versus severe (IQ B 50) mental retardation: depressive
syndrome: 4% vs. 1.5%, emotional disorder: 10% vs.
4.5%, conduct disorder: 12% vs. 4.5%, psychosomatic
disorder: 4% vs. 3%, hyperactive disorder: 11% vs. 0%,
2002 Taylor & Francis

PSYCHIATRIC

psychotic behaviour: 14% vs. 50% and other disorders:


2% vs. 0%. Jacobson (13) found that 1.83% of mentally
retarded children and adolescents had non-psychotic
organic brain syndrome, 6.68% psychosis, 1.32% neurosis, 5.06% personality disorder and 10.78% childhood
behaviour disorder. In the study of Steffenburg et al.
(11), 27% of children with mental retardation and
active epilepsy had autistic disorder and 11% had an
autistic-like condition. In Strmme and Diseth (12),
16% had hyperkinesia, 8% pervasive developmental disorder, 6% behavioural or emotional disorder, 3% conduct disorder, 3% anxiety:phobic:obsessive-compulsive
disorder and 1% tics.
Psychiatric disorders have been reported to be more
frequent among intellectually disabled males than females (6, 12 14). However, Einfeld & Tonge (5) concluded that sex does not signi cantly affect the
prevalence of psychiatric disorders. They found that the
prevalence was lower among subjects with profound
intellectual disability, whereas Gillberg et al. (6) and
Strmme & Diseth (12) reported a higher prevalence
among the severely (IQ B50) mentally retarded than
among the mildly (IQ 50 70) retarded. In Gillberg et
al. (6), autistic-like psychotic behaviour was common in
the severely retarded, and the majority of children with
other psychiatric diagnoses were mildly retarded. Einfeld & Tonge (5) and Hardan & Sahl (14) have also
reported autistic behaviour to be more prominent in
persons with severe intellectual disability. Einfeld &
Tonge (5) found that disruptive and antisocial behaviours were more common in the mild intellectual
disability group. The prevalence of psychiatric disorders
has been reported to be high among children with
severe mental retardation and epilepsy (6).
Assessment of psychiatric disorders in persons with
intellectual disability is often problematic, being complicated by, for example, communication disturbances
and other handicaps. Reiss et al. (15) have introduced
the concept of diagnostic overshadowing, referring to
the tendency of diagnosticians to attribute abnormal
behaviour to mental retardation and to overlook co-existent psychopathology . This leads to underdiagnosis
and undertreatment of psychiatric disorders.
The aim of this study was to investigate psychiatric
disorders according to case les in a population-base d
series of children with intellectual disability; the prevalence rate and types of psychiatric disorders, and the
association of psychiatric disorders with sex, residence
type, level of disability and epilepsy were examined.

Materials and Methods

The subjects were intellectually disabled children who


lived in Southern Hame, the catchment area of the
Paajarvi Rehabilitation Centre, Finland. Paajarvi Rehabilitation Centre provides services for intellectually
disabled persons residing in its catchment area, which is
NORD J PSYCHIATRY VOL 56 NO 2 2002

DISORDERS IN CHILDREN

one of the 18 special care districts in Finland. The area


includes 25 municipalities. Five of these are towns
containing from 16,000 to 95,000 inhabitants. The others are smaller rural municipalities. The total population base of this area in 1995 was roughly 337,000
inhabitants, approximately 28,000 of whom were born
between 1982 and 1988.
The cases were sought and identi ed from the patient
register of the Paajarvi Rehabilitation Centre and other
regional hospitals and special schools. The study population comprised all intellectually disabled children
born between 1982 and 1988, and residing in the district
in 1995. The number of identi ed cases was 155, corresponding to 0.55% of the age group in the area.
The following variables were collected from the case
les: sex, age, residence type, results of psychological
examination (IQ) and presence of epilepsy. At the time
of the study, the children were aged 6 13 years (mean
age 9.7 years). Of these, 92 were males and 63 females.
Further population characteristics are presented in
Table 1.
The level of intellectual disability was de ned in
accordance with the ICD-10 criteria by intelligence
quotient (IQ) as follows: IQ 50 69 as mild, IQ 35 49
as moderate, IQ 20 34 as severe and IQ B 20 as profound intellectual disability.
Information on the level of intellectual disability was
obtained from case les. Psychological examinations
had previously been done for 139 children, and the tests
most often used were WISC-R (Wechsler Intelligence
Scales for Children Revised), Merrill-Palmer Scale of
Mental Tests, Leiter International Performance Scale
and Vineland Social Maturity Scale.
Results of cognitive assessments were not available
for 16 children. All of these children were presumably
intellectually disabled. Most of them had a severe motor disability due to cerebral palsy or inherited
metabolic disease, and thus could not be tested. Three
children had Down syndrome. All information in the
case les (e.g. motor, communication and self-help
skills) was used to evaluate the level at which they
operated. The evaluated level of intellectual disability
was mild for 3, moderate for 2, severe for 2 and
profound for 9 children.
Information on psychiatric diagnoses and symptoms
was obtained from the patient register and each case
le. This information was analysed by the rst author.
Previously made psychiatric diagnoses, based on DSMIII R criteria, were recorded and re-evaluated according
to information in the case les. Some of the case les of
children with no previous psychiatric diagnoses included information on the basis of which a psychiatric
disorder was determined. The psychiatric diagnoses
were assessed according to ICD-10 criteria (diagnostic
criteria for research).
Statistical comparison was based on Fishers exact
tests and the Cochran-Armitage trend test.

127

T. KOSKENTAUSTA

ET AL .

Table 1. Characteristics of the study population (N 155).


Psychiatrically non-disturbed
children (n 104)
Characteristic
Sex
Male
Female
Total
Age (years)
6
7
8
9
10
11
12
13
Total
Residence type
Parents home
Specialized family care
Nursing home or institution
Total
Level of intellectual disability
Mild
Moderate
Severe
Profound
Total
Epilepsy
No
Yes
Total

Psychiatrically disturbed
children (n 51)

Total no. of children


(n 155)

59
45
104

57
43
100

33
18
51

65
35
100

92
63
155

59
41
100

13
10
12
14
13
24
12
6
104

13
10
12
13
13
23
12
6
102*

4
4
3
8
10
6
11
5
51

8
8
6
16
20
12
22
10
102*

17
14
15
22
23
30
23
11
155

11
9
10
14
15
19
15
7
100

94
5
5
104

90
5
5
100

47
3
1
51

92
6
2
100

141
8
6
155

91
5
4
100

63
15
11
15
104

61
14
11
14
100

24
15
7
5
51

47
29
14
10
100

87
30
18
20
155

56
19
12
13
100

68
36
104

65
35
100

32
19
51

63
37
100

100
55
155

65
35
100

* Percentages not equal to 100 due to rounding-up.

Results

A psychiatric disorder had originally been diagnosed


for 17 (11%) out of 155 children. When the case les
were re-examined carefully, the total number of children with a psychiatric disorder increased to 51 (33%).
Of these, 35 (23%) children ful lled the ICD-10 criteria for a speci ed psychiatric diagnosis. For the remaining 16 (10%) children, numerous mental or
behavioural symptoms were reported in the les, but
information was insuf ciently detailed to ful l all
criteria demanded for an ICD-10 diagnosis. These disorders were classi ed as unspeci ed mental disorders
(F99).
Most of the children with unspeci ed mental disorder (12:16) had several symptoms of hyperkinetic disorders, including attention de cit, hyperactivity and
impulsiveness, but the symptoms recorded in the case
le did not fully meet the diagnostic criteria of the
disorder. Four children had symptoms, such as aggression, depression, poor attention or self-injurious be-

128

haviour, on the basis of which no speci c diagnosis


could be established. Of the 16 children, 9 were mildly,
5 moderately and 2 severely intellectually disabled.
The 51 psychiatrically disordered children included
all 17 cases with a previous psychiatric diagnosis on
le. Initial psychiatric diagnoses and those based on
re-examination of les are presented in Table 2.
The most common diagnoses were pervasive developmental disorders, including childhood autism and
atypical autism (20 patients), and hyperkinetic disorders (10 patients). The prevalence of psychiatric disorders was higher among males (36%) than among
females (29%), but the difference was statistically insigni cant. The overall spectrum of psychiatric disorders was approximately the same for both sexes.
Pervasive developmental disorders and hyperkinetic
disorders were slightly more common in boys than in
girls (14% vs. 11% and 9% vs. 3%, respectively). Mean
age was 10.0 years in the psychiatrically disturbed
group and 9.5 years in the non-disturbed group.
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DISORDERS IN CHILDREN

Table 2. Number of children with psychiatric diagnoses in case les (DSM-III R) and with new ICD-10 diagnoses based on
re-examination of les.
Diagnosis based on re-examination of the case le
F331

Diagnosis in the case le


Autism (299)
Conduct disorder (312)
Attention-de cit disorder (314)
Speci c developmental disorder (315)
No psychiatric diagnosis
Total

F502

F843

F904

F91 5

F936

F997

Total

16
16

8
1
6
2
34
51

8
1

1
1

1
1

11
20

6
1
3
10

Recurrent depressive disorder. 2Eating disorders. 3Pervasive developmental disorders.


Emotional disorders with onset speci c to childhood. 7Unspeci ed mental disorder.

1
1
4

1
1
2

Hyperkinetic disorders.

Conduct disorders.

The prevalence of psychiatric disorders was 33% for


children living with their parents, 38% for those living
in specialized family care and 17% for those living in a
nursing home or an institution. Of the children living in
specialized family care, two had a pervasive developmental disorder and one an unspeci ed mental disorder. Of those living in a nursing home or an institution,
one had a pervasive developmental disorder.
Psychiatric disorders were most frequent among children with moderate intellectual disability and least
frequent among those with profound intellectual
disability, but the difference was not statistically signi cant (Table 3). Pervasive developmental disorders were
less common among children with mild intellectual
disability than in the rest of the series (6% vs. 22%,
P B 0.01). No statistically signi cant associations were
found between the other psychiatric diagnoses and the
level of intellectual disability.
Among children with or without epilepsy, the prevalence of psychiatric disorders was not signi cantly
different.
Excluding the 16 children with no psychological tests
did not have a marked impact on results. The total
frequency of psychiatric disorders was 37% compared
with the former rate of 33%. The frequency and distribution of psychiatric disorders according to sex, residence type or the presence of epilepsy were also not
signi cantly different from the results reported above.
The distribution of psychiatric disorders according to
Table 3. Number and proportion of children with psychiatric
disorder according to level of intellectual disability (n 51).

Intellectual
disability
Mild
Moderate
Severe
Profound

Total no.
of children
(n )
87
30
18
20

NORD J PSYCHIATRY VOL 56 NO 2 2002

Children with
psychiatric
disorder (n )
24
15
7
5

%
28
50
39
25

the level of intellectual disability was slightly different;


the frequency of psychiatric diagnoses was lower
among the mildly (29%) than the moderately
(54%), severely (44%) or profoundly (45%) disabled
children.

Discussion

Our ndings indicate that psychiatric disorders among


children with intellectual disability are fairly common,
yet a considerable number of these disorders fail to be
diagnosed.
Of the 51 psychiatric diagnoses assessed, 34 had not
been previously recorded in case les. Even though
psychiatric symptoms had been recorded, the diagnosis
might have been lacking due to shortcomings in the
knowledge of psychiatric disorders and in adequate
tools for their establishment. In some cases, while the
disorder may have been noticed, it had not been documented because of no clear ideas about how the diagnosis would in uence treatment.
The total frequency of psychiatric disorders, including both the children with a psychiatric ICD-10 diagnosis and those with an unspeci ed mental disorder, is
smaller than the frequencies reported previously (4 7)
but rather close to that in the recently published Nordic
studies (8, 12). The gure in our study is a minimum
frequency because data were based solely on case les.
Psychiatric interviews and observations would probably
have revealed a higher frequency of psychiatric
disorders.
The spectrum of psychiatric disorders, with the
highest frequency occurring in pervasive developmental
disorders and hyperkinetic disorders, was similar to
that in the Norwegian study (12) but differed from
those in the studies of Koller et al. (7), Gillberg et al.
(6) and Jacobson (13). The classi cation of behaviour
disturbances in Koller et al. (7) was based on psychiatric symptoms (emotional disturbance, hyperactive behaviour, aggressive conduct disorder and antisocial
behaviour), and actual psychiatric diagnoses were not
used.

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T. KOSKENTAUSTA

ET AL .

Compared with our study, depressive syndromes,


emotional disorders, conduct disorders and psychosomatic disorders were more frequent in Gillberg et al.
(6). This may be explained by the difference in study
methods; Gillberg et al. was based on psychiatric diagnostic assessments, and the present study on case les.
Symptoms of depression or emotional disorder, for
instance, may fail to be recorded in case les because
they are more likely to go unrecognized than those of,
for example, pervasive developmental disorder or hyperkinetic disorder.
Conduct disorders and personality disorders were less
frequent, and autistic disorders and hyperkinetic disorders more frequent, than in Jacobson (13). However,
Jacobsons study included adolescents aged up to 21
years, whereas our children were 6 13 years. This may
explain the greater proportion of conduct disorders and
personality disorders in Jacobsons study.
In Strmme & Diseth (12), the frequency of hyperkinesia was higher (16% vs. 6%) and that of pervasive
developmental disorders lower (8% vs. 20%) than in the
present study. If the 12 children in our study with
several symptoms of hyperkinetic disorders, but
classi ed as having unspeci ed mental disorder (F99)
because of insuf cient information, were presumed to
have hyperkinetic disorder, the prevalence of hyperkinetic disorder would be 14%.
The nding that the prevalence of psychiatric disorders was not statistically different among males and
females is consistent with the results of Einfeld &
Tonge (5). The frequency of psychiatric disorders being
higher for children living with their parents than for
those living in specialized family care, nursing homes or
institutions (33% vs. 29%) means that psychiatric disorders do not usually result in institutionalization , as has
been suggested for adult persons with intellectual
disability.
The low frequency of psychiatric disorders among
children with profound intellectual disability is in accord with the nding of Einfeld & Tonge (5), which is
one of the few published reports on the association
between level of intellectual disability and psychiatric
disorders. The low frequency may be partly due to
psychiatric evaluation among non-verbal persons with
profound intellectual disability and additional handicaps being dif cult, and therefore it is probably an
underestimation. The nding that pervasive developmental disorders were most frequent among children
with severe intellectual disability concurs with previous
studies (5, 6, 14).
The observation that the prevalence of psychiatric
disorders was not statistically different among children
with and without epilepsy is interesting. Gillberg et al.
(6) suggested that epilepsy correlates to a high degree
with psychiatric disorders. The population investigated
by Gillberg et al. was born between 1966 and 1970, and
examined in 1984. Since that time, however, treatment

130

of epilepsy has improved, which likely has had a positive effect on the mental health of children with
epilepsy and may explain the present nding.
Some limitations are present in the generalizability of
results. Although our study population is fairly representative of the population in Finland, it does not fully
represent the largest urban populations which, however,
comprise a relatively small portion of the Finnish population overall. The Paajarvi Rehabilitation Centre provides services for intellectually disabled persons residing
in its catchment area, and the patient register certainly
includes most of the intellectually disabled people living
in the area. In addition, intellectually disabled children
belonging to the basic sample were located in special
schools and hospitals used by the population. Assessment of psychiatric disorders was based on diagnoses
made by an experienced clinician according to the case
les. As the case les did not include all data needed for
reliable diagnoses, the frequencies found in this study
are still underestimations.
Knowledge about neuropsychiatric disorders has recently increased greatly. This must be kept in mind
when comparing distributions of psychiatric disorders
in different studies carried out at different times. The
comparability of studies is expected to gradually improve as structured assessment methods become
available.
In conclusion, we suggest that at least one-third of
children with intellectual disability have a psychiatric
disorder. Although all symptoms and signs are present,
many of these disorders fail to be diagnosed. This may
be due to inadequate diagnostic skills of professionals
working with intellectually disabled persons, and diagnostic overshadowing. Therefore, doctors working with
children with intellectual disability need further
education.
Most intellectually disabled children live with their
families and many of them are integrated in normal
schools. Emotional and behavioural problems should
be identi ed and treated as early in childhood as possible, because effective treatment and rehabilitation obviously promotes the individual development of the
disabled child, enhances the management of the medical
and intellectual disorder and supports the adoption of a
better social life.
Acknowledgements This study was supported by the Paajarvi Rehabilitation Centre, Lammi, Finland, the Research Foundation for
Child Psychiatry, Finland, and the Rinnekoti Research Foundation,
Espoo, Finland.

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Terhi Koskentausta, M.D., Central Hospital of Pa ija t-Ha me,
Keskussairaalankat u 7, FI-15850 Lahti, Finland.
Matti Iivanainen, M.D., Ph.D., Emeritus Professor of Child
Neurology, Department of Child Neurology, Hospital for Children
and Adolescents, University of Helsinki, Lastenlinnantie 2,
FI-00250 Helsinki, Finland.
Fredrik Almqvist, M.D., Ph.D., Professor of Child Psychiatry,
Department of Child Psychiatry, Hospital for Children and
Adolescents, University of Helsinki, Lastenlinnantie 2 FI-00250
Helsinki, Finland.

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