Friday, October 27, 2006

Cognitive disability and emotional/behavioral problems: a study

This week's JAMA has summative results from a longitudinal study of 578 Australian children and adolescents receiving services for intellectual disability. The study started in 1991 with 5 to 19.5 year olds, so the group is now 20 to 35. The study has produced several similar articles, this is one of the bigger ones.
Einfeld et al. Psychopathology in young people with intellectual disability. JAMA. 2006 Oct 25;296(16):1981-9.:

CONTEXT: Comorbid severe mental health problems complicating intellectual disability are a common and costly public health problem. Although these problems are known to begin in early childhood, little is known of how they evolve over time or whether they continue into adulthood.

... MAIN OUTCOME MEASURES: The Developmental Behaviour Checklist (DBC), a validated measure of psychopathology in young people with intellectual disability, completed by parents or other caregivers. Changes over time in the Total Behaviour Problem Score and 5 subscale scores of the DBC scores were modeled using growth curve analysis. ...

RESULTS: High initial levels of behavioral and emotional disturbance decreased only slowly over time, remaining high into young adulthood, declining by 1.05 per year on the DBC Total Behaviour Problem Score. Overall severity of psychopathology was similar across mild to severe ranges of intellectual disability (with mean Total Behaviour Problem Scores of approximately 44).

Psychopathology decreased more in boys than girls over time (boys starting with scores 2.61 points higher at baseline and ending with scores 2.57 points lower at wave 4), and more so in participants with mild intellectual disability compared with those with severe or profound intellectual disability who diverged from having scores 0.53 points lower at study commencement increasing to a difference of 6.98 points below severely affected children by wave 4. This trend was observed in each of the subscales, except the social-relating disturbance subscale, which increased over time. Prevalence of participants meeting criteria for major psychopathology or definite psychiatric disorder decreased from 41% at wave 1 to 31% at wave 4. Few of the participants (10%) with psychopathology received mental health interventions during the study period.
It's a dense and not very readable article. I couldn't figure out what "normal" children score on their developmental behaviour checklist; there's no control group in this study. They did say a score of 46 was definitely pathologic, so the mean score starting out was just below that. Boys started out a bit worse than girls and ended up slightly better, but you have to squint to see the difference. I doubt it means all that much.

I found the negative spin of the article a bit odd. Did anyone really expect that these behavioral disorders would completely resolve? I thought it was quite encouraging that a quarter of children who started out with a psychicatric disorder ended up without one - despite what appeared to be few mental health interventions. The low rate of intervention is remarkable, I wonder if it's any different in the US?

So the bottom line? Boys seem to improve more, but boys and girls don't end up that differently. Without much mental health intervention there's still very significant improvement over 10 years or so. We might do much better with half-decent pychiatric services, but that is not proven (Personally I would bet on it).

Sunday, October 15, 2006

Medical care of cognitively disabled persons

The American Academy of Family Practice provides public access to their journal articles. They are written for physicians, but they're relatively readable for informed laypersons. Relatives, caretakers and friends of persons with cognitive disabilities may want to review and keep a recent summary of care recommendations: Medical Care of Adults with Mental Retardation - June 15, 2006. It's written specifically for MR, but it's a good source of ideas for the care of all persons with cognitive disability.

I don't haven't seen anything of this sort before. Kudos to AFP for covering the topic. (A later issue also covers care of the homeless, an unfortunately related domain.)

Friday, October 13, 2006

Using electric shocks to manage the behavior of special needs children and adults

New York state's Rotenberg center uses skin shock to change the behavior of special needs children. It sounds pretty much identical to the use of shock collars to change the behaviors of dogs. The head of the school is a disciple of BF Skinner, of operant conditioning (behaviorism fame).

All animals, including humans, respond to a range of rewards and punishments. Punishments are all a form of "pain", whether than pain is psychic (time out, shame, isolation) or physical (spanking, shocking). Humans are not very different from dogs and other mammals; methods used to train dolphins work quite well on husbands.

Remote electric shock, whether used on dogs or humans is another form of punishment. Some animals might "prefer" it to isolation or time out, others would prefer a time out, still others may respond primarily to positive reinforcement and weakly to negative reinforcement.

The problem with shock is the same as with spanking and torture (the most extreme form of negative reinforcement). It is very hard to do it appropriately -- especially on other humans. I suspect it's easier to be calm and measured about using a shock-collar on a dog, but, on the other hand, I've seen very good and loving dog "masters" unintentionally abuse "training" (choke) chains on dogs who are being obtuse. Another problem is that both animals and humans develop tolerance to negative reinforcement. Voltage levels rise. A dog who responded to a simple snap of a training collar needs a much harder snap. Aversive measures must be metered to avoid tolerance.

This is difficult territory. We need wisdom, science, humility and a good measure of dread to walk these roads with relatively safety. Last resorts indeed.