Knowledge Database

• Topic of lecture: Who are These People? A Profile of Patients and their Families Treated by the Schneider Outpatient Unit for Developmental Psychiatry

• Lecturer name: Mike Stawski Schneider Children's Medical Center, Israel

• The lecture was given at the Beit Issie Shapiro’s 6th International Conference on Disabilities - Israel

• Year: 2015 Length of lecture: 12:27 minutes

WHO ARE THESE PEOPLE? A PROFILE OF PATIENTS AND THEIR FAMILIES

TREATED BY THE SCHNEIDER OUTPATIENT UNIT FOR DEVELOPMENTAL PSYCHIATRY 

Presentation to BIS Conference, Tel Aviv, July 2015

Dr. Mike Stawski, M.B., B.S., MRCPsychThe Outpatient Unit for Neurodevelopmental Psychiatry, Dept. of Psychological Medicine, Schneider Children’s Medical Center in Israel

The problem Available solutions

◦Non-specialist◦Specialist

A profile of OUDP patients Discussion, feedback

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Today’s menu

◦ In European countries 2% mild learning disability, 0.35% severe learning disability (Roy et al., 2000)

◦ In Israel about 0.4 % of the general population are formally (legally) diagnosed

◦ Point prevalence of psychiatric disturbance is from 10% to upwards of 60% (King et al., 1997)

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Intellectual disability: Prevalence

Generic psychiatry departments Schneider Developmental Psychiatry Outpatient Unit Beit Issie Shapiro Dual Diagnosis Unit

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Agencies working with people with ID who have mental health

problems

Werner S., Stawski, M., Y. Polakiewicz, Y. & Levav, I. (2013). Psychiatrists’ knowledge, training and attitudes regarding the care of individuals with intellectual disability, Journal of Intellectual Disability Research, 57(8),  774–782

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How well does the current system work?

Conclusions Our findings suggest inadequacy of existing services. The problem is probably with the basic model, rather just its local implementation. There are various options for improving services.

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For children/adolescents with intellectual disability and additional psychopathology

Established in 2001 Psychiatrists and paramedical staff

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The Schneider Outpatient Unit for Developmental Psychiatry

To obtain a clinical and demographic profile of the patients and their families

To examine the effectiveness of treatment To test a number of hypotheses regarding

factors related to the severity of behavioural/psychiatric disturbance

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Research aims

1.The OUDP Demographic Questionnaire2.The Aberrant Behaviour Checklist (ABC)3.The Family Assessment Device (FAD) General Functioning subscale4.The 12- item General Health Questionnaire (GHQ-12)5.Vineland Adaptive Behavior Scales, Second Edition (Vineland-II)

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Measures

Assessments were performed zero (T1), four (T2), eight (T3), and twelve months (T4) after intake

Vineland Questionnaire only at intake Satisfaction Questionnaire only at twelve

months Other measures at every time point

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Methodology

“Behavioural problems”/ “violence” - 34% “Hyperactivity” - 24% “Social withdrawal”- 8% “Obsessive-compulsive behaviour” - 6% Various other complaints - 28%

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Presenting complaint

High rate of physical disability, often more than one

CP / other motor impairment - 44% Epilepsy - 33% Visual impairment - 22% Other physical disability - 18%

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Physical disability

Prior psychotropic medication - 78% Types:

◦Antipsychotics - 33%◦Stimulants - 22%◦Other - 22

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Prior psychotropic medication

None - 74% Psychotherapy - 12% Other kind of non-medical treatment - 14% Behavioural therapy - none

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Prior non-medical treatment

For those patients for whom level of ID could be ascertained:

Mild - 51% Moderate - 28% Severe - 16% Profound - 5%

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Level of ID

PDD - 33% Externalizing disorders (hyperkinetic disorder or

conduct disorder) – 30% Internalizing disorders (OCD, other anxiety

disorders, selective mutism, depressive disorder, PTSD) - 18%

Various other - 18% No disturbance - 3%

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Principal psychiatric ICD-10 diagnoses at intake

ABC Irritability scale score - 17.6, (SD 11.5 ), i.e. 1 SD over the mean of a “normative” sample, i.e. “significant behavioural problems”

ABC stereotypy scale score - 6.0, (SD 7.2 ) i.e.

1 SD over the mean of a “normative” sample, i.e. “significant behavioural problems”

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Behavioural problems

Antipsychotics - 20% of cases Stimulants - 25% Other medication - 18%; No medication - 38%

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Treatment recommendations:Medical

Individual psychotherapy – 10% Family therapy / work with parents - 56% Behavioural therapy - 34% Other non-medical recommendations - 5% None - 21%

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Treatment recommendations:

Non-medical

Level of adaptive behavior relative to age (assessed by Vineland Adaptive Behavior Scales) would be negatively correlated with behavioral problems (assessed by ABC scale scores)

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Relative level of adaptive behavior vs. behavioural

problems-Hypothesis

Vineland score correlated negatively with ◦ABC irritability scale score (Spearman's rho= -.35,

p=.025)◦ ABC lethargy scale score (Spearman's rho= -.40,

p=.009) ◦ABC stereotypy scale score (Spearman's rho=

-.41, p=.007)

i.e., the lower the relative adaptive behaviour level of child, the higher the irritability, lethargy and stereotypy scale scores

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Relative level of adaptive behavior vs. behavioral

indicators - Findings

Level of adaptive behavior relative to age (assessed by the Vineland Adaptive Behavior Scales) would correlate negatively with level of parental disturbance (assessed by GHQ-12)

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Relative level of adaptive behavior vs. level of parental disturbance -

Hypothesis

Relative level of adaptive behaviour was significantly correlated with mothers’ mental health problems (Spearman's rho = -.35, p

= .048), but not at all with fathers’ (Spearman's rho= -.07).

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Relative level of adaptive behavior vs. level of parental

disturbance - Findings

Over time, we would see clinical improvement, i.e., a reduction in behavioral disturbance (assessed by ABC scale scores)

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Clinical improvement - Hypothesis

Significant improvement on ABC Irritability scale score on repeated measures ANOVA (F = 46.4, p = 0.025)

Trend towards significance in improvement on:◦ ABC Stereotypy scale score (F = 2.62, p = 0.06) ◦ Hyperactivity scale score (F = 1.70, p = 0.18)

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Clinical improvement- Findings

Family disturbance (assessed by FAD General Functioning subscale) would at different time points correlate positively with parental disturbance (assessed by GHQ-12)

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Family disturbance vs. parental disturbance -

Hypothesis

FAD General Functioning subscale correlated positively with maternal GHQ-12 at a significant or highly significant level at all time points except the first (at which a positive correlation trending towards significance was found)

No such correlation was found for fathers

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Family disturbance vs. parental disturbance -

Findings

79% of respondents were satisfied / very satisfied with their treatment.

Parents’ feelings of having been understood by their therapists were highly significantly correlated with maternal mental health problems (GHQ-12)!!

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Parental satisfaction at ending

More single - parent families High rate of physical disability, often multiple “Behavioural problems” / “violence” are the

commonest complaints Prior treatment with psychotropics is frequent Any other prior treatment is infrequent 2/3 of diagnoses are accounted for by PDD

and externalizing disorders

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Summary of salient findings-I

Main problems are in the realms of irritability and stereotypy

Families functioning in the “stressed“ range We used less antipsychotic, more stimulants,

more non-medical interventions

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Summary of salient findings-II

The lower the relative adaptive behaviour level of child, the more irritability, lethargy and stereotypy-type problems

Relative level of adaptive behaviour as well as problems in the realms of irritability, stereotypy and hyperactivity were correlated with mothers’ mental health problems

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Summary of salient findings-III

Perceived family functioning is positively correlated with maternal but not paternal mental health

Significant improvement in area of irritability over one year

Reasonable satisfaction rating

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Summary of salient findings-IV

Clinical sample Attrition rate / self-selection Non- objective measures

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Limitations

This is generally a sicker-than-usual population

This specialist psychiatric clinic uses less psychotropic medications, less antipsychotics, more non-medical modes of intervention

Keep an eye out for parental mental health, gaps between parents, and family functioning

We need to find ways of achieving improvement in areas other than just irritability

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Tentative conclusions

Dual diagnosis is a common and poorly treated problem

The nonspecialist psychiatrist needs to keep in mind non-psychotropic modes of treatment

Specialist care can be effective and is appreciated

We need to keep in mind patients' physical and parents’ mental health, and family functioning

Be nice to dogs and little children

Summary

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THAT’S ALL, FOLKS!