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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 68-73

Clinical profile and maternal depression and anxiety in children and adolescents with intellectual disability: A study from outpatient child psychiatry


1 Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Pediatrics, Government Medical College, Srinagar, Jammu and Kashmir, India

Date of Web Publication18-Nov-2019

Correspondence Address:
Dr. Bilal Ahmad Bhat
Departments of Psychiatry, Government Medical College, Srinagar - 190 003, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ami.ami_25_19

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  Abstract 

Background: With prevalence between 1% and 3%, intellectual disability (ID) not only affects the children and adolescents with this disability but also the caregivers, particularly the mothers. Aims: The aim was to study the clinical profile of children and adolescents with ID along with the prevalence of depressive and anxiety disorders in their mothers. Settings and Design: Cross-sectional descriptive study was conducted in Outpatient child psychiatry clinic. Methodology: Children and adolescents diagnosed with ID by a psychiatrist and clinical psychologist where subjected to a semi-structured questionnaire to record the sociodemographic status, antenatal history, perinatal history, and developmental history, presenting complaints, current behavioral problems, and medical history. Psychiatric comorbidity in the study participants and depression and anxiety disorders in their mothers was also assessed. Results: With the mean age of 8.68 years ± 2.63, majority (81.2%) belonged to the age group of 6–12 years with predominance of boys (60%). Antenatal factors were present in about 18%, whereas perinatal factors were present in about 48%. Delayed developmental history was present in 75%. Psychiatric comorbidity was present in about 32%, whereas current behavioral problems were present in about 47%. Majority (about 71%) had mild ID. Maternal depression and anxiety disorders were present in about 70%. Statistical Analysis: Descriptive analysis was performed with the Statistical Package for the Social Sciences. Conclusion: High rates of antenatal and perinatal factors with a history of developmental delay in a significant number of children and adolescents with ID were found. Mild ID predominated. Behavioral problems, psychiatric comorbidity, and medical comorbidity were frequently observed. Maternal depression and anxiety were also very high.

Keywords: Intellectual disability, maternal, psychiatric comorbidity


How to cite this article:
Bhat BA, Dar SA, Qadir W, Pandith MH. Clinical profile and maternal depression and anxiety in children and adolescents with intellectual disability: A study from outpatient child psychiatry. Acta Med Int 2019;6:68-73

How to cite this URL:
Bhat BA, Dar SA, Qadir W, Pandith MH. Clinical profile and maternal depression and anxiety in children and adolescents with intellectual disability: A study from outpatient child psychiatry. Acta Med Int [serial online] 2019 [cited 2019 Dec 6];6:68-73. Available from: http://www.actamedicainternational.com/text.asp?2019/6/2/68/263625


  Introduction Top


Intellectual disability (ID) or mental retardation is a neurodevelopmental disorder that begins in childhood and characterizes by impaired skills, manifested in the developmental period, which determine the overall level of intelligence, i.e., language, cognitive, social, and motor abilities.”[1] The American Association on Intellectual and Developmental Disabilities defines ID as a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills.[2] The global prevalence of ID has been reported between 1% and 3%. Girimaji and Srinath from Indian perspective reported a prevalence of 2.5% in the general population.[3] The heterogeneous factors related to environment and genetics can lead to ID. Maternal infections in pregnancy such as toxoplasmosis, rubella, cytomegalovirus, syphilis, and HIV; prenatal exposure in early pregnancy to drugs such as thalidomide, phenytoin and warfarin sodium, and radiation; perinatal factors such as prematurity and birth asphyxia; postnatal complications such as sepsis, kernicterus, meningitis, and encephalitis are the main environmental factors among others (poverty, cultural factors, etc.) which can contribute in the development of ID.[4] Among the genetic factors which can lead to ID are chromosomal abnormalities, whether overt (e.g., trisomy 21) or cryptic (e.g., deletions or duplications) and genetic mutations.[4] A study on Psychopathology in Young People With ID concluded that comorbid psychopathology with ID is substantial as well as persistent and needs an effective intervention to increase the quality of life in these individuals.[5] Research has also revealed that psychiatric morbidities such as depression and anxiety are common among mothers of mentally challenged children. Studies from different countries on parents of children with disabilities suggested that 35%–53% of mothers of children with disabilities have the symptoms of depression.[6] The psychological well-being of parents caring individuals with ID is of utmost importance for the overall development of these individuals and thus needs due attention while managing these individuals. Besides the dearth of literature on ID from our part of the world, the multi-ethnic, multi-cultural, and multi-linguistic nature of India makes it a difficult task to draw a generalized conclusion about ID. With these points in mind, in this article, our attempt was to provide a view of the clinical profile of children and adolescents with ID along with the prevalence of anxiety and depression in their mothers.


  Methodology Top


This was a cross-sectional observational descriptive study. The participants of the study were all children and adolescents diagnosed with ID as per the International Statistical Classification of Diseases and Related Health Problems. Tenth Revision (ICD-10) and their mothers attending the outpatient child psychiatry unit of Postgraduate Department of Psychiatry, Government Medical College, Srinagar from March 2017 to March 19, 2018.[1] The study was approved by the Institutional Ethical Committee. Children of both the sexes with the age group of 6–18 years whose parent/guardian gave the consent and who were diagnosed with ID were included in the study. Written informed consent from the parent/guardian was obtained in a simple and easily understandable unambiguous language. A semi-structured questionnaire was instituted to record the sociodemographic status, antenatal history, perinatal history and developmental history, presenting complaints, current behavioral problems, and medical history. ID was diagnosed after a thorough clinical assessment by a psychiatrist and a clinical psychologist and was categorized into mild, moderate, severe, or profound levels as per the ICD-10 classification. The Mini-international neuropsychiatric interview for children and adolescents (MINI-KID) was used in these children and adolescents to document Psychiatric comorbidity.[7] Mothers of these children and adolescents were assessed for anxiety disorders or depression using the MINI-International Neuropsychiatric Interview (MINI(-Plus)).[8] The severity of anxiety and depression was also assessed using the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D 17). Data were analyzed using descriptive statistics and Chi-square test. P <0.05 was considered statistically significant. Statistical analyses were carried out using SPSS version 16 software the Statistical Package for the Social Sciences; IBM Software, NY, USA.


  Results Top


The mean age of these children and adolescents was 8.68 years ± 2.63. Most of them belonged to the age group of 6–12 years (81.2%). Boys (approximate 60%) outnumbered the girls. Most of these children and adolescents were from rural background (approximate 60%) and from nuclear families (approximate 69%) [Table 1].
Table 1: Sociodemographics

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Antenatal factors were present in a significant minority of patients (approximately 18%) with pregnancy-induced hypertension in 7 (7.3%), antepartum hemorrhage in 4 (4.2%), lower respiratory tract infection, and hypothyroidism in 3 (3.1%) each and hyperemesis gravidorum in 2 (2.1%) [Table 2].
Table 2: Antenatal factors

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Perinatal factors were present in approximately 48% with birth asphyxia in 29 (30.2%), neonatal jaundice and low birth weight (LBW) in 6 (6.2%) each, preterm delivery in 3 (3.1%), and meconium aspiration and prolonged labor in 1 (1.0%) each [Table 3].
Table 3: Perinatal factors

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About 75% of our study subjects had a history of delay in developmental milestones with global delay in 54 (56.2%) and speech delay in 18 (18.8%) [Table 4].
Table 4: Developmental delay

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The mild ID was present in 68 (70.8%), whereas moderate ID in 26 (27.1%). Severe and profound were present in 1 (1.0%) each [Table 5].
Table 5: Grades of intelligence quotient

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In presenting complaints, 43 (44.8%) had absent/difficulty in speech, 29 (30.2%) had hyperactivity, 23 (24.0%) had poor school performance and difficulty in learning each, 12 (12.5%) had regression in mile stones, and 6 (6.2%) had self-harm [Table 6].
Table 6: Presenting complaints

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Current behavioral problems were present in 45 (46.9%) with hyperactivity in 33 (34.4%), repetitive behaviors in 14 (14.6%), aggression in 12 (12.5%), and self-harm in 6 (6.2%) [Table 7].
Table 7: Current behavioral problems

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31 (32.3%) were with other psychiatric comorbidity of which pervasive developmental disorders in 15 (15.6%), hyperkinetic disorder in 10 (10.4%), and anxiety disorders in 6 (6.2%) (panic disorder plus separation anxiety disorder in 3, specific phobia in 1, separation anxiety disorder in 1, and specific phobia plus separation anxiety disorder in 1) [Table 8].
Table 8: Psychiatric co-morbidity

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Medical comorbidity was present approximately in 22% with epilepsy in 14 (14.6%), Down's syndrome in 5 (5.2%), congenital heart disease in 1 (1.0%), and hypothyroidism in 1 (1.0%). One child with epilepsy had also galactosemia [Table 9].
Table 9: Medical co-morbidity

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Maternal psychiatric morbidity was found in about 70% with major depressive episode in 51 (53.1%) and anxiety disorders in 20 (20.9%). (Panic disorder in 16, social anxiety disorder in 3 and generalized anxiety disorder in 1). Four patients with MDE had also panic disorder. According to the Hamilton rating scale for depression (HAM-D) scores, 15 (15.6%) had mild depression, 34 (35.4%) had moderate depression, whereas 2 (2.1%) had severe depression. The HAM-A scores showed that 18 (18.8%) had mild anxiety, whereas 2 (2.1%) had moderate anxiety [Table 10].
Table 10: Maternal anxiety and depression

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With the severity of ID, the prevalence of depression and anxiety in mothers increased significantly with 69.1% of mothers in mild ID category, 69.2% in moderate ID category, and 100% in both severe and profound categories were suffering from anxiety and/or depression [Table 11].
Table 11: Relation between grade of intelligence quotient and maternal anxiety and/or depression

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  Discussion Top


The study showed about 80% of children and adolescents with ID in 6–12 years age group. Nagarkar et al., in their study, found most of these children were diagnosed with ID by the age of 10 years.[9] Like other Indian studies on ID, males predominated in our study.[9],[10] Most of our participants were from rural background and belonging to nuclear families. A study on child and adolescent psychiatric disorders from the same center had also shown similar findings.[11] Although our study revealed antenatal history in a significant minority of our participants (17.7%), perinatal adverse history was present in approximately 48%. Based on etiology, ID can have both genetic and nongenetic causal factors. Genetic causes account for about 30%–50% of all ID cases and include chromosomal abnormalities such as Down's syndrome, inherited genetic traits like Fragile-X syndrome and disorders of single gene like Prader–Willi syndrome.[12],[13],[14] However, the nongenetic causes of ID are not clearly known. It has been suggested that nongenetic risk factors for ID are heterogeneous and can be classified as per timing into prenatal, perinatal, and neonatal factors.[15] If these nongenetic risk factors are identified early, ID can be timely intervened, which would be beneficial in clinical practice and for public health. A recent meta-analysis analyzed 16 potential risk factors and found a significant association with increased risk of ID with 10 prenatal maternal factors (advanced age, black race, low education, third or more parity, alcohol use, tobacco use, diabetes, hypertension, epilepsy, and asthma), one perinatal factor (preterm delivery), and two neonatal factors (male sex and LBW).[15] Most of our participants had a history of delayed developmental milestones which is consistent with earlier studies.[16],[17] Accurate recognition of developmental delay and ID is a central precondition to their correct evaluation and management.[18] The grades of IQ in the study are also consistent with both clinical and epidemiological studies from India.[3],[17] The level of ID is important as it has been found to determine the emotional and behavioral disorders as well as comorbid psychiatric disorders. Disruptive and antisocial behaviors are predominant in mild ID group, whereas those with severe ID are predominantly self-absorbed with autistic behaviors. Those with profound ID have, on an overall, very low levels if behavioral disturbances than the other three categories.[19] Moreover, a strong negative association has been showed between the severity of ID and life expectancy.[20] It is expected of these individuals to present in outpatient with difficulty in adaptive functioning as well as with delayed milestones along with behavioral disturbances. In our study also, the presenting complaints in most of the subjects were absent/difficulty in speech, poor performance in school, difficulty in learning daily activities, regression in milestones, hyperactivity, and self-harm. Current problem behaviors were present in about 47% of our subjects. Children with ID frequently have behavior disorders in them which can lead to many problems in their everyday life besides masking or revealing an organic or psychiatric disorder in them.[21] In a recent narrative review, four common behavior disorders in such individuals were disturbances in sleep, agitation related to the hyperkinetic disorder, aggression, and self-injury.[21] The situation is further complicated by the presence of more than one behavioral disturbance in the same individual as well as the chronicity of such behavior.[21] The parents often relate these behaviors to the disability in these individuals and rarely seek help. To treat such behaviors, it is crucial to follow a multidisciplinary approach.[21] Although pharmacotherapy appears to be effective for reducing such behaviors in short-term among these children, the risk of significant side effects is always there.[21],[22] There is evidence suggesting that behavioral interventions targeting the function of behavior are more effective in managing the aggressive and tantrum behaviors in ID while pharmacological approaches to these behaviors are often ineffective and may result in more harm to the individual.[23] In our study, about 32% of these children and adolescents had psychiatric comorbidities. Comorbid psychopathology in young people with ID has been found to be 3–4 times higher than the youth without ID. A recent study on the co-occurrence of mental disorders in children and adolescents with ID found co-occurring mental disorders in about 40% of these individuals, with persistent mental disorders in about around 30%.[24] Evidence suggests that the presence of comorbid psychiatric disorders add substantially to morbidity in individuals with ID.[25] Comorbidity also has a negative influence on adaptation to independent living and adjustment to the workplace in youth with ID.[26] With such an impact, it is necessary to estimate the prevalence of comorbid psychiatric disorders in these individuals and to develop such services which will ameliorate these comorbidities.[26] Approximately 22% of our subjects had also a comorbid medical condition. Like psychiatric comorbidities, these can also have a negative influence on their lives and need to be managed along with other associated conditions.

Raising children with ID can also have a negative impact on the mental health of their parents in such a way that they are at an increased risk for developing depression and anxiety.[27] Mothers, in particular, have difficulty in finding or maintaining a job, feel isolated, and have low self-esteem.[28] In our study, maternal depressive and/or anxiety disorders were present in 32% of our study participants. A study in Japan on investigating the parents of children with ID confirmed that mental health problem may be present in 46.7%.[29] In our study also, we found about 70% of mothers suffering from depressive and/or anxiety disorders. Other studies from India and Pakistan have also found similar results with 70%–85% of mothers of children with ID suffering from depression and anxiety.[9],[16],[30],[31] About 70% of mild ID individuals and about 70% of moderate ID individuals had maternal depression and/or anxiety. However, studies have found a significant association between the degree of ID and maternal anxiety and depression, more severe the ID, greater was the prevalence of these disorders.[9],[16],[30],[31] Other than the degree of ID, there are studies which have highlighted various child, parent, and environment-related factors which predict the development of mental health problems in parents of children with ID. Some of these factors include low socioeconomic status, female sex, single motherhood, poor psychosocial support, and more than one disability in the child.[32],[33],[34] The distress among mothers of children with ID is expected due to the irreversible nature of the disorder, associated social stigma, future caring burden, among other factors.[35] The psychological well-being of mothers of children with ID is not only important for their own health but also for the disabled child as well. Therefore, it is very essential to determine the predictors of depression and anxiety among these mothers so that they are identified and intervened in time to reduce the risk of mental health issues in them and restore their psychological well-being. If adequate information on the disability of child is provided along with the available services and caring skills training to deal a child with ID, the psychological distress among mothers of disabled children will be reduced significantly.[36]


  Conclusion Top


Although there have been efforts in India to understand the needs of individuals with ID and their families and to build services to empower their well-being, it is still a long way to go at grassroots-level. There is very less evidence with regard to the clinical profile of these individuals and their parental distress. In our attempt to understand the clinical profile and maternal depression and anxiety in children and adolescents with ID, we found high rates of antenatal and perinatal factors with history of developmental delay in significant number of children and adolescents with ID. Most of them had mild level of ID. Behavioral problems, psychiatric comorbidity, and medical comorbidity were also frequently observed in these individuals. Prevalence of depression and anxiety in mothers of these individuals was also very high. Although we did not found a relation between the level of ID and maternal anxiety and depression, significant association has been found with the level of ID in other studies. Determining the predictors of maternal depression and anxiety among mothers of ID children may help to identify the at risk mothers early for overall well-being of both mother and child with ID.

Limitations

Our study should be viewed with the following limitations in mind:

  • Due to its cross-sectional nature, changes over time could not be discerned
  • Sample size was small
  • There was no comparison group of mothers of healthy children
  • Only outpatient children and adolescents with ID were included which limit the generalizability of our results
  • Our subjects were highly heterogeneous with different types of medical comorbidities and multiple levels of ID
  • Reliance on history from mothers is prone to give biased results on antenatal factors, perinatal factors, and medical comorbidities with over/under reporting.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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