INTRODUCTION

Aspects of intellectual disability

Intellectual disability can be defined as significant limitations in intellectual skills (involving learning, reasoning and problem solving) and limitations in adaptive behaviours (such as social, conceptual and practical skills) that usually can be identified before the age of 18 years ( Vuijk et al., 2010 ). According to DSM- IV and ICD-10, intellectual developmental disorder is classified into mild, moderate, severe and profound subtypes depending upon deficits in conceptual, social and practical domains whereas currently IQ scores measurements are no longer needed for classifying intellectual disability ( ) identifying the classification elements, using relevant information, and using clearly stated and purposeful subgroup classification terms. This systematic approach reflects current changes in the field of intellectual disability (ID. Mild intellectual disability is considered the most common type, which can be caused by a variety of genetic and environmental factors, and affects around 0.5 to 8% of THE general population and it is expected to be higher in prisoners ( Simonoff et al., 2006 ) ( Hellenbach et al., 2017 ) 2017 ( Tort et al., 2016 ) there is little in the way of reliable data.\nObjectives: 1. Mild intellectual disability can be missed if detailed psychiatric evaluation has not been performed, including recording the collateral history from parents, teachers and significant others.

Mild intellectual disability is characterised by deficits in the conceptual domain such as difficulties in reading, writing, arithmetic skills. While in adults, there are deficits in abstract thinking, executive function, planning, cognitive flexibility and short-term memory, compared with healthy age-related counterparts (APA, 2013).

Furthermore, deficits in the social domains can exhibit as immature social interactions, difficulty in perceiving social cues, difficulties regulating emotion and behaviour in an age-appropriate way, limited understanding in social situations and an impaired social judgment (APA, 2013).

Practical domain disturbance often appears as needing some support with complex daily living tasks in comparison to peers. Supports typically involve shopping, transportation, home and child-care organising, money management as well as support in making health and legal decisions (APA, 2013).

Conduct disorders in detainees and prisoners

Conduct disorder is one of the most common mental illnesses among boys especially in forensic settings ( Gosden et al., 2003 ). It is characterised by persistent antisocial and aggressive behaviours toward other children, adults and even animals. And it ranges from bullying, lying, theft and running away from home to more serious violations such as forced sexual acts, fire setting, destruction of property and even murder ( Buitelaar et al., 2013 ). Boys who receive a diagnosis of conduct disorder are frequently involved in alcohol and substance abuse/dependence along with mild intellectual disability ( ). Such comorbidities mask symptoms of each other, increase the likelihood of missing underlying psychiatric disorders, worsen legal, social and academic consequences, complicate management plans and predict a less promising prognosis.

Author’s experience

The corresponding author has been an attending psychiatrist in one of the women and juvenile prisons in Iraq for more than three years, performing detailed psychiatric evaluations for all prisoners. All juvenile prisoners are assessed initially at least once by a different psychiatrist throughout court procedures and evaluated again by a second psychiatrist within the prison. One of the most common psychiatric diagnoses in this juvenile prison is conduct disorder, a finding that is confirmed in the literature ( Gosden et al., 2003 ) ( Buitelaar et al., 2013 ) ( ). Whereas, the two most common associations with conduct disorders in the prison, are alcohol/substance dependence and mild intellectual disability. Surprisingly the diagnosis of mild intellectual disability was missed in most conduct disordered juveniles in their primary mental health evaluation around the time of the trial orders. However, comorbid diagnoses of mild intellectual disabilities were provided by the attending psychiatrist in the prison through 1-2 assessment sessions, using DSM-5 diagnostic criteria.

Causes of missing mild intellectual disability

Reasons for overlooking a diagnosis of mild intellectual developmental disorder can be explained by several factors: lack of time to focus on developmental level, failure to differentiate mildly low intellectual development from normal, masking or confusing symptoms with conduct disorders, lack of psychiatrists subspecialised in intellectual developmental disorders in whole of the country of Iraq.

Consequences of missing intellectual disability among prisoners

The implications of missing diagnoses of mild intellectual disability in prisoners having conduct disorders include significant psychiatric, legal and social consequences.

Considering the psychiatric consequences, it’s well known that mild intellectual disability is usually a permanent condition that needs long-term management and requires a special, appropriately resourced school or health centre to assist such individuals. Psychotherapeutic treatments for such individuals mostly favour behavioural approaches rather than cognitive, mainly due to their limited intellectual capacity. Such juveniles cannot weigh and understand their behaviours independently, in other words they require appropriate support, in order to make logical decisions. They are also not good candidates for motivational interviewing to manage their frequently common comorbid substance-use disorders compared to their intellectually normal counterparts, again because of their poor cognitive skills. So juveniles with conduct disorders but without intellectual developmental disorders, have totally different management plans, compared to those with mild intellectual disability.

Regarding the legal consequences, juveniles who have both conduct and mild intellectual developmental disorders might not be deemed responsible for their illegal acts, so the appropriate outcome based on a forensic assessment would not be incarceration but appropriate diversion to receive the necessary psychiatric treatment.

In addition, social benefits provided by the government differ from one country to another. In Iraq, juveniles who are diagnosed with mild intellectual developmental disorder should receive a fixed monthly grant, enrolment at specifically equipped schools for such disorders, unlimited health insurance, as well as interventions from social services.

DECLARATIONS

Acknowledgements: None.

Authors’ contributions: Both authors contributed equally in writing and approving this manuscript.

Conflict of interest: None.

Ethical approval: The study was conducted in accordance with the ethical standards of the Helsinki Declaration of 1975, as revised in 2008. No formal ethical clearance was sought for conducting the study.

Informed consent: Not required.

Funding: None.

Study registration: Not required.

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