Psychopathology from Childhood to Adolescence in children with and without Mild Intellectual Disability (MID): a comparison across three MID operationalizations

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G. Hulsmans, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7907188/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract The DSM-5(-TR) expanded the definition of Mild Intellectual Disability (MID) to include adaptive functioning (AF) alongside intelligence quotient (IQ). In this population-based study, we examined behavioral and emotional problems in children with MID and matched controls from early childhood to adolescence. We evaluated how three operationalizations of MID –varying by IQ and AF– influence outcomes. Cognitive assessments and parent-reported problems from 4,643 children from 1.5 to 15 years (T1 to T5) in the Generation R Study were used. MID was defined as: (1) IQ ≤ 75; (2) IQ ≤ 75 with impairments in AF; (3) IQ ≤ 85 with impairments in AF. Propensity score matching ensured comparable MID and non-MID groups. Linear mixed models were employed to assess multiple domains of psychopathology over time. Across all MID definitions, children with MID exhibited elevated behavioral and emotional problems compared to matched controls. Children meeting the criteria for MID3, the broadest definition, showed the highest problem levels, with elevated ADHD (β = 0.37, pFDR < .001), affective (β = 0.25, pFDR < .001), and autistic problem scores (β = 0.25, pFDR < .001) at baseline, with differences widening over time. Children with MID1 and MID2 also displayed unfavorable ADHD trajectories, although no baseline differences were observed. The findings suggest the extent of mental health problems depend on how MID is operationalized and suggest that psychopathology may be particularly present in children with borderline intellectual disability 75 ≤ IQ ≤ 85. Mild Intellectual Disability Psychopathology DSM-5 Longitudinal Studies Figures Figure 1 Figure 2 Introduction Approximately 2–3% of children and adolescents have an Intellectual Disability (ID), defined by significant limitations in intellectual and adaptive functioning (AF) relative to developmental expectations [ 1 – 3 ]. Intellectual functioning reflects general cognitive abilities such as reasoning, problem-solving, and learning, whereas AF encompasses the conceptual, social, and practical skills needed for everyday life. The severity of ID is classified as mild, moderate, severe, or profound, with about 85% of affected children falling within the mild range (MID), which is the focus of this study. Children with ID show a markedly higher prevalence of mental health problems than their peers without ID, with rates of 30–50% compared to 13–16% in the general population [ 3 – 5 ]. Elevated internalizing (e.g., anxiety, depression) and externalizing (e.g., aggression, hyperactivity) symptoms emerge early in childhood [ 6 – 8 ] and often persist across development [ 6 ]. In the general population, externalizing behaviors decline from preschool to adolescence [ 9 – 11 ], whereas internalizing problems stabilize or increase, particularly among girls [ 10 , 12 – 14 ]. Children with ID, who face challenges in adaptive functioning, may have fewer resources to manage developmental demands, leading to slower reductions in externalizing and greater increases in internalizing symptoms over time. However, longitudinal evidence remains inconsistent: some studies report a sharper rise in internalizing and slower decline in externalizing problems [ 7 ], while others find similar or even faster decreases among children with ID [ 6 , 8 ]. Such discrepancies likely reflect differences in informants, developmental periods, and especially in how ID has been operationalized across studies. In this study, we investigated associations between ID status and psychopathology using three operationalizations of ID, which differ in their focus on IQ and AF. These operationalizations reflect both historical reliance on IQ scores and the more recent emphasis on AF introduced in the DSM-5. In line with common clinical and research practice, our first operationalization (MID1) is based on IQ alone and defined as an IQ score of ≤ 75 (70 + a 5-point measurement error margin). That is, even though both intellectual functioning (reflected by an IQ score) and clinical judgment [ 4 ]) and AF have been included in the criteria for (M)ID across subsequent versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and similar psychopathology classification systems in the past decades, in practice, IQ tended to be regarded as the most important criterion for identifying ID. This means that AF was often not considered, and a MID diagnosis was based solely on an IQ score between 50–70 [ 15 – 17 ]. In keeping with this practice, MID1 is based solely on IQ. With the introduction of the DSM-5, the emphasis in diagnostic criteria shifted towards AF in contrast to previous editions. The severity of ID is currently determined by the degree of impairment in AF. The DSM-5-TR further clarifies that a MID diagnosis is not appropriate when IQ scores are substantially higher than 65–75. Our second operationalization (MID2) aligns with the DSM-5-TR definition for MID: IQ ≤ 75 combined with impairments in at least one of the three AF domains (conceptual, social and practical). Our third conceptualization (MID3) additionally included individuals with IQ scores between 75 and 85 who also show impairments in at least one of the three AF. This broader conceptualization acknowledges that individuals in this range often require support [ 18 ]. In line with this perspective, the Netherlands uses a broader definition of MID, extending IQ to 85 to include this group. This study examined the developmental trajectories of psychopathology from early childhood to adolescence among children with and without MID within a population-based cohort. Given that definitions of MID vary across research and clinical practice, we also evaluated whether the choice of operationalization influenced observed associations. Beyond internalizing, externalizing, and neurodevelopmental domains, we included less frequently studied problems, such as sleep disturbances and picky eating. We hypothesized that, compared with their typically developing peers, children with MID would show (i) less improvement in domains that generally decline with age (ADHD, oppositional, autistic, somatic, sleep, picky eating) and (ii) greater increases in domains that typically rise (affective and anxiety problems). (iii) Differences in these associations were further explored across the three MID definitions. Methods Setting and Participants This study was part of the Generation R Study, a large, population-based cohort from Rotterdam, the Netherlands, designed to follow children’s development from fetal life to adolescence. Details can be found elsewhere [ 19 ]. The Medical Ethics Committee of Erasmus Medical Centre, Rotterdam, approved the study. Written informed assent/consent was obtained from all participants. For the present analyses, the final analytic sample consisted of children who completed both cognitive assessments and at least one parent-reported behavioral evaluation (N = 4,643) (Figure S1 ). Measures Cognitive Functioning Cognitive functioning at age 13 was assessed using a short version of the Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V) [ 20 ]. The WISC-V, widely used to evaluate children's cognitive abilities, includes four subtests: Matrix Reasoning, Digit Span, Vocabulary, and Coding. These subtests were designed to assess specific cognitive domains and were used to estimate the Full Scale Intelligence Quotient (FSIQ). Trained research assistants conducted the assessments, with results recorded either on an iPad or through traditional paper methods. Adaptive Functioning Adaptive functioning was assessed across three domains—conceptual, social, and practical functioning—based on DSM-5 criteria. Parent-reported items from various questionnaires across measurement waves were used to identify difficulties in these domains. Additional details and a full list of items are provided in Supplement . Conceptual Functioning was assessed by determining whether the child attended a special education school, repeated grades, or had a parent-reported intellectual disability during assessments at ages 6, 10 and 14. Social Functioning was measured using selected items from the Child Behavior Checklist (CBCL) at age 10 [ 21 ], the Social Responsiveness Scale (SRS) at age 6 [ 22 ], and the Behavior Rating Inventory of Executive Function (BRIEF) [ 23 ] at age 4. These items assessed the child's capacity for social interactions, interpretation of social cues, and emotion regulation. Practical Functioning was assessed using items that evaluated the child’s ability to manage daily tasks, such as hygiene, safety, and household chores. Relevant items were also drawn from the CBCL assessed at 1.5 and 10 years. Psychopathology Domains Child mental health was assessed at five time points (1.5, 3, 5, 10, and 14 years) using age-appropriate Child Behavior Checklist (CBCL) versions [ 24 ]. We analyzed eight DSM-oriented domains—affective, anxiety, ADHD, oppositional defiant, pervasive developmental (autistic), somatic, sleep, and picky eating problems. Raw CBCL scores were converted to mean item scores and z-standardized across the analytic sample to allow comparison across age versions. Detailed item composition are provided in the Supplement . Statistical Analyses All analyses were pre-registered (osf.io/k7562) and conducted using R version 4.3.2. Missing data on covariates were imputed using ‘ mice ’ package, which generated 25 imputed datasets [ 25 ]. Each imputed dataset was analyzed separately, and the results were pooled into combined estimates using Rubin's rules. Operationalizing MID The three operationalizations of MID were defined as follows: IQ ≤ 75: Children were classified as having MID if they scored ≤ 75 on the WISC-V, without considering AF. IQ ≤ 75 + AF: Children were classified as having MID if they scored ≤ 75 on the WISC-V and exhibited impairments in at least one of the following AF domains: conceptual, social, or practical functioning. Conceptual functioning impairments were defined as attending a special education school, progressing through primary school in a special education setting, or repeating a grade at least once. Social functioning impairments were identified by scoring ≥ 2SD above the mean on the sum of social functioning items. Practical functioning impairments were identified by scoring ≥ 2SD above the mean on the sum of practical functioning items. IQ ≤ 85 + AF: Children were classified as having MID if they scored ≤ 85 on the WISC-V and exhibited impairments in at least one of the AF domains (conceptual, social, or practical functioning) as described for MID2. For each MID operationalization, participants with and without MID were matched on child age (at T1), sex, national origin, maternal educational attainment, and household income using Propensity Score Matching. Nearest neighbor matching was applied at a ratio of 1:3 (MID: control) using the R package ‘ MatchIt ’ [ 26 ]. Further details are provided in the Supplement . Multilevel modeling After matching, we employed linear mixed models [ 27 ] to investigate the longitudinal trajectories of psychopathology from T1 to T5, stratified by MID status. Separate models were conducted for each DSM-oriented problem area (Depressive, Anxiety, ADHD, and ODD), while the trajectories of pervasive developmental problems, somatic problems, sleep problems, and picky eating symptoms were analyzed across T1 to T3. Each linear mixed model included fixed effects for age at assessment, MID status, and their interaction, enabling the examination of differences in psychopathology trajectories between children with and without MID over time. Random intercepts and slopes were included to account for individual variability in baseline psychopathology levels and in the rate of change over time. For each psychopathology domain, we specified the following fixed effects: intercept, age, MID status, and MID status*age. We report both the overall main effect (from models without the interaction) and the age interaction effect; where significant interactions were present, conditional main effects were additionally reported with age centered at baseline. Predicted trajectories of psychopathology domains for each operationalization were plotted to illustrate how these trajectories vary over time. To control for multiple comparisons across the primary outcomes (n = 8), a false discovery rate correction (FDR-Benjamini Hochberg) was applied [ 28 ]. Results Descriptive Information Table 1 summarizes the demographic characteristics of the MID and control groups across operationalizations. Male participants consistently constituted the majority in the MID groups, ranging from 64.2% to 69.6%. The percentage of participants with Dutch-origin mothers increased from 36.5% in MID1 to 52.5% in MID3, while the proportion in the lowest income group (< €1,200/month) decreased from 43.5% in MID1 to 27.7% in MID3. Similarly, the percentage of mothers with higher education levels increased from 22.6% in MID1 to 36.0% in MID3. These patterns suggest that broader definitions of MID (e.g., MID3) include individuals from more socioeconomically advantaged backgrounds compared to stricter definitions (e.g., MID1). Psychopathology Domains (T1 to T5) Affective Problems Children with MID3 showed higher affective problems at baseline, and these differences further increased over time (β = 0.25, SE = 0.05, pFDR < .001; age interaction β = 0.01, SE = 0.00, pFDR = .004; Table 2 , Fig. 1 ). MID1 and MID2 showed significantly higher affective problems compared to matched controls (MID1: β = 0.18, SE = 0.08, pFDR = .04; MID2: β = 0.23, SE = 0.09, pFDR = .02), but these differences did not change over time. Anxiety Problems Anxiety problems were significantly elevated across all MID groups (Table 2 , Fig. 1 ). MID3 showed the highest effect (β = 0.35, SE = 0.04, pFDR < .001), followed by MID1 (β = 0.26, SE = 0.07, pFDR = .001), MID3 (β = 0.24, SE = 0.00, pFDR = .002), and MID2 (β = 0.28, SE = 0.07, pFDR = .008). No significant age interactions were observed in any group. ADHD Problems All MID groups showed significant age interactions, suggesting that ADHD problems increased over time compared to matched controls (Table 2 , Fig. 1 ). MID3 showed significantly higher problems at baseline compared to controls (β = 0.37, SE = 0.5, pFDR < .001), with differences further widening over time (age interaction β = 0.02, SE = 0.0, pFDR < .001). In contrast, next to diverging trajectories over time, MID1 (β = 0.2, SE = 0.11, pFDR = .87) and MID2 (β = 0.13, SE = 0.08, pFDR = .21) showed no baseline differences. ODD Problems Elevated ODD symptoms were observed in all MID groups (Table 2 , Fig. 1 ), with the largest effect in MID3 (β = 0.40, SE = 0.04, pFDR < .001). Significant effects were also noted for MID1 and MID2, but no age interactions were found, indicating that differences in symptoms do not vary by age over time. Psychopathology Domains (T1 to T3) Somatic Problems No significant effects were observed for somatic problems in MID1 or MID2. However, MID3 demonstrated a significant main effect (β = 0.25, SE = 0.04, pFDR < .001), indicating higher levels of somatic problems in children with MID compared to controls, with no significant age interactions (Table 2 , Fig. 2 ). Picky Eating Problems A significant main effect for picky eating problems was observed in MID3 (β = 0.29, SE = 0.04, pFDR < .001), with children with MID exhibiting higher levels of picky eating than controls. No significant age interactions were observed (Table 2 , Fig. 2 ). Autism Spectrum Disorder (ASD) Problems Children with MID3 showed significantly higher ASD problems at baseline (β = 0.25, SE = 0.08, pFDR < .004), and these differences increased further over time (age interaction β = 0.05, SE = 0.01, pFDR < .001; Table 2 , Fig. 2 ). MID1 (β = 0.26, SE = 0.09, pFDR = .01) and MID2 (β = 0.31, SE = 0.11, pFDR = .01) also showed higher baseline symptoms, but no significant changes in trajectories. Sleep Problems Significant main effects for sleep problems were observed in MID2 (β = 0.20, SE = 0.07, pFDR = .02) and MID3 (β = 0.23, SE = 0.04, pFDR < .001), indicating elevated sleep problems in children with MID compared to controls. No significant age interactions were observed in any group (Table 2 , Fig. 2 ). Discussion This longitudinal study examined the developmental trajectories of behavioral and emotional problems in children with MID compared to matched controls, using three MID definitions reflecting changes in DSM criteria and common practice. Our findings revealed that children with MID exhibit higher levels of behavioral and emotional problems. The observed findings across operationalizations for ADHD, ODD, affective, anxiety, and ASD problems among children with MID align with prior research highlighting the increased vulnerability of children with mild intellectual or developmental impairments [ 3 – 7 , 29 ], and we showed that this vulnerability is persistent in the age ranges studied. In addition, somatic problems (MID3), picky eating (MID3) and sleep problems (MID2&3) were higher in MID than non-MID participants, indicating persistent vulnerability. Moreover, the higher vulnerability of children with MID compared to non-MID peers increased over time for ADHD (all operationalizations), and for affective (MID3) and ASD problems (MID3). This did not hold for the other psychopathology domains, so findings partially support our hypothesis. We hypothesized that problems which tend to decrease over time in the general population, would decrease less in children with MID, while problems that tend to increase, would increase more in children with MID. In line with this, across MID operationalizations, ADHD symptoms remained either stable or increased over time in children with MID, while non-MID participants showed decreasing ADHD symptom trajectories, suggesting that children with MID may face prolonged difficulties with ADHD symptoms [ 6 , 7 ]. Additionally, affective and ASD problems in MID3 (but not MID1&2) showed a significantly greater increase over time compared to matched controls. Of note, we hypothesized a smaller decrease in autism symptoms in children with MID, but found an increase over time relative to children without MID who, indeed, decreased. Problems in AF may overlap with mental health problems, and adding AF to the operationalization in MID1 and MID2 may therefore increase mental health problems. Focusing further on the results according to differences in MID operationalizations, we found that compared to MID1 (IQ ≤ 75), adding AF criteria (MID2) resulted in only slightly stronger associations across most psychopathology domains, with the exception of a notable effect on sleep problems. In contrast, further expanding the IQ threshold from ≤ 75 to ≤ 85 and incorporating adaptive impairments (MID3) revealed more pronounced behavioral and emotional problems compared to MID1 and 2. Together the findings suggests that (a) a MID operationalization based solely on IQ (IQ ≤ 75) already identifies children with elevated behavioral and emotional problems and (b) The higher level of problems found in the MID3 compared to the MID2 operationalization, which apply the same AF criteria, seems to come from increasing the IQ threshold (from ≤ 75 in MID2 to ≤ 85 in MID3). The results for the MID3 group are consistent with previous findings indicating that individuals with IQs in the borderline range (75–85) experience significant psychosocial and mental health needs [ 30 – 32 ]. In fact, our results suggest that they have more mental health needs than the subset of children with lower IQ (i.e., MID1 & 2). A comparison with a highly similar study in the TRAILS cohort (ages 11–26; [ 33 ]) using equivalent MID operationalizations highlights both similarities and differences in psychopathology, as well in how MID operationalizations affect the outcomes. In both studies, the overall pattern showed increased vulnerability across domains of psychopathology for those with MID compared to their peers without MID, with few differences in trajectories over time. Interestingly, where the current study found diverging ADHD trajectories, with children with MID increasing in their symptoms while non-MID children decreased, TRAILS found decreasing trajectories with MID youth showing a slightly faster decrease over time in MID3. For ASD, TRAILS showed increasing vulnerability for MID youth over time for the MID1&2 groups, whereas in our study, ASD problems increased more over time only in MID3 (IQ ≤ 85 + adaptive impairments). A notable difference in findings between the two studies is that in TRAILS the strength of the associations increased gradually from MID1 to MID3, while in the current study associations only slightly increased when AF was added to the MID operationalization (MID1 ◊ MID2) and became considerably stronger when the operationalization was further expanded by extending the IQ criteria to ≤ 85 (MID3). We can only speculate about the reasons underlying these differences. One possible reason is that during the early childhood period, as covered in the current study, supportive structures (e.g., in school) may be available for those children with lower IQ scores (≤ 75), regardless of AF, which may not be available to the same degree for children with AF problems scoring just above the common IQ threshold of 75. For the older TRAILS children, societal demands for AF may be higher and AF impairments more debilitating. Thus, the association between AF, and by extension the MID operationalization, and mental health problems, may differ depending on age and available support structures. A strength of this study is its comprehensive examination of various MID operationalizations within a large dataset. To our knowledge, the current study and the study by [ 33 ] are the first studies to test psychopathology trajectories across multiple commonly used MID definitions, providing valuable insights into how different diagnostic criteria capture distinct profiles of behavioral and emotional problems in children. In doing so, the findings raise important questions about the conceptual boundaries of MID. Expanding diagnostic criteria to include a broader range of cognitive and AF difficulties may lead to increasing overlap with mental health problems. This raises concerns about whether MID is evolving into an overly broad category that encompasses a very diverse set of mental health, AF and cognitive difficulties rather than a clearly defined diagnostic group. While our study cannot provide definitive answers to this, it highlights the need for continued reflection on how to best delineate MID from mental health problems. Alternatively, reflection may also lead to the conclusion that this differentiation is irrelevant and that a broad MID group is not overly broad as long as those in need receive appropriate support. A second strength of this study is that it contributes to the sparse literature on sleep problems and picky eating in children with MID [ 3 ]. Higher levels of sleep problems in MID2 and MID3 may indicate that AF problems may exacerbate sleep problems, which, in turn, could impair daily functioning and overall quality of life [ 34 , 35 ]. Picky eating was also significantly elevated in MID3, drawing attention to an area that may be related to nutritional status and growth. These findings suggest the need for comprehensive assessments that encompass behavioral and emotional as well as functional areas, enabling more targeted support for children with MID and their parents [ 36 , 37 ]. Several methodological limitations warrant consideration. First, some criteria used to define AF overlapped with items included in the outcome measures of behavioral and emotional problems. This overlap may have influenced the observed associations and could partially explain the relationships identified in the study. What speaks against this is that, as argued, we found no clear differences between MID1 and MID2. Second, while we controlled for key demographics (age, sex, national origin, maternal education, and household income) using propensity score matching, unmeasured factors -including parenting styles, environmental stressors, and genetic predispositions- could have influenced the findings. We did not include these variables in the matching, as they may act as mediators or colliders rather than confounders, and therefore do not invalidate the current findings. Third, reliance on parent-reported measures for AF and behavioral/emotional problems rather than a clinician may introduce biases. Although AF and mental health problems conceptually overlap, it is possible that a clinician may still be better able to differentiate between these to the extent that differentiation is possible. Fourth, and related to this, none of the MID definitions used in this study incorporated clinical judgment, even though DSM-5 explicitly states that an MID diagnosis should not rely solely on test scores. The absence of qualitative, clinician-driven assessments may mean that some children who would be diagnosed in clinical settings were not identified as MID in this study, and vice versa. Fifth, group sizes and therefore power, differed between MID operationalizations, which is why MID group comparisons were also based on effect sizes. However, estimation accuracy differs among the three MID groups, although the smallest MID2 group was still substantial (MID2; n = 82). Our study underscores that both narrower (IQ ≤ 75) and particularly broader (IQ ≤ 85) definitions of MID capture children at risk of persistent behavioral and emotional problems. In addition, mostly for the latter group, the increasing risk of psychopathology from childhood into adolescence for ASD, affective, and ADHD problems may suggest that there is insufficient support to cater to the developmental needs of children with MID or that available support does not reach them. That is, the presence of mental health problems on top of MID may further hamper adaptive and daily life functioning. Children with an IQ score between 75 and 85 may have less access to specialized care and facilities than children with lower intellectual functioning. Our results also have implications for research. Various MID operationalizations may result in different associations with external variables, possibly affecting the implications of study results. The comparison with the TRAILS study shows that the age of the sample may affect the effect of the particular MID operationalization on the results. Not including AF in MID operationalizations, as has been common in research for practical reasons [ 38 ], may lead to underestimation of associations with psychopathology problems when a DSM-5-TR definition of MID is accepted. MID operationalizations should therefore be taken into account when comparing study results, and MID definitions should be harmonized in future research. In conclusion, this study showed that children with MID, particularly when defined as IQ ≤ 85 and including AF impairments, exhibit persistent as well as increasing behavioral and emotional problems compared to their matched peers. Standardizing MID criteria in research and clinical practice are needed to improve comparability between studies and enhance diagnosis accuracy. Declarations Author Contribution Concept and design: Koc, Masselink, Hartman, Jansen. Acquisition, analysis, and interpretation: Koc, Masselink, Hulsmans. Drafting of the manuscript: Koc, Masselink, Hulsmans. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Koc. Obtained funding: Hartman, Jansen. Supervision: Hartman, Jansen. Acknowledgement This study was funded by the Netherlands Organization for Health Research and Development (ZonMw project 636340003). The general design of the Generation R Study is supported by the Erasmus Medical Center, Erasmus University Rotterdam, the Netherlands Organization for Health Research and Development, the Netherlands Organization for Scientific Research, the Ministry of Health, Welfare and Sport, the Municipal Health Service Rotterdam area, and the Stichting Trombosedienst & Artsenlaboratorium Rijnmond. Data Availability Data can be obtained upon request. 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Proc Nutr Soc 78:161–169. https://doi.org/10.1017/S0029665118002586 Munir KM (2016) The co-occurrence of mental disorders in children and adolescents with intellectual disability/intellectual developmental disorder. Curr Opin Psychiatry 29:95. https://doi.org/10.1097/YCO.0000000000000236 Obi O, Van Naarden Braun K, Baio J et al (2011) Effect of Incorporating Adaptive Functioning Scores on the Prevalence of Intellectual Disability. Am J Intellect Dev Disabil 116:360–370. https://doi.org/10.1352/1944-7558-116.5.360 Tables Table 1 Participant demographics per MID operationalization, and matched controls. MID1 (IQ ≤ 75) MID2 (IQ ≤ 75 + Conc., Soc., or Prac) MID3 (IQ ≤ 85 + Conc., Soc., or Prac.) MID Control MID Control MID Control N participants 115 345 82 246 408 1224 T1 age, mean (SD) 1.55 (0.10) 1.55 (0.08) 1.54 (0.08) 1.54 (0.10) 1.53 (0.08) 1.54 (0.10) IQ, mean (SD) 69.1 (6.4) 100.0 (12.8) 68.3 (5.4) 99.7 (13.4) 75.2 (8.3) 102.0 (12.8) IQ Range 45–74 76–140 45–74 76–139 45–84 76–139 Male, n (%) 80 (69.6) 240 (69.6) 57 (69.5) 171 (69.5) 262 (64.2) 790 (64.5) Maternal national origin, n (%) Dutch 42 (36.5) 125 (36.2) 33 (40.2) 98 (39.8) 214 (52.5) 631 (51.6) Non-Dutch European 9 (7.8) 27 (7.8) 6 (7.3) 18 (7.3) 25 (6.1) 71 (5.8) Non-European 64 (55.7) 193 (56) 43 (52.5) 130 (52.9) 169 (41.4) 522 (42.6) Monthly household income (€/month), n (%) 2,000 53 (46.1) 158 (45.8) 40 (48.8) 120 (48.8) 234 (57.4) 706 (57.7) Maternal education level, n (%) Primary or lower 26 (22.6) 76 (22.0) 17 (20.7) 50 (20.3) 55 (13.5) 163 (13.3) Secondary 55 (47.8) 167 (48.4) 38 (46.3) 114 (46.3) 206 (50.5) 623 (50.9) Higher 34 (29.6) 102 (29.6) 27 (32.9) 82 (33.3) 147 (36.0) 438 (35.8) Note : Conc. = Conceptual functioning problems; Soc. = Social functioning problems; Prac. = Practical functioning problems; MID = Mild Intellectual Disability group; Control = Matched control for the MID group; IQ = Intelligence quotient based on the WISC-V. Table 2 Association between MID status and psychopathology domains over time. MID1 (IQ ≤ 75) MID2 (IQ ≤ 75 + Conc., Soc., or Prac.) MID3 (IQ ≤ 85 + Conc., Soc., or Prac.) Main effect Age Interaction Main effect Age Interaction Main effect Age Interaction Std Β (SE) p pFDR Std Β (SE) p pFDR Std Β (SE) p pFDR Std Β (SE) p pFDR Std Β (SE) p pFDR Std Β (SE) p pFDR Somatic Problems 0.03 (0.09) .72 .80 -0.03 (0.03) .37 .56 0.02 (0.11) .81 .81 -0.05 (0.04) .14 .21 0.25 (0.04) < .001 < .001 -0.00 (0.01) .84 .87 Picky eating 0.07 (0.09) .42 .50 -0.04 (0.03) .19 .35 0.12 (0.09) .23 .26 -0.06 (0.03) .07 .21 0.29 (0.04) < .001 < .001 -0.01 (0.02) .73 .79 ASD 0.26 (0.09) .008 .01 0.06 (0.03) .06 .18 0.31 (0.11) .005 .01 0.05 (0.03) .17 .21 0.47 (0.04) < .001 < .001 0.05 (0.01) < .001 < .001 Main effect at T1 0.25 (0.08) .001 .004 Sleep Problems 0.03 (0.09) .71 .80 0.00 (0.03) .87 .87 0.20 (0.07) .009 .02 0.02 (0.03) .63 .63 0.23 (0.04) < .001 < .001 -0.00 (0.01) .65 .75 Affective 0.18 (0.08) .03 .04 0.01 (0.01) .40 .56 0.23 (0.09) .01 .02 0.02 (0.01) .16 .21 0.38 (0.04) < .001 < .001 0.01 (0.00) .001 .004 Main effect at T1 0.25 (0.05) < .001 < .001 Anxiety 0.26 (0.07) < .001 .001 0.01 (0.01) .23 .39 0.28 (0.07) .002 .008 0.02 (0.01) .19 .21 0.35 (0.04) < .001 < .001 0.01 (0.00) .03 .10 ADHD 0.40 (0.08) < .001 .001 0.04 (0.01) < .001 . 001 0.44 (0.09) < .001 . 001 0.05 (0.01) < .001 . 001 0.57 (0.04) < .001 < .001 0.02 (0.00) < .001 < .001 Main effect at T1 0.02 (0.11) .82 .87 0.13 (0.08) .10 .21 0.37 (0.05) < .001 < .001 ODD 0.19 (0.08) .02 . 03 0.01 (0.01) .09 .21 0.21 (0.09) .02 .03 0.02 (0.01) .10 .21 0.40 (0.04) < .001 < .001 -0.00 (0.00) .61 .75 Note . Linear mixed-effect models were used to test the associations of MID status and repeatedly psychopathology domains from T1 to T5. Standardized effect estimates including the main effect and interaction effect( β ) (Symptoms change; interaction of MID*age), as well as standard errors (SE), p , and p FDR values are shown. Conc. = Conceptual functioning problems; Soc. = Social functioning problems; Prac. = Practical functioning problems; MID = Mild Intellectual Disability group; IQ = Intelligence quotient based on the WISC-V; ASD = autism spectrum disorder problems. ADHD = Attention-deficit/hyperactivity problems; ODD = Oppositional defiant problems. Additional Declarations No competing interests reported. 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14:40:30","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":144197,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7907188/v1/1062154dbc128afaa2a08a28.html"},{"id":96364977,"identity":"d9b62d13-1b32-466c-b3b2-fda664bcad4f","added_by":"auto","created_at":"2025-11-20 10:09:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":150058,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLongitudinal trajectories of psychopathology domains for children with MID and matched controls from T1 to T5. \u003c/strong\u003eThe figure presents longitudinal trajectories of psychopathology domains for children with MID (MID status = 1, represented in \u003cstrong\u003eblue\u003c/strong\u003e) and matched controls without MID (MID status = 0, represented in \u003cstrong\u003ered\u003c/strong\u003e) across three different MID operationalizations (MID1, MID2, and MID3). The shaded areas around the lines represent the confidence intervals for each trajectory. ADHD = Attention-deficit/hyperactivity problems; ODD = \u0026nbsp;Oppositional defiant problems.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7907188/v1/c5eaeefa3dba2dd355578f55.png"},{"id":96302178,"identity":"74e6af3d-9dfe-4ccc-aa4c-a7c380b168e2","added_by":"auto","created_at":"2025-11-19 14:40:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":134195,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLongitudinal trajectories of psychopathology domains for children with MID and matched controls from T1 to T3. \u003c/strong\u003eThe figure presents longitudinal trajectories of psychopathology domains for children with MID (MID status = 1, represented in \u003cstrong\u003eblue\u003c/strong\u003e) and matched controls without MID (MID status = 0, represented in \u003cstrong\u003ered\u003c/strong\u003e) across three different MID operationalizations (MID1, MID2, and MID3). The shaded areas around the lines represent the confidence intervals for each trajectory. ASD = Autism Spectrum Disorder problems.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7907188/v1/7763260dde485d01d36bbb15.png"},{"id":96452966,"identity":"4b0db442-d809-4798-ad5d-724548266315","added_by":"auto","created_at":"2025-11-21 09:56:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1417356,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7907188/v1/f7508eb8-61dc-43f8-a720-01f16ae20530.pdf"},{"id":96364668,"identity":"1d560697-ffe0-47d0-9338-5332850c0298","added_by":"auto","created_at":"2025-11-20 10:09:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":363645,"visible":true,"origin":"","legend":"","description":"","filename":"Supplement.docx","url":"https://assets-eu.researchsquare.com/files/rs-7907188/v1/1ae6b41e48be86d53657d12d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychopathology from Childhood to Adolescence in children with and without Mild Intellectual Disability (MID): a comparison across three MID operationalizations","fulltext":[{"header":"Introduction","content":"\u003cp\u003eApproximately 2\u0026ndash;3% of children and adolescents have an Intellectual Disability (ID), defined by significant limitations in intellectual and adaptive functioning (AF) relative to developmental expectations [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Intellectual functioning reflects general cognitive abilities such as reasoning, problem-solving, and learning, whereas AF encompasses the conceptual, social, and practical skills needed for everyday life. The severity of ID is classified as mild, moderate, severe, or profound, with about 85% of affected children falling within the mild range (MID), which is the focus of this study.\u003c/p\u003e\u003cp\u003eChildren with ID show a markedly higher prevalence of mental health problems than their peers without ID, with rates of 30\u0026ndash;50% compared to 13\u0026ndash;16% in the general population [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Elevated internalizing (e.g., anxiety, depression) and externalizing (e.g., aggression, hyperactivity) symptoms emerge early in childhood [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and often persist across development [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the general population, externalizing behaviors decline from preschool to adolescence [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], whereas internalizing problems stabilize or increase, particularly among girls [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Children with ID, who face challenges in adaptive functioning, may have fewer resources to manage developmental demands, leading to slower reductions in externalizing and greater increases in internalizing symptoms over time. However, longitudinal evidence remains inconsistent: some studies report a sharper rise in internalizing and slower decline in externalizing problems [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], while others find similar or even faster decreases among children with ID [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Such discrepancies likely reflect differences in informants, developmental periods, and especially in how ID has been operationalized across studies.\u003c/p\u003e\u003cp\u003eIn this study, we investigated associations between ID status and psychopathology using three operationalizations of ID, which differ in their focus on IQ and AF. These operationalizations reflect both historical reliance on IQ scores and the more recent emphasis on AF introduced in the DSM-5. In line with common clinical and research practice, our first operationalization (MID1) is based on IQ alone and defined as an IQ score of \u0026le;\u0026thinsp;75 (70\u0026thinsp;+\u0026thinsp;a 5-point measurement error margin). That is, even though both intellectual functioning (reflected by an IQ score) and clinical judgment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]) and AF have been included in the criteria for (M)ID across subsequent versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and similar psychopathology classification systems in the past decades, in practice, IQ tended to be regarded as the most important criterion for identifying ID. This means that AF was often not considered, and a MID diagnosis was based solely on an IQ score between 50\u0026ndash;70 [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In keeping with this practice, MID1 is based solely on IQ. With the introduction of the DSM-5, the emphasis in diagnostic criteria shifted towards AF in contrast to previous editions. The severity of ID is currently determined by the degree of impairment in AF. The DSM-5-TR further clarifies that a MID diagnosis is not appropriate when IQ scores are substantially higher than 65\u0026ndash;75. Our second operationalization (MID2) aligns with the DSM-5-TR definition for MID: IQ\u0026thinsp;\u0026le;\u0026thinsp;75 combined with impairments in at least one of the three AF domains (conceptual, social and practical). Our third conceptualization (MID3) additionally included individuals with IQ scores between 75 and 85 who also show impairments in at least one of the three AF. This broader conceptualization acknowledges that individuals in this range often require support [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In line with this perspective, the Netherlands uses a broader definition of MID, extending IQ to 85 to include this group.\u003c/p\u003e\u003cp\u003eThis study examined the developmental trajectories of psychopathology from early childhood to adolescence among children with and without MID within a population-based cohort. Given that definitions of MID vary across research and clinical practice, we also evaluated whether the choice of operationalization influenced observed associations. Beyond internalizing, externalizing, and neurodevelopmental domains, we included less frequently studied problems, such as sleep disturbances and picky eating. We hypothesized that, compared with their typically developing peers, children with MID would show (i) less improvement in domains that generally decline with age (ADHD, oppositional, autistic, somatic, sleep, picky eating) and (ii) greater increases in domains that typically rise (affective and anxiety problems). (iii) Differences in these associations were further explored across the three MID definitions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSetting and Participants\u003c/h2\u003e\u003cp\u003eThis study was part of the Generation R Study, a large, population-based cohort from Rotterdam, the Netherlands, designed to follow children\u0026rsquo;s development from fetal life to adolescence. Details can be found elsewhere [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Medical Ethics Committee of Erasmus Medical Centre, Rotterdam, approved the study. Written informed assent/consent was obtained from all participants. For the present analyses, the final analytic sample consisted of children who completed both cognitive assessments and at least one parent-reported behavioral evaluation (N\u0026thinsp;=\u0026thinsp;4,643) (Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eCognitive Functioning\u003c/h2\u003e\u003cp\u003eCognitive functioning at age 13 was assessed using a short version of the Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The WISC-V, widely used to evaluate children's cognitive abilities, includes four subtests: Matrix Reasoning, Digit Span, Vocabulary, and Coding. These subtests were designed to assess specific cognitive domains and were used to estimate the Full Scale Intelligence Quotient (FSIQ). Trained research assistants conducted the assessments, with results recorded either on an iPad or through traditional paper methods.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAdaptive Functioning\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003eAdaptive functioning\u003c/em\u003e was assessed across three domains\u0026mdash;conceptual, social, and practical functioning\u0026mdash;based on DSM-5 criteria. Parent-reported items from various questionnaires across measurement waves were used to identify difficulties in these domains. Additional details and a full list of items are provided in \u003cb\u003eSupplement\u003c/b\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eConceptual Functioning\u003c/em\u003e was assessed by determining whether the child attended a special education school, repeated grades, or had a parent-reported intellectual disability during assessments at ages 6, 10 and 14.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSocial Functioning\u003c/em\u003e was measured using selected items from the Child Behavior Checklist (CBCL) at age 10 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], the Social Responsiveness Scale (SRS) at age 6 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and the Behavior Rating Inventory of Executive Function (BRIEF) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] at age 4. These items assessed the child's capacity for social interactions, interpretation of social cues, and emotion regulation.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePractical Functioning\u003c/em\u003e was assessed using items that evaluated the child\u0026rsquo;s ability to manage daily tasks, such as hygiene, safety, and household chores. Relevant items were also drawn from the CBCL assessed at 1.5 and 10 years.\u003c/p\u003e\n\u003ch3\u003ePsychopathology Domains\u003c/h3\u003e\n\u003cp\u003eChild mental health was assessed at five time points (1.5, 3, 5, 10, and 14 years) using age-appropriate Child Behavior Checklist (CBCL) versions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. We analyzed eight DSM-oriented domains\u0026mdash;affective, anxiety, ADHD, oppositional defiant, pervasive developmental (autistic), somatic, sleep, and picky eating problems. Raw CBCL scores were converted to mean item scores and z-standardized across the analytic sample to allow comparison across age versions. Detailed item composition are provided in the \u003cb\u003eSupplement\u003c/b\u003e.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analyses\u003c/h2\u003e\u003cp\u003eAll analyses were pre-registered (osf.io/k7562) and conducted using R version 4.3.2. Missing data on covariates were imputed using \u0026lsquo;\u003cem\u003emice\u003c/em\u003e\u0026rsquo; package, which generated 25 imputed datasets [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Each imputed dataset was analyzed separately, and the results were pooled into combined estimates using Rubin's rules.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOperationalizing MID\u003c/h3\u003e\n\u003cp\u003eThe three operationalizations of MID were defined as follows:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIQ\u0026thinsp;\u0026le;\u0026thinsp;75: Children were classified as having MID if they scored\u0026thinsp;\u0026le;\u0026thinsp;75 on the WISC-V, without considering AF.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIQ\u0026thinsp;\u0026le;\u0026thinsp;75\u0026thinsp;+\u0026thinsp;AF: Children were classified as having MID if they scored\u0026thinsp;\u0026le;\u0026thinsp;75 on the WISC-V and exhibited impairments in at least one of the following AF domains: conceptual, social, or practical functioning. Conceptual functioning impairments were defined as attending a special education school, progressing through primary school in a special education setting, or repeating a grade at least once. Social functioning impairments were identified by scoring\u0026thinsp;\u0026ge;\u0026thinsp;2SD above the mean on the sum of social functioning items. Practical functioning impairments were identified by scoring\u0026thinsp;\u0026ge;\u0026thinsp;2SD above the mean on the sum of practical functioning items.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIQ\u0026thinsp;\u0026le;\u0026thinsp;85\u0026thinsp;+\u0026thinsp;AF: Children were classified as having MID if they scored\u0026thinsp;\u0026le;\u0026thinsp;85 on the WISC-V and exhibited impairments in at least one of the AF domains (conceptual, social, or practical functioning) as described for MID2.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e For each MID operationalization, participants with and without MID were matched on child age (at T1), sex, national origin, maternal educational attainment, and household income using Propensity Score Matching. Nearest neighbor matching was applied at a ratio of 1:3 (MID: control) using the R package \u0026lsquo;\u003cem\u003eMatchIt\u003c/em\u003e\u0026rsquo; [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Further details are provided in the \u003cb\u003eSupplement\u003c/b\u003e.\u003c/p\u003e\n\u003ch3\u003eMultilevel modeling\u003c/h3\u003e\n\u003cp\u003eAfter matching, we employed linear mixed models [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] to investigate the longitudinal trajectories of psychopathology from T1 to T5, stratified by MID status. Separate models were conducted for each DSM-oriented problem area (Depressive, Anxiety, ADHD, and ODD), while the trajectories of pervasive developmental problems, somatic problems, sleep problems, and picky eating symptoms were analyzed across T1 to T3. Each linear mixed model included fixed effects for age at assessment, MID status, and their interaction, enabling the examination of differences in psychopathology trajectories between children with and without MID over time. Random intercepts and slopes were included to account for individual variability in baseline psychopathology levels and in the rate of change over time. For each psychopathology domain, we specified the following fixed effects: intercept, age, MID status, and MID status*age. We report both the overall main effect (from models without the interaction) and the age interaction effect; where significant interactions were present, conditional main effects were additionally reported with age centered at baseline.\u003c/p\u003e\u003cp\u003ePredicted trajectories of psychopathology domains for each operationalization were plotted to illustrate how these trajectories vary over time. To control for multiple comparisons across the primary outcomes (n\u0026thinsp;=\u0026thinsp;8), a false discovery rate correction (FDR-Benjamini Hochberg) was applied [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive Information\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the demographic characteristics of the MID and control groups across operationalizations. Male participants consistently constituted the majority in the MID groups, ranging from 64.2% to 69.6%. The percentage of participants with Dutch-origin mothers increased from 36.5% in MID1 to 52.5% in MID3, while the proportion in the lowest income group (\u0026lt; \u0026euro;1,200/month) decreased from 43.5% in MID1 to 27.7% in MID3. Similarly, the percentage of mothers with higher education levels increased from 22.6% in MID1 to 36.0% in MID3. These patterns suggest that broader definitions of MID (e.g., MID3) include individuals from more socioeconomically advantaged backgrounds compared to stricter definitions (e.g., MID1).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePsychopathology Domains (T1 to T5)\u003c/h2\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003eAffective Problems\u003c/h2\u003e\u003cp\u003eChildren with MID3 showed higher affective problems at baseline, and these differences further increased over time (β\u0026thinsp;=\u0026thinsp;0.25, SE\u0026thinsp;=\u0026thinsp;0.05, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001; age interaction β\u0026thinsp;=\u0026thinsp;0.01, SE\u0026thinsp;=\u0026thinsp;0.00, pFDR\u0026thinsp;=\u0026thinsp;.004; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). MID1 and MID2 showed significantly higher affective problems compared to matched controls (MID1: β\u0026thinsp;=\u0026thinsp;0.18, SE\u0026thinsp;=\u0026thinsp;0.08, pFDR\u0026thinsp;=\u0026thinsp;.04; MID2: β\u0026thinsp;=\u0026thinsp;0.23, SE\u0026thinsp;=\u0026thinsp;0.09, pFDR\u0026thinsp;=\u0026thinsp;.02), but these differences did not change over time.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eAnxiety Problems\u003c/h2\u003e\u003cp\u003eAnxiety problems were significantly elevated across all MID groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). MID3 showed the highest effect (β\u0026thinsp;=\u0026thinsp;0.35, SE\u0026thinsp;=\u0026thinsp;0.04, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001), followed by MID1 (β\u0026thinsp;=\u0026thinsp;0.26, SE\u0026thinsp;=\u0026thinsp;0.07, pFDR\u0026thinsp;=\u0026thinsp;.001), MID3 (β\u0026thinsp;=\u0026thinsp;0.24, SE\u0026thinsp;=\u0026thinsp;0.00, pFDR\u0026thinsp;=\u0026thinsp;.002), and MID2 (β\u0026thinsp;=\u0026thinsp;0.28, SE\u0026thinsp;=\u0026thinsp;0.07, pFDR\u0026thinsp;=\u0026thinsp;.008). No significant age interactions were observed in any group.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eADHD Problems\u003c/h2\u003e\u003cp\u003eAll MID groups showed significant age interactions, suggesting that ADHD problems increased over time compared to matched controls (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). MID3 showed significantly higher problems at baseline compared to controls (β\u0026thinsp;=\u0026thinsp;0.37, SE\u0026thinsp;=\u0026thinsp;0.5, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001), with differences further widening over time (age interaction β\u0026thinsp;=\u0026thinsp;0.02, SE\u0026thinsp;=\u0026thinsp;0.0, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001). In contrast, next to diverging trajectories over time, MID1 (β\u0026thinsp;=\u0026thinsp;0.2, SE\u0026thinsp;=\u0026thinsp;0.11, pFDR\u0026thinsp;=\u0026thinsp;.87) and MID2 (β\u0026thinsp;=\u0026thinsp;0.13, SE\u0026thinsp;=\u0026thinsp;0.08, pFDR\u0026thinsp;=\u0026thinsp;.21) showed no baseline differences.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eODD Problems\u003c/h2\u003e\u003cp\u003eElevated ODD symptoms were observed in all MID groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), with the largest effect in MID3 (β\u0026thinsp;=\u0026thinsp;0.40, SE\u0026thinsp;=\u0026thinsp;0.04, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001). Significant effects were also noted for MID1 and MID2, but no age interactions were found, indicating that differences in symptoms do not vary by age over time.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003ePsychopathology Domains (T1 to T3)\u003c/h2\u003e\u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\u003ch2\u003eSomatic Problems\u003c/h2\u003e\u003cp\u003eNo significant effects were observed for somatic problems in MID1 or MID2. However, MID3 demonstrated a significant main effect (β\u0026thinsp;=\u0026thinsp;0.25, SE\u0026thinsp;=\u0026thinsp;0.04, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001), indicating higher levels of somatic problems in children with MID compared to controls, with no significant age interactions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003ePicky Eating Problems\u003c/h2\u003e\u003cp\u003eA significant main effect for picky eating problems was observed in MID3 (β\u0026thinsp;=\u0026thinsp;0.29, SE\u0026thinsp;=\u0026thinsp;0.04, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001), with children with MID exhibiting higher levels of picky eating than controls. No significant age interactions were observed (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eAutism Spectrum Disorder (ASD) Problems\u003c/h2\u003e\u003cp\u003eChildren with MID3 showed significantly higher ASD problems at baseline (β\u0026thinsp;=\u0026thinsp;0.25, SE\u0026thinsp;=\u0026thinsp;0.08, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.004), and these differences increased further over time (age interaction β\u0026thinsp;=\u0026thinsp;0.05, SE\u0026thinsp;=\u0026thinsp;0.01, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). MID1 (β\u0026thinsp;=\u0026thinsp;0.26, SE\u0026thinsp;=\u0026thinsp;0.09, pFDR\u0026thinsp;=\u0026thinsp;.01) and MID2 (β\u0026thinsp;=\u0026thinsp;0.31, SE\u0026thinsp;=\u0026thinsp;0.11, pFDR\u0026thinsp;=\u0026thinsp;.01) also showed higher baseline symptoms, but no significant changes in trajectories.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eSleep Problems\u003c/h2\u003e\u003cp\u003eSignificant main effects for sleep problems were observed in MID2 (β\u0026thinsp;=\u0026thinsp;0.20, SE\u0026thinsp;=\u0026thinsp;0.07, pFDR\u0026thinsp;=\u0026thinsp;.02) and MID3 (β\u0026thinsp;=\u0026thinsp;0.23, SE\u0026thinsp;=\u0026thinsp;0.04, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001), indicating elevated sleep problems in children with MID compared to controls. No significant age interactions were observed in any group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis longitudinal study examined the developmental trajectories of behavioral and emotional problems in children with MID compared to matched controls, using three MID definitions reflecting changes in DSM criteria and common practice. Our findings revealed that children with MID exhibit higher levels of behavioral and emotional problems. The observed findings across operationalizations for ADHD, ODD, affective, anxiety, and ASD problems among children with MID align with prior research highlighting the increased vulnerability of children with mild intellectual or developmental impairments [\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and we showed that this vulnerability is persistent in the age ranges studied. In addition, somatic problems (MID3), picky eating (MID3) and sleep problems (MID2\u0026amp;3) were higher in MID than non-MID participants, indicating persistent vulnerability.\u003c/p\u003e\u003cp\u003eMoreover, the higher vulnerability of children with MID compared to non-MID peers increased over time for ADHD (all operationalizations), and for affective (MID3) and ASD problems (MID3). This did not hold for the other psychopathology domains, so findings partially support our hypothesis. We hypothesized that problems which tend to decrease over time in the general population, would decrease less in children with MID, while problems that tend to increase, would increase more in children with MID. In line with this, across MID operationalizations, ADHD symptoms remained either stable or increased over time in children with MID, while non-MID participants showed decreasing ADHD symptom trajectories, suggesting that children with MID may face prolonged difficulties with ADHD symptoms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, affective and ASD problems in MID3 (but not MID1\u0026amp;2) showed a significantly greater increase over time compared to matched controls. Of note, we hypothesized a smaller \u003cem\u003edecrease\u003c/em\u003e in autism symptoms in children with MID, but found an \u003cem\u003eincrease\u003c/em\u003e over time relative to children without MID who, indeed, decreased. Problems in AF may overlap with mental health problems, and adding AF to the operationalization in MID1 and MID2 may therefore increase mental health problems. Focusing further on the results according to differences in MID operationalizations, we found that compared to MID1 (IQ\u0026thinsp;\u0026le;\u0026thinsp;75), adding AF criteria (MID2) resulted in only slightly stronger associations across most psychopathology domains, with the exception of a notable effect on sleep problems. In contrast, further expanding the IQ threshold from \u0026le;\u0026thinsp;75 to \u0026le;\u0026thinsp;85 and incorporating adaptive impairments (MID3) revealed more pronounced behavioral and emotional problems compared to MID1 and 2. Together the findings suggests that (a) a MID operationalization based solely on IQ (IQ\u0026thinsp;\u0026le;\u0026thinsp;75) already identifies children with elevated behavioral and emotional problems and (b) The higher level of problems found in the MID3 compared to the MID2 operationalization, which apply the same AF criteria, seems to come from increasing the IQ threshold (from \u0026le;\u0026thinsp;75 in MID2 to \u0026le;\u0026thinsp;85 in MID3). The results for the MID3 group are consistent with previous findings indicating that individuals with IQs in the borderline range (75\u0026ndash;85) experience significant psychosocial and mental health needs [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In fact, our results suggest that they have more mental health needs than the subset of children with lower IQ (i.e., MID1 \u0026amp; 2).\u003c/p\u003e\u003cp\u003eA comparison with a highly similar study in the TRAILS cohort (ages 11\u0026ndash;26; [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]) using equivalent MID operationalizations highlights both similarities and differences in psychopathology, as well in how MID operationalizations affect the outcomes. In both studies, the overall pattern showed increased vulnerability across domains of psychopathology for those with MID compared to their peers without MID, with few differences in trajectories over time. Interestingly, where the current study found diverging ADHD trajectories, with children with MID increasing in their symptoms while non-MID children decreased, TRAILS found decreasing trajectories with MID youth showing a slightly faster decrease over time in MID3. For ASD, TRAILS showed increasing vulnerability for MID youth over time for the MID1\u0026amp;2 groups, whereas in our study, ASD problems increased more over time only in MID3 (IQ\u0026thinsp;\u0026le;\u0026thinsp;85\u0026thinsp;+\u0026thinsp;adaptive impairments). A notable difference in findings between the two studies is that in TRAILS the strength of the associations increased gradually from MID1 to MID3, while in the current study associations only slightly increased when AF was added to the MID operationalization (MID1 \u0026loz; MID2) and became considerably stronger when the operationalization was further expanded by extending the IQ criteria to \u0026le;\u0026thinsp;85 (MID3). We can only speculate about the reasons underlying these differences. One possible reason is that during the early childhood period, as covered in the current study, supportive structures (e.g., in school) may be available for those children with lower IQ scores (\u0026le;\u0026thinsp;75), regardless of AF, which may not be available to the same degree for children with AF problems scoring just above the common IQ threshold of 75. For the older TRAILS children, societal demands for AF may be higher and AF impairments more debilitating. Thus, the association between AF, and by extension the MID operationalization, and mental health problems, may differ depending on age and available support structures.\u003c/p\u003e\u003cp\u003eA strength of this study is its comprehensive examination of various MID operationalizations within a large dataset. To our knowledge, the current study and the study by [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] are the first studies to test psychopathology trajectories across multiple commonly used MID definitions, providing valuable insights into how different diagnostic criteria capture distinct profiles of behavioral and emotional problems in children. In doing so, the findings raise important questions about the conceptual boundaries of MID. Expanding diagnostic criteria to include a broader range of cognitive and AF difficulties may lead to increasing overlap with mental health problems. This raises concerns about whether MID is evolving into an overly broad category that encompasses a very diverse set of mental health, AF and cognitive difficulties rather than a clearly defined diagnostic group. While our study cannot provide definitive answers to this, it highlights the need for continued reflection on how to best delineate MID from mental health problems. Alternatively, reflection may also lead to the conclusion that this differentiation is irrelevant and that a broad MID group is not overly broad as long as those in need receive appropriate support. A second strength of this study is that it contributes to the sparse literature on sleep problems and picky eating in children with MID [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Higher levels of sleep problems in MID2 and MID3 may indicate that AF problems may exacerbate sleep problems, which, in turn, could impair daily functioning and overall quality of life [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Picky eating was also significantly elevated in MID3, drawing attention to an area that may be related to nutritional status and growth. These findings suggest the need for comprehensive assessments that encompass behavioral and emotional as well as functional areas, enabling more targeted support for children with MID and their parents [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral methodological limitations warrant consideration. First, some criteria used to define AF overlapped with items included in the outcome measures of behavioral and emotional problems. This overlap may have influenced the observed associations and could partially explain the relationships identified in the study. What speaks against this is that, as argued, we found no clear differences between MID1 and MID2. Second, while we controlled for key demographics (age, sex, national origin, maternal education, and household income) using propensity score matching, unmeasured factors -including parenting styles, environmental stressors, and genetic predispositions- could have influenced the findings. We did not include these variables in the matching, as they may act as mediators or colliders rather than confounders, and therefore do not invalidate the current findings. Third, reliance on parent-reported measures for AF and behavioral/emotional problems rather than a clinician may introduce biases. Although AF and mental health problems conceptually overlap, it is possible that a clinician may still be better able to differentiate between these to the extent that differentiation is possible. Fourth, and related to this, none of the MID definitions used in this study incorporated clinical judgment, even though DSM-5 explicitly states that an MID diagnosis should not rely solely on test scores. The absence of qualitative, clinician-driven assessments may mean that some children who would be diagnosed in clinical settings were not identified as MID in this study, and vice versa. Fifth, group sizes and therefore power, differed between MID operationalizations, which is why MID group comparisons were also based on effect sizes. However, estimation accuracy differs among the three MID groups, although the smallest MID2 group was still substantial (MID2; n\u0026thinsp;=\u0026thinsp;82).\u003c/p\u003e\u003cp\u003eOur study underscores that both narrower (IQ\u0026thinsp;\u0026le;\u0026thinsp;75) and particularly broader (IQ\u0026thinsp;\u0026le;\u0026thinsp;85) definitions of MID capture children at risk of persistent behavioral and emotional problems. In addition, mostly for the latter group, the increasing risk of psychopathology from childhood into adolescence for ASD, affective, and ADHD problems may suggest that there is insufficient support to cater to the developmental needs of children with MID or that available support does not reach them. That is, the presence of mental health problems on top of MID may further hamper adaptive and daily life functioning. Children with an IQ score between 75 and 85 may have less access to specialized care and facilities than children with lower intellectual functioning.\u003c/p\u003e\u003cp\u003eOur results also have implications for research. Various MID operationalizations may result in different associations with external variables, possibly affecting the implications of study results. The comparison with the TRAILS study shows that the age of the sample may affect the effect of the particular MID operationalization on the results. Not including AF in MID operationalizations, as has been common in research for practical reasons [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], may lead to underestimation of associations with psychopathology problems when a DSM-5-TR definition of MID is accepted. MID operationalizations should therefore be taken into account when comparing study results, and MID definitions should be harmonized in future research.\u003c/p\u003e\u003cp\u003eIn conclusion, this study showed that children with MID, particularly when defined as IQ\u0026thinsp;\u0026le;\u0026thinsp;85 and including AF impairments, exhibit persistent as well as increasing behavioral and emotional problems compared to their matched peers. Standardizing MID criteria in research and clinical practice are needed to improve comparability between studies and enhance diagnosis accuracy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConcept and design: Koc, Masselink, Hartman, Jansen. Acquisition, analysis, and interpretation: Koc, Masselink, Hulsmans. Drafting of the manuscript: Koc, Masselink, Hulsmans. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Koc. Obtained funding: Hartman, Jansen. Supervision: Hartman, Jansen.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis study was funded by the Netherlands Organization for Health Research and Development (ZonMw project 636340003). The general design of the Generation R Study is supported by the Erasmus Medical Center, Erasmus University Rotterdam, the Netherlands Organization for Health Research and Development, the Netherlands Organization for Scientific Research, the Ministry of Health, Welfare and Sport, the Municipal Health Service Rotterdam area, and the Stichting Trombosedienst \u0026amp; Artsenlaboratorium Rijnmond.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData can be obtained upon request. Requests should be directed towards the management team of the Generation R Study ([email protected]), which has a protocol for approving data requests. Because of restrictions based on privacy regulations and informed consent of participants, data cannot be made freely available in a public repository.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCARULLA LS, REED GM, VAEZ-AZIZI LM et al (2011) Intellectual developmental disorders: towards a new name, definition and framework for mental retardation/intellectual disability in ICD-11. World Psychiatry 10:175\u0026ndash;180\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatel DR, Cabral MD, Ho A, Merrick J (2020) A clinical primer on intellectual disability. Transl Pediatr 9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21037/tp.2020.02.02\u003c/span\u003e\u003cspan address=\"10.21037/tp.2020.02.02\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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BJPsych Open 9:e48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1192/bjo.2023.31\u003c/span\u003e\u003cspan address=\"10.1192/bjo.2023.31\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNieuwenhuis JG, Lepping P, Mulder NL et al (2021) Increased prevalence of intellectual disabilities in higher-intensity mental healthcare settings. BJPsych Open 7:e83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1192/bjo.2021.28\u003c/span\u003e\u003cspan address=\"10.1192/bjo.2021.28\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarzeva SA, Masselink M, Hulsmans D et al Psychopathology and Substance Use Across Adolescence and Early Adulthood in Youth with and without Mild Intellectual Disability. Prep\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarper L, McAnelly S, Walshe I et al (2023) Behavioural sleep problems in children and adults with intellectual disabilities: An integrative literature review. J Appl Res Intellect Disabil 36:916\u0026ndash;928. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jar.13116\u003c/span\u003e\u003cspan address=\"10.1111/jar.13116\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSurtees ADR, Oliver C, Jones CA et al (2018) Sleep duration and sleep quality in people with and without intellectual disability: A meta-analysis. Sleep Med Rev 40:135\u0026ndash;150. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.smrv.2017.11.003\u003c/span\u003e\u003cspan address=\"10.1016/j.smrv.2017.11.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaylor CM, Emmett PM (2019) Picky eating in children: causes and consequences. Proc Nutr Soc 78:161\u0026ndash;169. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0029665118002586\u003c/span\u003e\u003cspan address=\"10.1017/S0029665118002586\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMunir KM (2016) The co-occurrence of mental disorders in children and adolescents with intellectual disability/intellectual developmental disorder. Curr Opin Psychiatry 29:95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/YCO.0000000000000236\u003c/span\u003e\u003cspan address=\"10.1097/YCO.0000000000000236\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eObi O, Van Naarden Braun K, Baio J et al (2011) Effect of Incorporating Adaptive Functioning Scores on the Prevalence of Intellectual Disability. Am J Intellect Dev Disabil 116:360\u0026ndash;370. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1352/1944-7558-116.5.360\u003c/span\u003e\u003cspan address=\"10.1352/1944-7558-116.5.360\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e Participant demographics per MID operationalization, and matched controls.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMID1\u003c/p\u003e\u003cp\u003e(IQ\u0026thinsp;\u0026le;\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eMID2\u003c/p\u003e\u003cp\u003e(IQ\u0026thinsp;\u0026le;\u0026thinsp;75\u0026thinsp;+\u0026thinsp;Conc., Soc., or Prac)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eMID3\u003c/p\u003e\u003cp\u003e(IQ\u0026thinsp;\u0026le;\u0026thinsp;85\u0026thinsp;+\u0026thinsp;Conc., Soc., or Prac.)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eN participants\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e246\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e408\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1224\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT1 age, mean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.55 (0.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.55 (0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.54 (0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.54 (0.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.53 (0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.54 (0.10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIQ, mean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69.1 (6.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100.0 (12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68.3 (5.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e99.7 (13.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e75.2 (8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e102.0 (12.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIQ Range\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45\u0026ndash;74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76\u0026ndash;140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45\u0026ndash;74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e76\u0026ndash;139\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e45\u0026ndash;84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e76\u0026ndash;139\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMale, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80 (69.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e240 (69.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57 (69.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e171 (69.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e262 (64.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e790 (64.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMaternal national origin, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDutch\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42 (36.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e125 (36.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (40.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e98 (39.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e214 (52.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e631 (51.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNon-Dutch European\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (7.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 (7.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25 (6.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e71 (5.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNon-European\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64 (55.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e193 (56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43 (52.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e130 (52.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e169 (41.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e522 (42.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMonthly household income (\u0026euro;/month), n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;1,200\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (43.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e151 (43.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35 (42.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e105 (42.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e113 (27.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e325 (26.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1,200-2,000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (10.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (10.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 (8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e61 (15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e193 (15.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026gt;2,000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53 (46.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e158 (45.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40 (48.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e120 (48.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e234 (57.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e706 (57.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMaternal education level, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePrimary or lower\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (22.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (22.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (20.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50 (20.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e55 (13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e163 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSecondary\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55 (47.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e167 (48.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38 (46.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e114 (46.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e206 (50.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e623 (50.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHigher\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (29.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e102 (29.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (32.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e82 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e147 (36.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e438 (35.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: Conc. = Conceptual functioning problems; Soc. = Social functioning problems; Prac. = Practical functioning problems; MID\u0026thinsp;=\u0026thinsp;Mild Intellectual Disability group; Control\u0026thinsp;=\u0026thinsp;Matched control for the MID group; IQ\u0026thinsp;=\u0026thinsp;Intelligence quotient based on the WISC-V.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation between MID status and psychopathology domains over time.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"20\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eMID1\u003c/p\u003e\u003cp\u003e(IQ\u0026thinsp;\u0026le;\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c13\" namest=\"c8\"\u003e\u003cp\u003eMID2\u003c/p\u003e\u003cp\u003e(IQ\u0026thinsp;\u0026le;\u0026thinsp;75\u0026thinsp;+\u0026thinsp;Conc., Soc., or Prac.)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"7\" nameend=\"c20\" namest=\"c14\"\u003e\u003cp\u003eMID3\u003c/p\u003e\u003cp\u003e(IQ\u0026thinsp;\u0026le;\u0026thinsp;85\u0026thinsp;+\u0026thinsp;Conc., Soc., or Prac.)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eMain effect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eAge Interaction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003eMain effect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u003cp\u003eAge Interaction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c17\" namest=\"c14\"\u003e\u003cp\u003eMain effect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c20\" namest=\"c18\"\u003e\u003cp\u003eAge Interaction\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStd Β (SE)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003epFDR\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStd Β (SE)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003epFDR\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eStd Β (SE)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003epFDR\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eStd Β (SE)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c13\"\u003e\u003cp\u003e\u003cem\u003epFDR\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c14\"\u003e\u003cp\u003eStd Β (SE)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cem\u003epFDR\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u003cp\u003eStd Β (SE)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c19\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c20\"\u003e\u003cp\u003e\u003cem\u003epFDR\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSomatic Problems\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.03 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.03 (0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.02 (0.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e-0.05 (0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.25 (0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u003cp\u003e-0.00 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePicky eating\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.07 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.04 (0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.12 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e-0.06 (0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.29 (0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u003cp\u003e-0.01 (0.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eASD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.26 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.06 (0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.31 (0.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.05 (0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.47 (0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u003cp\u003e0.05 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain effect at T1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.25 (0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003e.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSleep Problems\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.03 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.00 (0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.20 (0.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.02 (0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.23 (0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u003cp\u003e-0.00 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAffective\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.18 (0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e.04\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.23 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.02 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.38 (0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u003cp\u003e0.01 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e\u003cb\u003e.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain effect at T1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.25 (0.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnxiety\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.26 (0.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.28 (0.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.02 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.35 (0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" 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align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.\u003cb\u003e001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.44 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.\u003cb\u003e001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.05 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e.\u003cb\u003e001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.57 (0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" 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colname=\"c4\"\u003e\u003cp\u003e.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.13 (0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.37 (0.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eODD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.19 (0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.\u003cb\u003e03\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.21 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.02 (0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.40 (0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\u003cp\u003e-0.00 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"20\" nameend=\"c20\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e. Linear mixed-effect models were used to test the associations of MID status and repeatedly psychopathology domains from T1 to T5. Standardized effect estimates including the main effect and interaction effect(\u003cem\u003eβ\u003c/em\u003e) (Symptoms change; interaction of MID*age), as well as standard errors (SE), \u003cem\u003ep\u003c/em\u003e, and \u003cem\u003ep\u003c/em\u003eFDR values are shown. Conc. = Conceptual functioning problems; Soc. = Social functioning problems; Prac. = Practical functioning problems; MID\u0026thinsp;=\u0026thinsp;Mild Intellectual Disability group; IQ\u0026thinsp;=\u0026thinsp;Intelligence quotient based on the WISC-V; ASD\u0026thinsp;=\u0026thinsp;autism spectrum disorder problems. ADHD\u0026thinsp;=\u0026thinsp;Attention-deficit/hyperactivity problems; ODD\u0026thinsp;=\u0026thinsp;Oppositional defiant problems.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Mild Intellectual Disability, Psychopathology, DSM-5, Longitudinal Studies","lastPublishedDoi":"10.21203/rs.3.rs-7907188/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7907188/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe DSM-5(-TR) expanded the definition of Mild Intellectual Disability (MID) to include adaptive functioning (AF) alongside intelligence quotient (IQ). In this population-based study, we examined behavioral and emotional problems in children with MID and matched controls from early childhood to adolescence. We evaluated how three operationalizations of MID \u0026ndash;varying by IQ and AF\u0026ndash; influence outcomes. Cognitive assessments and parent-reported problems from 4,643 children from 1.5 to 15 years (T1 to T5) in the Generation R Study were used. MID was defined as: (1) IQ\u0026thinsp;\u0026le;\u0026thinsp;75; (2) IQ\u0026thinsp;\u0026le;\u0026thinsp;75 with impairments in AF; (3) IQ\u0026thinsp;\u0026le;\u0026thinsp;85 with impairments in AF. Propensity score matching ensured comparable MID and non-MID groups. Linear mixed models were employed to assess multiple domains of psychopathology over time. Across all MID definitions, children with MID exhibited elevated behavioral and emotional problems compared to matched controls. Children meeting the criteria for MID3, the broadest definition, showed the highest problem levels, with elevated ADHD (β\u0026thinsp;=\u0026thinsp;0.37, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001), affective (β\u0026thinsp;=\u0026thinsp;0.25, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001), and autistic problem scores (β\u0026thinsp;=\u0026thinsp;0.25, pFDR\u0026thinsp;\u0026lt;\u0026thinsp;.001) at baseline, with differences widening over time. Children with MID1 and MID2 also displayed unfavorable ADHD trajectories, although no baseline differences were observed. The findings suggest the extent of mental health problems depend on how MID is operationalized and suggest that psychopathology may be particularly present in children with borderline intellectual disability 75\u0026thinsp;\u0026le;\u0026thinsp;IQ\u0026thinsp;\u0026le;\u0026thinsp;85.\u003c/p\u003e","manuscriptTitle":"Psychopathology from Childhood to Adolescence in children with and without Mild Intellectual Disability (MID): a comparison across three MID operationalizations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 14:40:25","doi":"10.21203/rs.3.rs-7907188/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-05T05:18:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T09:02:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15918322828783300888975828090487683731","date":"2026-02-06T13:13:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65122866347189250792674037623673392816","date":"2025-11-17T06:45:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-15T05:58:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122982358172220000444341789621616887285","date":"2025-11-12T10:14:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162193997200009910045327592408320461866","date":"2025-11-10T21:39:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-10T12:23:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-23T05:02:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-23T05:01:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Child \u0026 Adolescent Psychiatry","date":"2025-10-20T15:22:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ae1de60a-0e4e-43f3-833a-234a29465a86","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-03T09:38:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 14:40:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7907188","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7907188","identity":"rs-7907188","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}