Basic Psychological Needs and Mental Health in Adolescents with a Mild to Borderline Intellectual Disability

ABSTRACT

Introduction

Emotional and behavioral problems are common in adolescents with mild to borderline intellectual disabilities (MBID). Basic Psychological Needs Theory connects fulfillment of basic psychological needs (autonomy, relatedness, competence) to ill-being (mental health problems). The associations between the frustration and satisfaction of basic psychological needs and indicators of mental health problems are the subject of this study.

Method

Adolescents with MBID (N = 324, mean age 15.2 years), filled out questionnaires on basic psychological needs (BPNSFS-ID) and on anxiety (SCARED), depression (CDI) and aggression (Externalizing Problems scale of YSR). A subgroup of adolescents with MBID and severe behavioral problems (MBID-SBP) was compared to a general subgroup (MBID-G).

Results

Outcomes for adolescents with MBID-SBP were worse than for adolescents with MBID-G on most measures. BPNSFS-ID frustration was positively associated with mental health problems. Correlations for the BPNSFS-ID satisfaction scales were positive but weaker. Associations within the MBID-SBP subgroup were stronger than for the MBID-G subgroup.

Discussion

Frustration of BPN in particular is associated with mental health problems. Attending basic psychological needs may potentially help to counter ill-being.

KEYWORDS:

• Basic psychological needs (BPN)
• mental health
• adolescents
• MBID
• BPNSFS-ID
• externalizing behavior
• anxiety
• depression
• aggression

Emotional and behavioral problems are very common in Dutch children and adolescents with a mild to borderline intellectual disability (MBID; Dekker et al., 2002). Dekker et al. (2002) found that 48% of children and adolescents with MBID versus 18% of children and adolescents in the general population scored in the borderline or clinical range of the Total Problem Score of the Child Behavior Checklist (CBCL; Achenbach, 1991), a widely used instrument to measure a wide range of behavioral problems. For Internalizing Problems, which comprises somatic, anxiety and mood problems, they found percentages of 39% for children and adolescents with MBID and 19% for typically developing children and adolescents. For Externalizing Problems, which comprises aggression and conduct problems, they found 39% and 17% respectively. Mental disorders are more prevalent in adolescents with MBID than in non-MBID adolescents, and psychopathology in this group more often goes unrecognized and untreated (Emerson & Hatton, 2007; Wallander et al., 2003). Knowledge of psychological factors that are related to mental health problems in adolescents with MBID is needed to better understand these problems, and possibly find new ways to deal with them. An alternative way of looking at mental health problems (like internalizing and externalizing problems) in adolescents with MBID is based on Self-Determination Theory (SDT) and Basic Psychological Needs Theory (BPNT; Deci & Ryan, 2000, 2008, 2012; Ryan & Deci, 2000b, 2008). These theories are considered relevant, since they claim that well-being and ill-being depend on the level of fulfillment of basic psychological needs. Well-being refers to the eudaemonic, not the hedonic, meaning of the concept, when a person is fully functioning (Deci & Ryan, 2000; Ryan & Deci, 2000a). In the current study, the association between ill-being (mental health problems) and satisfaction and frustration about the fulfillment of basic psychological needs is studied in adolescents with MBID.

Basic Psychological Needs Theory (BPNT) is a central mini theory within Self-Determination Theory (Ryan & Deci, 2017). Competence, autonomy, and relatedness are considered innate, essential, and universal basic psychological needs (Chen et al., 2015; Ryan & Deci, 2000b). Fulfilment of these needs is claimed to be essential for an individual’s sense of integrity, constructive social development and personal well-being, and therefore motivates people to take action (Deci & Ryan, 2008). The need for competence refers to the effectiveness a person experiences in social interactions and in the opportunities to express his or her capabilities. The need for autonomy refers to a sense of choice, volition, and freedom from excessive external pressure toward behaving or thinking in a certain way. The need for relatedness refers to the feeling of connection to and caring for or being cared for by other people. Satisfaction of these needs goes along with self-fulfillment and self-realization through autonomously regulated action and is usually accompanied by a state of wellbeing. Thwarting of these needs is experienced as averse and undermines motivation for behaviors that would be compatible with competence, autonomy, and relatedness (Ryan & Deci, 2000b). In their review, Vansteenkiste and Ryan (2013) state the importance of distinguishing between need satisfaction and need frustration. Especially frustration of basic psychological needs is a predictor of ill-being (Bartholomew et al., 2011; Vansteenkiste & Ryan, 2013). Vansteenkiste and Ryan (2013) cite studies that demonstrated the link between need frustration and aggression, depression, and other indicators of ill-being, as well as the link between need satisfaction and indicators of well-being.

Stanley et al. (2021) found significant meta-analytic associations between greater satisfaction of each of the three basic psychological needs (BPN) with higher positive and less negative affect. Basic psychological needs and their relation to well-being and ill-being have been extensively studied and demonstrated in various populations, including people with different cultural backgrounds (Chen et al., 2015), adolescents (Yu et al., 2016), emerging adults (Reed-Fitzke & Lucier-Greer, 2021), adults with MBID (Frielink et al., 2018), students with learning disabilities (Deci et al., 1992), elderly people (Vanhove-Meriaux et al., 2018), and athletes (Bartholomew et al., 2011). However, the extent to which youth with MBID experience satisfaction and frustration of basic psychological needs is unclear, nor is clear what basic psychological needs may contribute to explaining their mental health.

Youth with MBID in particular might be prone to experience relatively low satisfaction and high frustration of BPN. For instance, it could be that fulfillment of their need for competence is thwarted due to low adaptive functioning. Low adaptive functioning means that persons find it difficult to handle common demands in life and function as independently as others of the same age and background (Schalock et al., 2010). The need for autonomy may be thwarted due to being aware of this dependence upon the support of others to function than peers without MBID. The need for relatedness may come under pressure due to social exclusion and the relatively small size of the social network of young people with MBID in general (e.g., Giesbers et al., 2020).

Actual research into BPN of people with MBID is scarce, however, and even more so for youth with MBID in particular. Frielink et al. (2018) have demonstrated a relation between autonomy support style and the level of satisfaction or frustration of BPN in adults with MBID. In their study, autonomous motivation and satisfaction of BPN were associated with well-being, statistically mediating the extent to which their direct support staff was perceived as autonomy supportive. These findings were consistent with findings in the general population. Late adolescents with intellectual disabilities experienced less autonomy than their peers without intellectual disability in daily life activities (Salt & Jahoda, 2020). In an experimental study the benefits of an autonomy-supportive teaching style in adolescents and adults with a mild intellectual disability were demonstrated (Emond Pelletier & Joussemet, 2016). Behzadnia et al. (2022) showed experimentally that need-supportive teaching led to improvement of BPN satisfaction and decrease of frustration in students with MBID. This went along with more positive and less negative affect, although it was not clear to what extent the changes in affect could be explained by the effects of the teaching style on need satisfaction and frustration, and no associations between BPN satisfaction, frustration, and affect were reported. In sum, while a plausible link may be made between BPN and mental health outcomes, it remains open for empirical testing.

In this study, we investigated the relationship between satisfaction and frustration of BPN and mental health problems in adolescents with MBID. The hypothesis tested was that satisfaction of BPN is lower, and frustration of BPN is higher, in anxious and/or depressed and/or aggressive adolescents than in non-anxious, non-depressed and non-aggressive adolescents with MBID.

METHODS

Participants

Adolescents with MBID were recruited from four special secondary schools and one special secondary school for students from a residential youth care facility in the Netherlands. We approached the same seven special secondary schools that had taken part in our previous study (Klein et al., 2018b). Four of these schools decided to participate again. The participating schools were asked to invite all of their students to participate in the study. Some schools decided to do so; some schools decided to invite only all students in their first and second or first, second and third year. Information letters were handed out or sent out to the students and the parents of the students by the schools (because of privacy regulations this had to be done by the schools). When students or their parents had informed the school that they objected to participation, the student was excluded from participation. We use the terms “MBID general” (MBID-G) and “MBID severe behavioral problems” (MBID-SBP) in this paper to differentiate between the groups. Admittance criteria for the four special secondary schools (practical, vocational schools) are an IQ-score between 55 and 80 and learning deficits (Rijksoverheid, n.d.). Admittance criteria for the residential youth care facility are adolescents with a mild intellectual disability or a borderline level of intellectual functioning (IQ range 55–85), including problematic adaptive behavior (American Psychiatric Association, 2013; Schalock et al., 2010) and severe behavioral or emotional problems. To be admitted, the severity of these problems must have led to an indication for this type of treatment care from the Municipality, under the Dutch Youth Act, for youth under 18 years of age, or from the Dutch Centre of Indications for Care, under the Dutch Long Term Care Act. We included this group to represent the population of MBID within a range of cognitive, social, and behavioral problems. Furthermore, we wanted to check exploratively if our hypotheses hold for adolescents with MBID and more severe behavioral problems. The difference in IQ-range in the admittance criteria between the schools for special secondary education and the treatment facility are due to differences between the Dutch laws for special education and youth care. Within the residential youth care facility, a school is located for special secondary education. About 80% of its students are adolescents who stay at the youth care facility. The remaining 20% are adolescents from the local region who also need this type of education. The main difference is that these adolescents usually live with their parent(s). Participants were between 11.3 and 19.3 years of age (M = 15.2; SD = 1.53) and 57.1% were male. Most participants were born in the Netherlands (91.4%).

The materials reported here are part of a larger community-based project on anxiety in adolescents with MBID (Houtkamp, 2017; Klein et al., 2018a, 2018b). The Ethics Review Board of the University of Amsterdam approved the original protocol and consent procedure (ISRCTN number 73367465). During data collection, the board changed the conditions for passive consent. So, whereas we started with passive informed consent for the students and their parents in three schools, we switched accordingly to active consent halfway through the study, in two schools. This switch in procedure was associated with a large difference in participation between the schools with passive consent (n = 361) and the schools with active consent (n = 19). See Figure 1 for the participant flow. Data collection took place in the first quarter of 2017.

Figure 1. Numbers of participants, non-responder and drop outs.

INSTRUMENTS

Screen for Child Anxiety Related Emotional Disorders

Anxiety was measured using the Dutch version of the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al., 1997, 1999; Muris & Steerneman, 2001). The adapted, slightly extended original version of the SCARED (41 items; Birmaher et al., 1999) was used. The SCARED is a self-report questionnaire that consists of 41 items that measure five categories of anxiety: panic/somatic, generalized anxiety, separation anxiety, social phobia, and school phobia, on a three-point Likert scale (not true/sometimes true/often true) and provides a total anxiety score as well. Items are scored 0-1-2. Higher scores are indicative of higher levels of anxiety. A cutoff score of 25 for the total score on the 41-item SCARED was obtained (Birmaher et al., 1999). The SCARED has good psychometric properties, with good internal consistency and good sensitivity and specificity. Discriminant validity is good, both in the original studies with the 38- and 41-item SCARED (Birmaher et al., 1997, 1999) and in a Dutch study among adolescents, with the Dutch version of the 38-item SCARED (Hale et al., 2005). Internal consistency of the SCARED was excellent in the current sample (Cronbach’s α = .93). To the best of our knowledge, no studies have been conducted to assess the reliability of the SCARED for adolescents with MBID. Because the SCARED is constructed for the use of children and adolescents from the age of 8 years, we considered the wording and concepts of the SCARED understandable for adolescents with MBID.

Child Depression Inventory

Mood problems were assessed using the Dutch revised version of the Child Depression Inventory (CDI; Kovacs, 1985; Timbremont et al., 2008). The CDI consists of 27 combinations of three comparable sentences that differ in intensity and participants must choose the sentence that best reflects their thoughts and feelings over the past two weeks (e.g.: if something bad happens, it is always my fault/if something bad happens, it is often my fault/if something bad happens, it is usually not my fault). Items are scored 0-1-2. Some items are scored reversed initially, but after reversing those items and calculating a total score, a higher score is indicative of a higher level of mood problems, with a cutoff score of 19, both in the original version and in the Dutch version (Kovacs, 1985; Timbremont et al., 2008). The Dutch CDI has good internal consistency and validity and discriminates between depressed and non-depressed children and adolescents in a clinical setting, with a sensitivity of 75% and a specificity of 82% (Timbremont et al., 2008). The internal consistency of the Dutch version of the CDI-2 (highly similar to the revised CDI used in this study; Bodden et al., 2016) for use with adolescents with MBID was studied by Lakeman et al. (2017). They found the CDI-2 to be an internally consistent measure for adolescents with MBID, even without extra explanation (Cronbach’s α = .78 and >.83 in Lakeman et al., 2017). The CDI and CDI-2 have been used in samples of adolescents with MBID before, with good internal consistency (e.g., CDI: Cronbach’s α = .80 in: Heiman, 2001; CDI-2: Cronbach’s α = .81 in: Weeland et al., 2017). In the present sample we found Cronbach’s α = .87.

Youth Self Report

Externalizing behavioral problems were assessed using the Externalizing Problems scale of the Dutch version of the Youth Self Report (YSR; Achenbach & Edelbrock, 1987; Achenbach & Rescorla, 2001, 2007; Verhulst et al., 1997). The 30 items were administered in the same order as in the full YSR and had to be answered on a three-point Likert scale (not at all/sometimes/often). Items are scored 0-1-2. Higher scores reflect more problematic behavior. Dutch cutoff scores of 16 and 18 were obtained for girls and boys, respectively. Scores at or above the cutoff score are considered (sub)clinical (Verhulst et al., 1997). The Dutch version of the Externalizing Problems scale of the YSR has good internal consistency and discriminates between a clinical and a norm group (Verhulst et al., 1997). The YSR can be used in adolescents with a mild or borderline intellectual disability (Douma et al., 2006). Internal consistency (Cronbach’s α) in this sample was .85 for the Externalizing Problems scale of the YSR.

Basic Psychological Needs Satisfaction and Frustration Scale – Intellectual Disability

The levels of satisfaction and frustration of participants’ basic psychological needs were assessed using the Basic Psychological Needs Satisfaction and Frustration Scale which was developed by Chen et al. (2015) and adapted by Frielink et al. (2019) into the BPNSFS-Intellectual Disability (BPNSFS-ID) to improve comprehension for people with mild to borderline intellectual disability. This questionnaire consists of 24 questions and uses a five-point Likert scale (completely untrue/untrue/neutral/true/completely true). Items are scored 1-2-3-4-5. Higher scores on the frustration items reflect higher levels of frustration; higher levels on the satisfaction items reflect higher levels of satisfaction. This questionnaire was validated in a Dutch sample of adults with mild to borderline ID, aged 18–84. Internal consistency (Cronbach’s α) of .92 was reported for the full scale, .78–.92 for the six factor scales, and .86–.91 for the composite factor scores (Frielink et al., 2019). The BPNSFS-ID has not been used in a sample of adolescents with ID before, to our knowledge, although De Valk et al. (2019a) used it in a sample of Dutch adolescents in open, secure, and forensic residential youth care institutions, that likely included youth with a low level of education or a mild intellectual disability. They found Cronbach’s α = .69–.90 on the six factor scales (De Valk et al., 2019a). In our sample, internal consistency was good for the total scale (Cronbach’s α = .89). Internal consistency for the six factor scales was substantially lower than in the sample by Frielink et al. (2019) and varied from questionable to good for five of the six factor scales (Cronbach’s α = .62–.83) with an exception for the factor Relatedness Frustration (Cronbach’s α = .54). Internal consistency for the composite factor scores (Autonomy .64, Relatedness .73, and Competence .84) was also substantially lower than in the sample by Frielink et al. (2019). The satisfaction and frustration scales are not fully orthogonal. For each of the three basic psychological needs we found weak to moderate, statistically significant (p < .01), negative correlations between the satisfaction and frustration scales (for Autonomy: r = −.17; for Relatedness: r = −.28; and for Competence: r = −.47).

In all questionnaires, simplified language was added between brackets after the original formulation of some words that were possibly too difficult to understand without further explanation for the participants, because of their MBID. Participants also had the opportunity to ask the researcher or the research assistant present, for clarification during participation. For participants who had trouble reading, the instructions and questions were read out loud to them, one-on-one.

PROCEDURE

Participation took place in classrooms where a computer was available for each student. The classroom- or IT-teacher was present during participation, as well as the researcher or one or two trained research assistant(s). Participation took about 45 minutes per participant and the students received a keyring as a token of appreciation for participating.

ANALYSES

For the preliminary analyses we used Chi square tests and t-tests for two independent samples to test for differences between the groups regarding gender, country of birth and age. We used correlation analyses to investigate the associations between fulfillment of basic psychological needs and indicators of mental health problems. To test for possible differences in correlations between the MBID-G and MBID-SBP groups, we used Fisher’s Z-test (Soper, 2021). To correct for the number of correlations calculated, we used the Benjamini-Hochberg procedure for post hoc correction of the false discovery rate (Benjamini & Hochberg, 1995).

RESULTS

Preliminary Analyses

First, we compared the dependent and independent variables within the MBID-G and MBID-SBP groups. No statistical differences were found for gender and country of birth. Mean age in the general MBID (MBID-G) group was statistically lower (M = 14.8 yrs, SD = 1.53) than in the MBID group with severe behavioral problems (MBID-SBP; M = 16.1 yrs, SD = 1.35). We also calculated the percentage of adolescents in the total group and both subgroups who scored above the cutoff score on the mental health indicators. In the MBID-G group 20.8% scored above the cutoff score on the anxiety measure, whereas in the MBID-SBP group 45.2% scored above the cutoff score. This difference was statistically significant (χ² = 18.73, p < .001). Similarly, on the depression measure, 11.3% of participants in the MBID-G group scored above the cutoff score, whereas 25% of participants in the MBID-SBP group scored above the cutoff score. This difference was statistically significant (χ² = 9.32, p = .002). For externalizing problems we found even higher differences: in the MBID-G group 11.8% scored above the cutoff score versus 39.3% in the MBID-SBP group. This difference was also statistically significant (χ² = 31.06, p < .001). On the three frustration scales of the BPNSFS-ID, for which no cutoff scores are available, participants in the MBID-G group scored statistically significantly lower (which is a better outcome) than participants in the MBID-SBP group, although these differences were clinically much smaller than for the mental health indicators. Participants in the MBID-G group also scored statistically significantly higher (which is a better outcome) than participants in the MBID-SBP group on two of the three satisfaction scales of the BPNSFS-ID, namely on Autonomy Satisfaction and on Competence Satisfaction. These differences were also clinically small. On the third dimension, Relatedness Satisfaction, the two groups did not differ significantly. See Table 1 for an overview of all descriptives and scores on the mental health indicators and the Basic Psychological Needs scales, for the total group and both subgroups. Because the groups differed on most outcome variables, correlations between the frustration and the satisfaction scales of each of the three basic psychological needs (BPN) and anxiety (total SCARED-41 score), depression (total CDI score) and externalizing behavior (Externalizing Problems scale score of the YSR), were calculated for both the total group of adolescents with MBID and for the two subgroups separately.

Table 1. Descriptives and outcome of mental health indicators and Basic Psychological Needs (BPN) for the total group and differences between the two subgroups.

	Total group (n = 324)		MBID-G^1 (n = 240)		MBID-SBP^2 (n = 84)		Differences between subgroups
	n	%	n	%	n	%	Sig.^3
Gender Female	139	42.9	100	41.7	39	46.4	.448
Country of birth (vs. other) The Netherlands	296	91.5	220	91.7	76	90.5	.738
	M	SD	M	SD	M	SD	Sig.
Age (yrs)	15.15	1.53	14.83	1.46	16.05	1.35	.000^4
SCARED-41 total score n and % on/above cutoff score	18.45 88	13.02 27.2%	16.56 50	11.47 20.8%	23.86 38	15.51 45.2%	.000^6 .000^3
CDI total score* n and % on/above cutoff score	10.34 48	8.14 14.81%	9.40 27	6.61 11.3%	13.02 21	11.06 25%	.006^6 .002^3
YSR Externalization score n and % on/above cutoff score	10.74 61	7.16 18.8%	9.27 28	5.67 11.8%	14.89 33	9.11 39.3%	.000^6 .000^3
Autonomy – satisfaction	13.20	3.34	13.52	3.24	12.31	3.46	.006^5
Autonomy – frustration	9.86	3.47	9.38	3.20	11.23	3.86	.000^5
Relatedness – satisfaction	15.76	3.91	15.80	3.74	15.64	4.39	.770^5
Relatedness – frustration	8.30	3.04	7.92	2.65	9.39	3.75	.001^6
Competence – satisfaction	15.20	3.81	15.48	3.59	14.38	4.29	.037^5
Competence – frustration	8.89	3.70	8.24	3.12	10.73	4.52	.000^6

Note: ¹ This group consists of the participants of four schools for students with MBID (“general” MBID group). ² This group consists of the participants from one school, affiliated with a residential treatment facility for adolescents with MBID and severe behavioral problems. ³ p-value, based on χ² test. ⁴ p-value, based on t-test. ⁵ p-value, based on one-way ANOVA. ⁶ p-value, based on one-way ANOVA with Welch correction for unequal variance.

Associations Between Need Satisfaction and Frustration and Mental ILL-Being

In Table 2, the main results of this study are presented. The frustration scales of the three basic psychological needs, autonomy, relatedness, and competence were all positively and statistically significantly associated with each of the three measures for mental health (anxiety, depression and externalizing behavior) in our sample of adolescents with MBID (correlations for each of the three frustration measures with each of the three mental health indicators varied for the total group from .35 to .66, all statistical tests p < .001). Adolescents with higher levels of frustration of their basic psychological needs also showed higher levels of mental health problems, on average. These results were found for the total group of participants, as well as for both subgroups separately (in the MBID-G subgroup correlations for each of the three frustration measures with each of the three mental health indicators varied from .23 to .59 and for the MBID-SBP subgroup from .45 to .74 respectively, all statistical tests p < .001). For the satisfaction scales, especially for relatedness satisfaction, correlations with the mental health outcome measures were somewhat weaker. Autonomy satisfaction and competence satisfaction were negatively and statistically significantly associated with anxiety and depression for the total group and both subgroups (correlations ranging from −.21 to −.83, all but one statistical tests p < .001; for the correlation between autonomy satisfaction and anxiety in the MBID-G group p = .001). Lower levels of satisfaction of these two basic psychological needs were associated with higher levels of internalizing mental health problems. Autonomy satisfaction and competence satisfaction were also negatively and statistically significantly associated with externalizing behavior for the total group (−.17, p = .002 and −.25, p < .001 respectively) and for one of the two subgroups (the MBID-SBP group: −.39 and −.45 respectively, both p < .001) but not for the MBID-G subgroup. Relatedness satisfaction was negatively and significantly related to depression in the total group (−.52, p < .001) and both subgroups (−.50 and −.59 for MBID-G and MBID-SBP respectively, both p < .001). It was negatively and significantly related to anxiety (−.25, p = .021) and externalizing behavior (−.36, p = .001) as well in the MBID-SBP subgroup only, but not in the MBID-G subgroup or in the total group. After applying the Benjamini-Hochberg procedure to correct for multiple testing (Benjamini & Hochberg, 1995), using a false discovery rate of .05, all statistical results remained unchanged.

Table 2. Pearson correlation coefficients for Basic Psychological Needs (BPN) in association with mental health indicators.

	SCARED-41 total score				CDI total score				YSR Externalization score
	Total group (n = 324)	MBID-G^1 (n = 240)	MBID-SBP^2 (n = 84)	Difference between subgroup correlations (Fisher’s Z)	Total group	MBID-G	MBID-SBP	Difference between subgroup correlations (Fisher’s Z)	Total group	MBID-G	MBID-SBP	Difference between subgroup correlations (Fisher’s Z)
Autonomy – satisfaction	−.29**	−.21**	−.39**	1.54	−.47**	−.40**	−.55**	1.51	−.17**	.03	−.39**	3.43**
Autonomy – frustration	.35**	.23**	.45**	−1.95	.39**	.23**	.57**	−3.21**	.43**	.29**	.53**	−2.27*
Relatedness – satisfaction	−.10	−.02	−.25*	1.83	−.52**	−.50**	−.59**	1.00	−.09	.10	−.36**	3.71**
Relatedness – frustration	.53**	.48**	.55**	−.74	.55**	.38**	.73**	−4.11**	.40**	.23**	.50**	−2.45*
Competence – satisfaction	−.35**	−.25**	−.48**	2.08	−.69**	−.61**	−.83**	3.72**	−.25**	−.08	−.45**	3.14**
Competence – frustration	.66**	.59**	.70**	−1.47	.59**	.44**	.74**	−3.72**	.50**	.29**	.63**	−3.44**

Note: ¹ This group consists of the participants of four schools for students with MBID (“general” MBID group). ² This group consists of the participants from one school, affiliated with a residential treatment facility for adolescents with MBID and severe behavioral problems. * significance p < .05. ** significance p < .01. Significance is only marked * or ** if the correlation or the difference between the subgroup correlations remained significant after applying the Benjamini-Hochberg procedure to reduce the false discovery rate.

Group Differences in Associations Between Need Satisfaction and Frustration and ILL-Being

As can be seen in Table 2, a little over half of the correlations between the basic psychological needs scales and the mental health scales were significantly stronger for the MBID-SBP subgroup than for the MBID-G subgroup. This was especially the case for correlations between the basic psychological need scales and the depression and aggression scales. For the anxiety scale the differences between the subgroups only reached significance (p < .05) for one basic psychological need factor (competence satisfaction), but the significance of this difference disappeared after applying the Benjamini-Hochberg procedure. All other differences we found, remained significant after applying the Benjamini-Hochberg procedure.

DISCUSSION

In this study we empirically tested the hypothesized links between basic psychological needs (BPN) and mental health in adolescents with MBID. We found significant associations between frustration and satisfaction of autonomy, relatedness and competence on the one hand and internalizing and externalizing problems on the other hand. The results are in line with previous studies into the relation between fulfillment of BPN and mental health, in cross-cultural student populations (Chen et al., 2015), in typically developing adolescents (Inguglia et al., 2018), and in adults with an intellectual disability (Frielink et al., 2018). Findings underscore the relevance of feelings about basic psychological need fulfillment for understanding mental health problems, offering a new perspective on the high prevalence of such problems among adolescents with MBID compared to their typically developing peers (Dekker et al., 2002).

Our results show that especially frustration of BPN is related to mental health problems in adolescents with MBID, because all frustration scales were statistically associated with all mental health measures, whereas statistically significant associations were not consistently found for all satisfaction scales in the overall sample and subgroups of adolescents with MBID from the general population (MBID-G) and those with severe behavior problems (MBID-SBP). These results also confirm previous findings that especially frustration of BPN is related to ill-being (Bartholomew et al., 2011; Vansteenkiste & Ryan, 2013). Whereas frustration and satisfaction of basic psychological needs may reflect two related but still distinct dimensions with unique correlates, mental ill-being and mental well-being may similarly be related but still distinct (Bartholomew et al., 2011). In the current study we did not measure well-being separately, and therefore we do not know whether basic psychological need satisfaction was more strongly associated with positive mental health outcomes than with negative outcomes.

In the MBID-SBP group, mental health problem scores were on average higher (more negative outcome) than in the MBID-G group. For externalizing problems this might not be surprising, because an important characteristic of adolescents in the MBID-SBP group is the presence of severe behavioral problems. One might even expect, based on the indication for intensive treatment, that a higher percentage of the MBID-SBP group would have scored above the cutoff score for externalizing problems on the Youth Self Report. A possible reason why not all youth in this group scored in the clinical range is that the treatment in the residential treatment facility reduced the display of externalizing problem behavior. Another explanation could be that placement is based on clinical assessments that not only include the perceptions of youth on their own functioning but also on the perceptions of parents and teachers, which may not always align with those of youth themselves. Adolescents with MBID who are being treated in a residential youth care facility might more often come from families that experience multiple problems compared to adolescents with MBID who live with their families (Harder et al., 2020) and they experience physical separation from their parents and siblings. More extreme levels of frustration of their need for relatedness may therefore be more likely. Also, the group climate in the residential youth care facility might lead to higher levels of frustration and lower levels of satisfaction of their need for autonomy, because of the rules and regulations in the youth care facility, that can be perceived as very restrictive by the residents (De Valk et al., 2019b).

For parents, caregivers, and teachers of adolescents with MBID, especially those who experience high levels of anxiety, depressive or behavioral problems, it may be helpful to be aware of the relation between frustration and satisfaction of basic psychological needs and mental health problems in adolescents with MBID. Although we could not test the causal direction of the associations between BPN satisfaction or frustration and mental health problems, diminishing frustration and enhancing satisfaction of all three basic psychological needs may help to create a better suited (care and school) environment for adolescents with MBID. This may offer an additional pathway to a better overall level of well-being and a better mental health for this vulnerable group, next to the pathway of treating individual mental health issues directly. This is especially valuable because only a few evidence-based psychosocial treatments of mental health problems, like anxiety, depression and externalizing behavioral disorders, are available for children and adolescents with MBID (Kok et al., 2016). By influencing the context, the levels of well-being of adolescents with MBID and mental health problems may be enhanced, without the difficulties of individual therapy (e.g., cognitive behavioral therapy) for the adolescents that stem from their MBID, such as difficulties with reflecting on their emotions and behavior or reasoning about cause and effect (Van den Bogaard et al., 2020). The treatment and care climate in residential youth care facilities, as well as the school climate, are likely to influence the levels of fulfillment of basic psychological needs, experienced by the adolescents, especially the level of fulfillment of their need for autonomy and relatedness (De Valk et al., 2019b; Yu et al., 2016). An explicitly need-supportive teaching style for adolescents with MBID (Behzadnia et al., 2022; Emond Pelletier & Joussemet, 2016) has been shown to contribute to less frustration and more satisfaction of basic needs in youth with MBID and may therefore be a promising component of efforts to increase the value of education and care for youth with MBID, even when they are experiencing mental health problems. Teixeira et al. (2020) have described motivation and behavior change techniques, helpful in supporting the needs for autonomy, relatedness, and competence. These techniques can be used by parents, teachers, support staff and others to support need satisfaction. Simple interventions in day-to-day life can help make a positive difference for this vulnerable group of young people.

To our knowledge, this was the first study to use the Basic Psychological Needs Satisfaction and Frustration Scale – Intellectual Disability (BPNSFS-ID) in a large sample of adolescents with MBID. The results with this questionnaire were largely consistent with theoretically derived hypotheses, supporting the value of this instrument for research in this area. However, results of the Relatedness Frustration scale need to be interpreted with care since the internal consistency of this scale was found to be poor in this sample. Given the importance of the domain of social functioning, further research and refinement of this instrument may be necessary.

In this study we not only addressed the general group of adolescents with MBID, but we also included a subgroup of adolescents with MBID whose behavioral problems had led them to be admitted to a residential youth care facility. This subgroup differed from the general group of adolescents with MBID on all mental health outcome measures, indicating a worse overall mental health. We also found that these participants experienced higher levels of frustration and lower levels of satisfaction of their basic psychological needs. However, these comparisons need to be interpreted with caution, given that the residential treatment group was recruited from a single organization, which may not be representative of youth with MBID in residential treatment facilities overall.

Other results of this study should be considered in light of the limitations of this study as well. One of which is the number of non-responders. We do not know if there was a nonresponse bias since no background characteristics of the non-responders were available. The change in procedure from requiring passive consent to requiring active consent has decreased our potential number of responders significantly. Of the three participating schools that participated under passive consent, high numbers of students took part in this study, whereas of the two schools that participated under active consent, only a handful of students took part. Moreover, two schools refused participation completely because of the requirement of active consent, due to their expectation that this would lead to a very limited positive response from the parents of their students. A second limitation of this study is that we did not include any measures for well-being. Future studies that include mental well-being might shed light on the potential for basic psychological need satisfaction to contribute to positive outcomes in adolescents with a mild to borderline intellectual disability. Another limitation of this study is the cross-sectional design, which precludes drawing conclusions about causality with any level of internal validity.

This study has demonstrated the relation between fulfillment of basic psychological needs and mental health problems, as indicators for ill-being, in a large sample of Dutch adolescents with MBID. Further research is needed, especially into the causality of this relation. For adolescents with MBID who experience low need satisfaction or even high need frustration, it may be helpful that their parents, carers, teachers and support staff engage with these feelings and consider the role they can play in their child’s or student’s daily life to enhance and support their need satisfaction and diminish their need frustration.

Acknowledgments

We would like to express our gratitude to the students and teachers of the participating schools, as well as to Esther de Boer, who organized the data collection for this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This project was funded by Protestant Fund for Mental Public Health, Scientific Research Foundation 's Heeren Loo, ʼs Heeren Loo Advisium Groot Emaus, and the Academic Collaborative Center ʼs Heeren Loo – VU University Amsterdam.