Pharmacotherapy of Disruptive Behaviors in Children with Intellectual Disabilities.

Disruptive behaviors are a class of predominantly externalizing behaviors that include physical aggression, property destruction, temper outbursts, verbal aggression, and some forms of self-injurious behaviors. Externalizing behaviors are also major components of disruptive, impulse-control and conduct disorders, disruptive mood dysregulation disorder, trauma-related and stressor-related disorders, intermittent explosive disorder, personality disorders, and other neuropsychiatric and neurodevelopmental disorders. Disruptive behaviors and associated disorders are among the most frequent reasons for child behavioral health referrals and are the most common reason for referrals among children with intellectual disabilities. The focus of this paper is on the adjunctive role of integrated psychopharmacological treatment in the management of children with disruptive behaviors and co-occurring intellectual disabilities. The decision-making process for adding pharmacotherapy to a comprehensive treatment plan incorporates not only a working knowledge of basic behavioral neurobiology of disruptive behaviors but also an understanding of the strengths and weaknesses of various pharmacotherapies. Importantly, there is little evidence to support the use of psychopharmacologic agents in managing difficult behaviors in children with intellectual disabilities, but with that said, risperidone has the strongest evidence base for its use.

Psychiatric Presentations and Medication Use in Older Adults With Intellectual and Developmental Disabilities.

OBJECTIVE: Adults with intellectual and developmental disabilities (IDD) are living longer, yet research about the medical and psychiatric needs of older adults still lags behind that of younger individuals with IDD. The aim of this study was to assess age-related differences in the mental health presentations of adults with IDD. METHODS: Fully deidentified data for adults 30 years and older were extracted from the START (Systemic, Therapeutic, Assessment, Resources, and Treatment) Information Reporting System, a deidentified database housed at the Center for START Services. Caregivers and START team documents reported psychiatric diagnoses, service use, recent stressors, and challenging behaviors. t Tests, Mann Whitney U tests, χ2 tests, and multinominal logistic regression models were used to compare the two age groups, 30-49 years (n = 1,188) versus 50 years and older (n = 464). RESULTS: Older adults had more medical conditions, fewer reported psychiatric conditions, and were more likely to be taking more psychiatric medications compared to younger adults, after adjusting for demographic variables, disability level, and number of recent stressors. CONCLUSION: Although older individuals reported fewer psychiatric diagnoses, they were more likely to take higher numbers of psychiatric medications and have more medical conditions. Clinicians and researchers ought to devote more attention to the healthcare needs of older adults with IDD, a vulnerable group exposed to polypharmacy and at risk of adverse events.

Predictors of Mental Health Crises Among Individuals With Intellectual and Developmental Disabilities Enrolled in the START Program.

OBJECTIVE: Individuals with intellectual and developmental disabilities disproportionately use emergency psychiatric services compared with their neurotypical peers, suggesting that such individuals and their supports are at increased risk for crisis events. This prospective study examined the timing, outcomes, and predictors of mental health crises for this population. METHODS: The data came from Systemic, Therapeutic, Assessment, Resources, and Treatment (START), a national model that provides mental health crisis services for those with intellectual and developmental disabilities in the United States. The study included 1,188 individuals from four U.S. regions enrolled between 2018 and 2019. The outcome was urgent crisis contacts with the START program. Baseline and clinical predictors were examined with multivariate regression analyses. RESULTS: More than a quarter had at least one crisis contact, and 9% had three or more. Contacts increased within the initial 3 months of START enrollment, followed by a steep drop-off thereafter; few contacts happened after 1 year. Almost 45% of the contacts occurred after hours, and 30% involved police. Clinical factors predicted crisis contact most robustly, followed by lack of occupational supports. After START crisis intervention, 73% of individuals remained in their primary setting. CONCLUSIONS: For individuals with intellectual and developmental disabilities and mental health needs, crisis stabilization resources are needed, including after hours. Results clearly identify times and risk factors for mental health crisis contacts, including frequent involvement with emergency responders. Importantly, gainful employment conveyed benefits for community stabilization. Findings may be leveraged to develop effective mental health crisis intervention services and supports for this underserved group.

A search for the common ground between Tic; Obsessive-compulsive and Autism Spectrum Disorders: part I, Tic disorders.

This article is the first of four articles designed to explore the complex interrelationship between Autism Spectrum Disorders (ASD); Obsessive compulsive and Related Disorders (OCRD) and Tic Disorders/Tourette's Syndrome (TD/TS). We begin with an overview TD/TS and follow-up with reviews of OCRD and ASD. The final article in this series represents a synthesis of the neurobiological and genetic markers shared by patients presenting with all three syndromes. The goal is to describe the complex endophenotype of these patients in an effort to better define gene markers that underlie these heterogeneous clinical syndromes. Tic disorders (TD) are a collection of hyperkinetic movements that begin in early childhood. Tics are transient for most affected preschool children but a subgroup development persistent movements or progress to develop Tourette Syndrome (TS). TDs as a group display high heritability rates but definitive gene markers still elude us. The difficulty defining genetic markers is in large part due to the diverse neurodevelopmental trajectory, changing topography and typology, development of a broad spectrum of neurocognitive and behavioral complications, and a mixed pattern of psychiatric comorbidities.

Serotonergic antidepressant effects on aggressive, self-injurious and destructive/disruptive behaviours in intellectually disabled adults: a retrospective, open-label, naturalistic trial.

There is a growing body of evidence that serotonergic antidepressants are useful in the treatment of maladaptive behaviours in the intellectually disabled. However, not all studies have shown positive results due to lack of efficacy, tolerance development, and troublesome side-effects. The current study consisted of a review of the treatment response to a variety of serotonergic antidepressants, consisting of selective serotonin reuptake inhibitors (SSRIs ) (n = 36) and clomipramine (n = 2) in 38 institutionalized intellectually disabled adults (20 males, 18 females; mean age 45.6 yr, age range 18-74 yr). Those studied were treated for aggression, self-injurious behaviours, destructive/disruptive behaviours, depression/dysphoria, or a combination of these or other challenging behaviours. Most were receiving concurrent psychotropic and/or anticonvulsant medications. Effectiveness was determined by a retrospective review of the summaries of multidisciplinary Neuropsychiatric Behavioural Reviews (NBRs) in which global and specific maladaptive behaviours were rated on a 1- to 7-point scale, and by psychologists' ratings of target behaviours. Overall, statistically significant decreases in the ratings of global maladaptive behaviour and aggression, self-injurious behaviour, destruction/disruption and depression/dysphoria and in psychologists' ratings occurred in the subject group after the initiation of antidepressants. The results suggest that serotonergic antidepressants are useful in the treatment of challenging/maladaptive behaviours in the intellectually disabled.

Effects of topiramate on aggressive, self-injurious, and disruptive/destructive behaviors in the intellectually disabled: an open-label retrospective study.

This study reviews the treatment response to the antiepileptic drug topiramate (Topamax-mean dose 202 mg/d, range 150-350 mg/d) of a group of 22 institutionalized intellectually disabled adults (8 males, 14 females, mean age 46.5 years, age range 25-70 years). These individuals were predominantly classified as having severe or profound intellectual disability and as having a mood disorder. The individuals studied were treated for aggression, self-injurious behaviors, destructive/disruptive behaviors or a combination of these, and/or other challenging and maladaptive behaviors. All subjects were receiving concurrent psychotropic and/or anticonvulsant medications. Effectiveness was determined by retrospective review of summaries of quarterly multidisciplinary Neuropsychiatric Behavioral Reviews. Assignment of global severity scores and evaluation of longitudinal behavioral graphs of target symptoms occurred. Overall, statistically significant decreases in global severity scores and in the cumulative aggression and worst behavior rates occurred in the subjects, especially when the 3 months before and the 3 to 6 months after starting topiramate were compared. The overall subject group showed no significant weight changes. One subject developed delirium, 1 developed hypoglycemia, 1 developed sedation, and 2 developed constipation. The results suggest that topiramate may have a role in the treatment of challenging/maladaptive behaviors in intellectually disabled individuals.