Abstract
In the International Classification of Diseases, 10th revision (ICD-10), the term correspondent to intellectual disability still is “mental retardation,” and it is specified according to current severity on the basis of IQ scores: F70 mild, F71 moderate, F72 severe, and F73 profound mental retardation (World Health Organization 1996. According to DSM-5 commentary in ICD-11, the diagnostic term will be “intellectual developmental disorders”). In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the diagnostic term is “intellectual disability” (code 319: assigned regardless of the severity specifier), and the various levels of severity (mild, moderate, severe, profound) are defined on the basis of adaptive functioning (based on the categories “conceptional domain,” “social domain,” “practical domain”) and not on the basis of IQ scores (American Psychiatric Association 2013). The diagnostic criteria include deficits in intellectual functioning and in adaptive functioning both with onset during the developmental period (DSM-5). The approach of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF, World Health Organization 2001) is the attempt to integrate medical and psychosocial features of disability and ability in activities in specific environmental and personal context.
Access provided by Autonomous University of Puebla. Download chapter PDF
Similar content being viewed by others
Keywords
- Intellectual Disability
- Congenital Hypothyroidism
- Psychopharmacological Treatment
- Impulse Control Disorder
- Diagnostic Term
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
1 Definition, Classification, and Target Symptoms
In the International Classification of Diseases, 10th revision (ICD-10), the term correspondent to intellectual disability still is “mental retardation,” and it is specified according to current severity on the basis of IQ scores: F70 mild, F71 moderate, F72 severe, and F73 profound mental retardation (World Health Organization 1996). According to DSM-5 commentary in ICD-11, the diagnostic term will be “intellectual developmental disorders”.
In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the diagnostic term is “intellectual disability” (code 319: assigned regardless of the severity specifier), and the various levels of severity (mild, moderate, severe, profound) are defined on the basis of adaptive functioning (based on the categories “conceptional domain,” “social domain,” “practical domain”) and not on the basis of IQ scores (American Psychiatric Association 2013). The diagnostic criteria include deficits in intellectual functioning and in adaptive functioning both with onset during the developmental period.
The approach of the World Health Organi-zation’s International Classification of Functioning, Disability and Health (ICF, World Health Organization 2001) is the attempt to integrate medical and psychosocial features of disability and ability in activities in specific environmental and personal context.
Intellectual disability is not per se a psychiatric disorder. But the probability of developing a psychiatric disorder is significantly high in patients with intellectual disability (Arron et al 2011; Bouras 2013; Bouras and Holt 2007; Buckles et al. 2013; de Ruiter et al. 2007; Emerson et al. 2010; Forster et al. 2011; Myrbakk and von Tetzchner 2008). Individuals with intellectual disability and co-occurring psychiatric disorders are at high risk of problems in social adjustment and at risk of suicidal behavior.
Prophylactic pharmacological measures exist only for some disorders that cause intellectual deficits, such as immunization against infections that can damage the brain. This category also includes dietetic measures, such as the phenylalanine-free diet for those suffering phenylketonuria, and hormonal substitution by timely administration of l-thyroxine during the first 4 weeks of life in congenital hypothyroidism. If the intellectual disability is already manifest, however, psychopharmacological therapy is not directed at these static losses but rather at the psychopathological symptoms or psychiatric disorders of the patients with intellectual deficiency. The indications for pharmacological therapy are therefore essentially the same as for people without mental handicaps. Medication is, as always, only one part of a care program that includes educational, psychotherapeutic, and socio-integrative measures (for review Sturmey 2012).
The prevalence of psychopharmacological treatment is very high in institutions for the handicapped (Robertson et al. 2000). There are several reasons for this, including:
-
Psychotherapy for people with intellectual deficiency is still only very inadequately developed, and the necessary framework and therapeutic qualifications are often lacking.
-
Diagnostic difficulties. The severity of psychiatric disturbances and uncertain responses to treatment in this vulnerable population may lead to a greater use of psychopharmacological interventions than in youths without intellectual disability.
Cave! Diagnosis is extremely complex (e.g., see Attiah and Antonacci 2008). As the severity of intellectual disability increases, it becomes increasingly difficult to determine if the symptoms are part of a psychiatric disorder (e.g., mutism in depression) or part of the basic limitations of the intellectual development, e.g., the basic limitations in the use of language that prevent the patient from describing his/her psychiatric symptoms.
2 Therapeutic Framework
Therapy with psychopharmacological agents is limited to psychiatric disorders included in the ICD-10 and in the DSM-5, and severe psychopathological symptoms that endanger the patient or others (e.g., self-harm, suicidal tendencies, severe aggressive impulse control disorders), but can also be undertaken in order to allow access to pedagogic and psychotherapeutic measures.
A number of specific concerns arise during pharmacotherapy of children and adolescents with intellectual disability.
-
The assessment of the benefits and adverse drug reactions (ADRs) of a medication is, for the same reason, complicated.
-
The cause of the intellectual disability is often unknown so that an etiology-based treatment is not possible.
-
Pharmacological treatment must be undertaken according to the observable behavioral symptoms and the context in which they are presented (i.e., on the basis of behavioral analysis). The more impeded the capacity of patient with an intellectual deficiency to communicate, the greater the necessity to observe such guidelines.
-
Psychiatric and other organic comorbidity (e.g., epilepsy, metabolic disease, cerebral paralysis, blindness, deafness) are more frequently encountered as the severity of mental handicap increases (Einfeld et al 2011), so that the patient may be subjected to multiple treatments, appreciably increasing the difficulty of monitoring the medication’s therapeutic drug benefits, its ADRs, and the interactions between different medications being used to treat the patient.
-
In patients with organic brain injuries the expected responses to pharmacological agents might not occur; unusual and even paradoxical effects may result from the unusual cerebral vulnerability in these patients (Barron and Sandman 1985; Handen et al. 1991, 1992, 1994; Kalachnik et al. 2002; King 2007; Matson and Mahan 2010).
-
Compliance is more difficult to achieve, as with increasing severity of the intellectual deficiency, the ability to communicate and autonomous behavioral monitoring are both reduced; assessment of compliance and drug effects must be undertaken by caregivers.
-
The decision to initiate pharmacotherapy should be examined with particular circumspection if it is primarily justified as providing relief for overburdened caregivers. Pharmacological therapy should not be employed to compensate deficiencies in institutions for the occupants with intellectual disability.
3 Choice of Pharmacotherapy
There have been very few clinical studies concerning the treatment of psychiatric disorders in youths with intellectual disability. As a result, recommendations are consensus-based and have essentially been derived from the empirical data of a number of therapeutic trials (Bramble 2007; Calles 2008; Häßler and Reis 2010; Handen and Gilchrist 2006; King 2007; Matson and Neal 2009; Matson and Hess 2011; Matson et al. 2000; Reis and Aman 1998; Robertson et al. 2000; Shapiro and Accardo 2010; Sturmey 2012).
4 Treatment Strategies
4.1 General Aspects of Treatment
Therapy with psychopharmacological agents in children and adolescents with intellectual deficiency, on the basis of these considerations alone, must be managed with particular caution. The complexity of the decision to initiate such therapy is often exacerbated by the fact that the patient is often intellectually incapable of granting legal consent. The following treatment guidelines have universal validity but should be particularly heeded in patients with intellectual developmental disorder and the comorbidity of psychiatric disorder:
-
Before initiating any treatment, the diagnosis and the assessment of the success of previously employed therapeutic approaches must be considered. The consensus-based treatment recommendations given by Schur et al. (2003), Jensen et al. (2004), and Pappadopulos et al. (2003) are a useful general guideline for the use of antipsychotics but also for any kind of psychopharmacological treatment (see also Fig. 9.1).
-
Do not be misled by the impression evoked by a crisis into a hasty decision to initiate a pharmacological intervention.
-
Keep the legal framework for your action in mind.
-
Have regard for the wishes of your patient, and inform she or her as far as possible about the measures you adopt.
-
Have regard of the opinion and decisions of the “legal adult responsible” person who can provide protections for the intellectually deficient patient. This “guardian” may sign consent for psychopharmacological treatment and be called upon to give his agreement to each new change in therapy. Having a specifically assigned family member is better than just picking out any family member transporting the patient to the clinic. This person might change with every clinic visit and not be well informed. People with intellectual disability often react in a vulnerable fashion to centrally active pharmaceuticals.
-
Therapy with psychopharmacological agents alone is rarely effective.
-
Therapy with psychopharmacological agents must be integrated into an individual multidimensional therapeutic concept.
-
Describe the goals of the treatment or the target symptom as precisely as possible.
-
The effect with regard to the defined treatment goals must be systematically documented.
-
Prolonged prescription of psychopharmacological agents must be subject to critical review.
-
Do not withdraw too rapidly a medication that has been employed for longer periods. Reduction of the dosage of anticholinergic pharmaceuticals is often initially associated with a cholinergic imbalance and thus possibly with agitation and irritability.
-
Keep in mind the psychiatric ADRs that can occur. Symptomatic deterioration during ad-justment of dosage is typical for such ADRs.
-
The general principles of therapy with psychopharmacological agents should be applied (compliance, pharmacodynamics, pharmacokinetics, etc.).
-
Pharmacological therapy in children and adolescents with intellectual deficiency additionally requires that the caregivers assume responsibility for reliable dosage, administration, and monitoring of effects.
4.2 Therapy in Crisis and Emergency Situations
The ideal of pharmacological therapy is based upon diagnosis, behavioral analysis, a psychoeducative framework (explanation of the diagnosis, of therapeutic alternatives, of the nature and use of the medication, etc.), and obtaining consent from the patient and/or the caregiver to employ a drug, preferably indicated for the intended purpose.
In an emergency situation the baseline conditions are quite different. The patient is often acutely agitated, helpless, and extremely vulnerable; the risk of harm to the patient or to others is significant; personnel are exhausted; the patient lacks insight into his disorder; and the relatives expect relief as quickly as possible. There is insufficient time and opportunity for a complete diagnostic evaluation, and obtaining consent may be impractical.
Cave! In such emergency situations there is not only a strong temptation to fast-track the initiation of pharmacological therapy, but it is often also necessary to do so. Documentation of such cases must therefore specifically stipulate that it involves acute pharmacological treatment requiring short-term review, initially on a continuous basis, with regard to indication, effect, and ADRs, and can provisionally be regarded only as a transitional therapy.
Table 24.1 provides an overview of the acute pharmacological treatment of psychiatric emergencies (see Chap. 24). Medications that are frequently employed in emergency situations include:
-
Anxiolytics, such as lorazepam (calming)
-
Sedatives, such as diazepam (sedative)
-
Antipsychotics, such as risperidone, olanzapine, pipamperone, melperone, and haloperidol (calm and sedate psychomotor activity)
4.3 Most Common Adverse Drug Reactions
The restricted ability of patients with intellectual deficiencies to communicate, their treatment with several different pharmaceuticals, and, in some cases, their altered cerebral responsiveness necessitate that increased vigilance for ADRs be used when treating children and adolescents with intellectual disabilities. The implementation of therapeutic drug monitoring (TDM) is strongly recommended (see Sect. 2.3). Among the most frequently encountered ADRs are the following:
-
The anticholinergic syndrome associated with the use of low-potency antipsychotics and tricyclic antidepressants is a concern. CNS symptoms include agitation, motor restlessness, dysarthria, disorientation, hallucinations, and cerebral seizures; peripheral symptoms include obstipation, urine retention, fever, mydriasis, and tachycardia.
-
Constipation. If overlooked in patients with severe mental handicaps, complaints can lead to uncharacteristic behavioral patterns, such as headache, agitation, depression, and sleep disturbances. Obstipation occurs mostly in association with low-potency antipsychotics, tricyclic antidepressants, benzodiazepines, and carbamazepine.
-
Extrapyramidal-motor disturbances. Aka-thisia, stereotypic gaze behavior, and parkinsonian psychomotor symptoms may be mistakenly interpreted as expressions of severe mental disability.
-
Hyperactivity, restlessness, and aggressive agitation are particularly associated with antiepileptic agents, benzodiazepines, and SSRIs.
Literature
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn (DSM-5TM). American Psychiatric Publishing, Washington/London
Arron K, Oliver C, Moss J, Berg K, Burbidge C (2011) The prevalence and phenomenology of self-injurious and aggressive behaviour in genetic syndromes. J Intellect Disabil Res 55:109–120
Attiah DJ, Antonacci N (2008) Diagnosis and treatment of mood disorders in adults with developmental disabilities. Psychiatr Q 79:171–192
Barron J, Sandman CA (1985) Paradoxical excitement to sedative-hypnotics in mentally retarded clients. Am J Ment Defic 90:124–129
Bouras N (2013) Reviewing research of mental health problems for people with intellectual disabilities. J Ment Health Res Intellect Disabil 6:71–73
Bouras N, Holt G (eds) (2007) Psychiatric and behavioral disorders in intellectual and developmental disabilities, 2nd edn. Cambridge University Press, Cambridge
Bramble D (2007) Psychotropic drug prescribing in child and adolescent learning disability psychiatry. J Psychopharmacol 21:486–491
Buckles J, Luckasson R, Keefe E (2013) A systematic review of the prevalence of psychiatric disorders in adults with intellectual disability, 2003–2010. J Ment Health Res Intellect Disabil 6:181–207
Calles JL (2008) Use of psychotropic medications in children with developmental disabilities. Pediatr Clin North Am 55:1227–1240
De Ruiter K, Dekker M, Verhulst F, Koot H (2007) Developmental course of psychopathology in youths with and without intellectual disabilities. J Child Psychol Psychiatry 48:498–507
Einfeld SL, Ellis LA, Emerson E (2011) Comorbidity of intellectual disability and mental disorder in children and adolescents: a systematic review. J Intellect Dev Disabil 36:137–143
Emerson E, Einfeld S, Standcliffe R (2010) The mental health of young children with intellectual disabilities or borderline intellectual functioning. Soc Psychiatry Psychiatr Epidemiol 45:579–587
Forster S, Grac K, Taffe J, Einfeld S, Tonge B (2011) Behavioural and emotional problems in people with severe and profound intellectual disability. J Intellect Disabil Res 55:190–198
Handen BL, Gilchrist R (2006) Practitioner review: psychopharmacology in children and adolescents with mental retardation. J Child Psychol Psychiatry 47:871–882
Handen BL, Feldman A, Gosling AM, Mc Auliffe S (1991) Adverse side effects of methylphenidate among mentally retarded children with ADHD. J Am Acad Child Psychiatry 30:241–245
Handen BJ, Breaux AM, Janosky J, Mc Auliffe S, Feldman H, Gosling A (1992) Effects and noneffects of methylphenidate in children with mental retardation and ADHD. J Am Acad Child Psychiatry 31:455–461
Handen BL, Janosky J, Mc Auliffe S, Breaux AM, Feldman H (1994) Prediction of response to methylphenidate among children with ADHD and mental retardation. J Am Acad Child Psychiatry 33:1185–1193
Häßler F, Reis O (2010) Pharmacotherapy of disruptive behavior in mentally retarded subjects: a review of the current literature. Dev Disabil Res Rev 16:265–272
Jensen PS, MacIntyre JC, Pappadopulos EA (eds) (2004) Treatment recommendations for the use of antipsychotic medications for aggressive youth (TRAAT): pocket reference guide for clinicians in child and adolescent psychiatry. New York State Office of Mental Health and Center for the Advancement of Children’s Mental Health at Columbia University, Department of Child and Adolescent Psychiatry, New York
Kalachnik JE, Hanzel TE, Sevenich R, Harder SR (2002) Benzodiazepine behavioral side effects: review and implications for individuals with mental retardation. Am J Ment Retard 107:376–410
King B (2007) Psychopharmacology in intellectual disabilities. In: Bouras N, Holt G (eds) Psychiatric and behavioral disorders in intellectual and developmental disabilities, 2nd edn. Cambridge University Press, Cambridge, pp 310–329
Matson JL, Hess JA (2011) Psychotropic drug efficacy and side effects for persons with autism spectrum disorders. Res Autism Spectr Disord 5:230–236
Matson JL, Mahan S (2010) Antipsychotic drug side effects for persons with intellectual disability. Res Dev Disabil 31:1570–1576
Matson JL, Neal D (2009) Psychotropic medication use for challenging behaviors in persons with intellectual disabilities. An overview. Res Dev Disabil 30:572–586
Matson JL, Bamburg JW, Mayville EA, Pinkston J, Bielecki J, Kuhn D, Smalls Y, Logan JR (2000) Psychopharmacology and mental retardation: a 10-year review (1990–1999). Res Dev Disabil 21:263–296
Myrbakk E, von Tetzchner S (2008) Psychiatric disorders and behavior problems in people with intellectual disability. Res Dev Disabil 29:316–332
Pappadopulos E, Mac Intyre JC II, Crismon L, Findling RL, Malone RP, Derivan A, Schooler N, Sikich L, Greenhill L, Schur SB, Felton CJ, Kranzler H, Rube DM, Sverd J, Finnerty M, Ketner S, Siennick SE, Jensen PS (2003) Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II. J Am Acad Child Psychiatry 42:145–161
Reis S, Aman M (eds) (1998) Psychotropic medications and developmental disabilities: the international consensus handbook. Ohio State University, Nisonger Center, Columbus
Robertson J, Emerson E, Gregory N, Hatton C, Kessissoglou S, Hallam A (2000) Receipt of psychotropic medication by people with intellectual disability in residential settings. J Intellect Disabil Res 44:666–676
Schur S, Sikich L, Findling RL, Malone RP, Crismon ML, Derivan A, Mac Intyre JC II, Pappadopulos E, Greenhill L, Schooler N, Van Orden K, Jensen PS (2003) Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part I. J Am Acad Child Psychiatry 42:132–144
Shapiro B, Accardo P (eds) (2010) Neurogenetic syndromes. Behavioral issues and their treatments. Baltimore, Brookes
Sturmey P (2012) Treatment of psychopathology in people with intellectual and other disabilities. Can J Psychiatry 57:593–600
World Health Organisation (1996) Multiaxial classification of child and adolescent psychiatric disorders. The ICD – 10 classification of mental and behavioral disorders in children and adolescents. Cambridge University Press, Cambridge
World Health Organization (2001) International classification of functioning, disability and health: ICF. World Health Organization, Geneva
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2014 Springer-Verlag Wien
About this chapter
Cite this chapter
Warnke, A., Greenhill, L. (2014). Psychiatric Disorders in Children and Adolescents with Intellectual Disability. In: Gerlach, M., Warnke, A., Greenhill, L. (eds) Psychiatric Drugs in Children and Adolescents. Springer, Vienna. https://doi.org/10.1007/978-3-7091-1501-5_23
Download citation
DOI: https://doi.org/10.1007/978-3-7091-1501-5_23
Published:
Publisher Name: Springer, Vienna
Print ISBN: 978-3-7091-1500-8
Online ISBN: 978-3-7091-1501-5
eBook Packages: MedicineMedicine (R0)