Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.3 Intellectual Disability

Behavioral and Cognitive-Behavioral Interventions.  The difficulties in adaptation among the intellectual disability populations are widespread and so varied that several inter- ventions alone or in combination may be beneficial. Behavior therapy has been used for many years to shape and enhance social behaviors and to control and minimize aggressive and destructive behaviors. Positive reinforcement for desired behaviors and benign punishment (e.g., loss of privileges) for objectionable behaviors has been helpful. Cognitive therapy, such as dispelling false beliefs and relaxation exercises with self-instruction, has also been recommended for intellectually disabled persons who can follow the instructions. Psychody- namic therapy has been used with patients and their families to decrease conflicts about expectations that result in persistent anxiety, rage, and depression. Psychiatric treatment modalities require modifications that take into consideration the patient’s level of intelligence. Family Education.  One of the most important areas that a clinician can address is educating the family of a child or ado- lescent with intellectual disability about ways to enhance com- petence and self-esteem while maintaining realistic expectations for the patient. The family often finds it difficult to balance the fostering of independence and the providing of a nurturing and supportive environment for an intellectually disabled child, who is likely to experience some rejection and failure outside the family context. The parents may benefit from continuous coun- seling or family therapy and should be allowed opportunities to express their feelings of guilt, despair, anguish, recurring denial, and anger about their child’s disorder and future. The psychiatrist should be prepared to give the parents all the basic and current medical information regarding causes, treatment, and other pertinent areas (e.g., special training and the correc- tion of sensory defects). Social Intervention.  One of the most prevalent prob- lems among persons with intellectual disability is a sense of social isolation and social skills deficits. Thus, improving the quantity and quality of social competence is a critical part of their care. Special Olympics International is the larg- est recreational sports program geared for this population. In addition to providing a forum to develop physical fitness, Special Olympics also enhances social interactions, friend- ships, and (it is hoped) general self-esteem. A recent study confirmed positive effects of the Special Olympics on the social competence of the intellectually disabled adults who participated. Psychopharmacologic Interventions.  Pharmaco­ logical approaches to the treatment of behavioral and psy- chological symptoms in children with intellectual disability follow the paradigms of the evidence-based literature on treatment for all children with psychiatric disorders. How- ever, given the paucity of randomized trials in the childhood intellectual disability population, an empirical approach must also be taken. common comorbid psychiatric symptoms and disorders Aggression, Irritability, and Self-injurious Behavior.  Risperidone has been well documented as an efficacious treatment for irritability

(aggression, self-injury, and severe tantrums) in children with ASD by the Research Units on Pediatric Psychopharmacology (RUPP, Autism Network 2002). Risperidone is helpful in treating disruptive behaviors in children with below-average intelligence, and has a good overall safety and tolerability profile. Cognitive testing has demonstrated small but significant improvement in cognitive ability with risperidone use. Children and adoles- cents with intellectual disability appear to be at higher risk for the development of tardive dyskinesia after use of antipsychotic medications; however, the atypical antipsychotics, including ris- peridone and clozapine (Clozaril), may provide some relief with a decreased risk of tardive dyskinesia. There is evidence to support the use of antipsychotic agents in the management of self-injurious behavior (SIB). Although data exist on the efficacy of thioridazine in improving SIB, a “black box” warning regarding QT pro- longation with thioridazine has drastically diminished use of this drug, and atypical antipsychotic agents are currently preferred. Attention-Deficit/Hyperactivity Disorder.  Estimates of atten- tion deficit/hyperactivity (ADHD) and ADHD-like symptoms among children with sub average intelligence, genetic disor- ders, and developmental delay is estimated to be significantly higher than rates in the community. Randomized clinical tri- als of several psychopharmacologic agents have been done in children with sub-average intelligence. These include trials with methylphenidate, clonidine, and risperidone. The existing data for the treatment of ADHD and ADHD-like symptoms in youth with sub-average intelligence and developmental disor- ders suggest that agents, particularly stimulants used to treat ADHD in typically developing children, provide some degree of benefit to children with intellectual disability and ADHD. However, the occurrence of side effects within this population appears to be greater than in children with ADHD in the com- munity. Thus, recommendations regarding treatment of ADHD in children and adolescents with comorbid ADHD include close monitoring for side effects. Studies of methylphenidate (Ritalin) treatment in those mildly intellectually disabled with ADHD have shown significant improvement in the ability to maintain attention and to stay focused on tasks. Methylpheni- date treatment studies have not shown evidence of long-term improvement in social skills or learning. Risperidone also has been found to be beneficial in reducing symptoms of ADHD in this population; however, it may produce an increase in serum prolactin level. It is prudent to begin with a trial of a stimu- lant medication before the use of antipsychotic agents for the treatment of ADHD symptoms in intellectual disorder. A new extended release methylphenidate oral suspension (Quillivant XR, 2013) is currently available in 25 mg/5 ml preparation, and is taken once daily for the treatment of ADHD in children 6 to 12 years of age. Amphetamine-based preparations have been shown to be efficacious in treating ADHD in typically developing children; however, it does not appear that these stimulant preparations have been specifically studied in children with intellectual dis- ability. Clonidine has been used clinically in this population, especially to ameliorate hyperactivity and impulsivity. Although there are scant data, clinical ratings by parents and clinicians suggest its efficacy.