Chapter 90: Intellectual and Developmental Disabilities: Down Syndrome and Autism Spectrum Disorder

KEY CONCEPTS

• People with intellectual and developmental disabilities (IDD) have higher incidence of mental illness and challenging behaviors, with dual diagnosis being common.

• Persons diagnosed with Down syndrome (DS) can be at increased risk for medical and psychiatric comorbidities.

• People with IDD experience high rates of polypharmacy and polypsychotropic medication use. Assessment should include physical disorders as well as social and environmental factors.

• People who have DS have higher rates of Alzheimer’s-type dementia. A thorough evaluation is needed to differentiate between depression and Alzheimer’s disease (AD).

• Treatment plans for persons with autism focus on increasing social interactions, improving verbal and nonverbal communication, and minimizing the occurrence or impact of ritualistic, repetitive behaviors and other related mood and behavioral problems (eg, overactivity, irritability, and self-injury).

• Many purported pharmacologic and nonpharmacologic treatments for autism spectrum disorder (ASD) lack objective evidence-based support.

• A structured teaching approach focusing on increasing social communication and integration with peers is needed when providing services to persons with ASD.

• Nonpharmacologic interventions for sleep disturbances in children with a diagnosis of ASD should be implemented prior to pharmacotherapy considerations.

• Psychopharmacologic treatment planning should include monitoring of objective, measurable medication-responsive target behaviors, and assessment of potential adverse effects, which are of critical importance when treating the behavioral symptoms of ASD. Furthermore, the response of individuals to medication therapy is highly variable.

• The use of FDA-approved medication for off-label indications is an acceptable clinical practice if founded on evidence-based research and informed consent.

Patient Care Process for Intellectual and Developmental Disabilities

Collect

• Involve patient as well as one or more caregivers in this process

• Patient characteristics such as age, gender, pregnancy status

• Past medical and psychological history

• Previous life events (eg, changes in living situation)

• Social history (tobacco/ethanol, substance abuse) and dietary habits

• Social and community-based activities

• Current prescription medications, nonprescription medications, and supplements

Assess

• Contraindications to potential medications

• Psychotropic medication already prescribed

• Presence of treatment adverse effects from psychotropic medications

• Physical causes for challenging behaviors such as constipation, gastroesophageal reflux, seizure, aspiration, pain including dental-related pain, sleeping problems (Table 90-1)

• Risk or evidence of harm to self, others, or property

• Frequency of challenging behavior

• Patient’s preference for type of therapy if appropriate and identify those involved in the patient’s medication use process

Plan^*

• Choose medication with strongest evidence and minimal adverse effects (Table 90-2)

• Determine potential drug interactions with other medications

• Education for patient and caregivers

• Develop non-medication intervention based on social and personal factors

• Type of prescription medication insurance and insurance-related regulations in choice of medication

Implement^*

• Provide patient education to patient and caregiver

• Work to understand issues related to medication adherence. Choose dosage form that will reduce likelihood of nonadherence

Follow-up: Monitor and Evaluate^*

• Reduction in frequency and severity of challenging behaviors

• Presence of adverse effects (Table 90-2)

• Patient adherence to therapy

• Patient’s ability to engage in activities ...