31.3 Intellectual Disability
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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.
