Challenging Behavior in Adults with Intellectual Disability

Challenging Behavior in Adults with Intellectual Disability

October 2013Jodi Tate, M.D.

Overview• Definitions

• Etiology, Epidemiology

• Challenging Behavior

• Etiology of Challenging Behavior

• Assessment of Challenging Behavior

• Treatment of Challenging Behavior

• ID: Intellectual Disability

• PWID: Persons with ID

• ASD: Autism Spectrum Disorders

• Dual Diagnosis: Axis I + ID

• CB: Challenging Behavior

Diagnostic Manual-Intellectual DisabilityDM-ID

Mental Retardation (MR)↓

MR/ID↓

Intellectual Disability (ID)

• http://www.dmid.org/

http://www.dmid.org/

DSM Changes

DSM-4: Mental Retardation

• Sub average intellectual functioning : an IQ of 70 or below on an IQ test

• Concurrent deficits or impairments in adaptive functioning in at least 2 areas

• Mild, moderate, severe, profound

DSM-5: Intellectual Disabilities:(Intellectual Developmental Disorder)

• Deficits in Intellectual Functions

• Deficits in adaptive functioning

• Onset of intellectual and adaptive deficits during developmental period

• Mild, moderate, severe, profound

DSM Changes

DSM-4

• MR, Severity Unspecified:• strong presumptions of MR • untestable by standard tests

DSM-5

• Global Developmental Delay• < 5 yrs old• Can’t determine level of

impairment• Reassess Later

• Unspecified ID• > 5 yrs old• Can’t determine degree of ID• Use Rarely• Reassessment Later

Severity Level Conceptual Domain

Social Domain Practical Domain

Mild

DSM 4:IQ: 50-55 to 70 Mental Age: 9-12yrs

Concrete ImmatureDifficulty with social cuesPoor social judgmentGullible

Age appropriate with personal caresNeed support Complex daily skills: grocery, money, medical/legal decisions

Moderate

DSM 4:IQ: 35-40 to 50-55 Mental Age: 6-9yrs

Elementary academic skill development

Difficulty with social cues and decision making,

Personal care possible with A LOT of teaching

Maladaptive behavior in a “significant minority”

Severe


Little understanding of written language or concepts

Limited spoken language. Single words.

Support for all activities

Profound


May be able to sort/match objects

May understand simple instructions or gestures

Dependent on others

Adaptive Functioning Determined by 3 Domains: Conceptual, Social and Practical

Etiology of ID• Highly Heterogeneous

• 30% of ID caused by:• Down Syndrome, Fragile X, Fetal Alcohol Syndrome

• Prenatal: 4-28%• Genetic, congenital malformations, exposure

• Perinatal: 2-10%• Infections, delivery problems

• Postnatal: 3-12%• Infections, toxins, psychosocial

• Unknown: 30-50%

EpidemiologyShoumitro, World Psychiatry, 2009

• 1-3% of population has an ID

• 1.5 ♂:1.0 ♀

• 30% Dual Diagnosis (mental illness + ID)• Wide discrepancy reported • Many limitations with studies

• 40% Autism Spectrum Disorder (ASD)•50-70% of individuals with ASD have an ID

Challenging Behavior• Challenging behavior (CB)

• Aggression• Property Destruction• Self injurious behavior (SIB)

• ID (Oliver-Africano, 2009)

• 25 – 50%

Etiology of Challenging Behavior

• Psychiatric Illness• I’m depressed. I’m manic. I’m anxious. I’m psychotic.

• Behavioral Phenotype• I have a genetic syndrome that predisposes me to become agitated and

angry.

• Medical Illness/ Side effects/Pain• I am constipated. I have an ear infection. I have a UTI.

• Function of Behavior • I want you to spend time with me = Attention• I don’t want to work = Escape• I want to a van ride = Access to tangibles• Internally driven = Sensory

Diagnostic Overshadowing

• Falsely attributing symptoms to ID• Health care providers overlook psychiatric or medical co-

morbidity

• “They are MR that is why they are acting that way”




angry.



Psychiatric Illness

What is the relationship between aggression and mental illness?

Psychiatric Illness

• Complex relationship• Literature isn’t much help• Use terms interchangeably• Discuss separately but don’t address their relationship

• Lots of opinions• Behavioral Equivalent (atypical presentation of mental illness)

• Strong Association between depression and challenging behavior (Moss, 2000)

• Lack specificity (Charlot, 2005)

• Challenging Behavior is not a psychiatric disorder and inclusion results in high rates of psychiatric morbidity (Whitaker, 2006)

Relationship between ASD and IDMatson, Research in Developmental Disabilities, 2009

•ASD + ID poor prognosis compared to ID – ASD

•ASD + ID = Strongest predictor of hospital admission, psychotropic use, Challenging behavior

•ASD + ID (McCarthy, 2010)

• High rate of challenging behavior (up to 88%)

•Transition to adulthood = DIFFICULT• Leaving high school results in decline in services• Slowing of improvement of symptoms after high school

DSM-4: Pervasive Developmental Disorders

• Autistic Disorder • Social interaction• Restricted Repetitive and Stereotyped behavior, interests, activities• Communication

• Asperger’s Disorder • Social interaction• Restricted Repetitive and Stereotyped behavior, interests, activities• No delay in language or cognitive development (can have odd use of language)

• PDD, NOS• Rett’s Disorder

• Loss of language, social, motor skills: 6-18 mo

• Childhood Disintegration Disorder• Regression after normal development: 2-10 yrs

Autism Spectrum Disorder

DSM-5: Autism Spectrum Disorder• Deficits in

• Social Communication and Social Interaction• Restricted Repetitive Patterns of Behavior, Interests, Activites• Present in early development• Cause impairment• Not better explained by ID

• Specify• With or without ID• With or without language impairment• Associated with known medical or genetic condition or environmental factor (Rett’s)• With Catatonia

• Severity Level• Level 1 Requiring Support• Level 2 Requiring Substantial Support• Level 3 Requiring Very Substantial Support




angry.



Behavioral Phenotype DM-ID

PKUPrader-Willi Rubinstein-TaybiSmith MagenisTuberous Sclerosis Complex

Velocardiofacial

Angelman Cri-du-chatDownFetal Alcohol Fragile XWilliams




angry.



Medical Illness/Side EffectsKran, 2006; Lidnsey, 2002; Fletcher, 2007; Sheepers, 2005

• Numerous studies indicating etiology of aggression • Undiagnosed medical condition and/or side effects from meds

• ID and Mental Illness (dual diagnosis)• One of the most underserved populations • Lack of recognition of common medical conditions• Lack of preventative health care• Increased Rates of Mortality and Morbidity

• Seizures, GI, DM, Poor dentition, Osteoporosis, • Aspiration Pneumonia, Hearing and Visual Impairments

Lack of adequate education/training

of health care providers is a major contributor

Medical Illness/Side Effects/Pain

• Kastner, 2001• n = 209 with problem behavior• 12% undiagnosed medical conditions• 7% unrecognized side effects

• Van Kyde, 1997• N = 25 with SIB• 28% undiagnosed medical conditions

• Savage, 2007• 42 yo ♂ SP, Severe ID, aggression• Constipation and urinary retention (psych meds?)• Metamucil, toilet training• No evidence psychosis, d/c all meds




angry.



Function of Behavior• Applied Behavioral Analysis: Functional Analysis/Assessment

• Center for Disability and Development (CDD)• Todd Kopelman, PhD = Dept of Psych

• Figure out “function” of behavior• 4 Functions:

• Attention= I want you to spend time with me • Escape = I don’t want to work • Access to tangible = I want to a van ride • Sensory = internally driven

• Treatment Based on Function

• Behavioral Plan• Functional Communication Training

Assessment of AggressionShoumitro, World Psychiatry, 2009

• Primary aim of management is NOT to treat behavior but to identify and address underlying CAUSE

• Unfortunately not always possible

• Thorough Assessment is prerequisite in managing aggression

• Formulation should be made even in absence of medical or psychiatric diagnosis

Assessment of AggressionExpert Consensus Guidelines, 2004

• Interview with family/caregivers• Chart Review

• Direct observation of behavior ideal (ABC)• Antecedents of behavior• Problem Behavior• Consequences (reactions and outcomes)

• Medical History and Physical Exam• Joni Bosch, ARNP

• Center for Disability and Development (CDD)

• Medication and Side effect evaluation

• Functional Behavior Assessment/Analysis (CDD)• Assessment that tries to identify the functions responsible for behavior• Attention, Access to preferred activities, Escape, Sensory

Step 1: Determine Reason for Behavior

• Psychiatric Illness• I’m depressed. I am manic. I am anxious. I am hearing voices.


angry.


• Function of Behavior • I want you to spend time with me = Attention• I don’t want to work = Escape• I want to a van ride = Access to tangibles• Internally driven = sensory or automatic

Pharmacological TreatmentExpert Consensus Guidelines, 2004

• Treat underlying cause but when unable…..

• Symptomatic Treatments.. No established pharmacotherapy for aggression• Atypicals (risperidone, olanzapine, consider seroquel)• Mood stabilizers (divalproex, tegretol consider Li)• Consider SSRI • 2nd line: Naltrexone, typical, beta-blocker, buspar

• Based on clinical opinion and very few studies, mostly case reports

AntipsychoticsDeb, Journal of Intellectual Disbility Research, 2007

• Review of Literature • 1990-2005• >18• IQ <70• Behavior Problem (aggression, SIB)• n >/= 10• Before & after outcome (any measure)

• 9 studies• 1 RCT - Risperidone

YearYear nn Target Target BehaviorBehavior

Type of Type of StudyStudy

RxRx

GageanoGageano

20052005

3939

(38)(38)

VariousVarious

AggressionAggression

SIBSIB

RCTRCT Risperidone (add on)Risperidone (add on)

1.8 mg1.8 mg

La MalfaLa Malfa

20012001

1818 AggressionAggression ProspectiveProspective

UncontrolledUncontrolled

RisperidoneRisperidone

2mg +/- 1 mg2mg +/- 1 mg

Lott Lott

19961996

3333 AggressionAggression

SIBSIB

Property Property DestructionDestruction

Prospective Prospective UncontrolledUncontrolled

Risperidone (add on)Risperidone (add on)

5.1 mg5.1 mg

La MalfaLa Malfa

20032003


SIBSIB

Prospective Prospective Uncontrolled Uncontrolled

QuetiapineQuetiapine

300-1200mg300-1200mg

YearYear nn Target Target BehaviorBehavior

Type of Type of StudyStudy

RxRx

ThalyasingamThalyasingam

(2004)(2004)


(psychosis)(psychosis)

Retrospective Retrospective


ClozapineClozapine

485 mg485 mg

Boachie & Boachie & McGinnityMcGinnity

19971997


(psychosis)(psychosis)

Retrospective Retrospective


ClozapineClozapine

640 mg in ♀640 mg in ♀

357 mg in ♂357 mg in ♂

JanowkyJanowky

20032003


SIBSIB

RetrospectiveRetrospective


OlanzapineOlanzapine

9.1 mg9.1 mg

GualtieriGualtieri

19901990

1212 SIBSIB Prospective Prospective UncontrolledUncontrolled

FluphenazineFluphenazine

1-15mg1-15mg

MaltMalt

19951995


SIBSIB

Prospective Prospective UncontrolledUncontrolled

*Zuclophenthixol*Zuclophenthixol

vsvs

HaldolHaldol

AntipsychoticsTyrer, Lancet, 2008

• RCT• Haloperidol (2.94mg)• Risperidone (1.78mg)• Placebo

• n = 86• Challenging behavior and aggression • Baseline, 4, 12, 26 weeks

• MOAS (Modified Overt Aggression Scale)

“Antipsychotic drugs should no longer be regarded as an acceptable routine treatment for aggression….”

Tyrer, Lancet, 2008

Mood StabilizersDeb, Journal of Intellectual Disability Research, 2008

• Review of Literature • <1990-2006• >18• IQ <70• Behavior Problem (aggression, SIB, hyperactivity,

stereotypical movements)• N >/= 10• Before & after outcome (any measure)

• 7 studies (Lithium, Valproate Acid, Topamax, Carbamazepine)• 2 RCT - Lithium• 1 negative - Carbamazepine

YearYear NN BehaviorBehavior Type of StudyType of Study RXRX

CraftCraft

19871987

2222 AggressionAggression RCTRCT Lithium (add on)Lithium (add on)

0.7 – 1.20.7 – 1.2

TyrerTyrer

19931993


SIBSIB

RCTRCT Lithium (add on)Lithium (add on)

0.5 – 0.80.5 – 0.8

LangeeLangee

19901990

6666 Aggression, Aggression, SIBSIB

41% sz41% sz

Retrospective Retrospective UncontrolledUncontrolled

Lithium (add on)Lithium (add on)

0.7 – 1.20.7 – 1.2

VerhoevenVerhoeven

20012001


28% sz28% sz

Prospective Prospective


Valproate (add on)Valproate (add on)

1345 mg 1345 mg

RuedrichRuedrich

19991999


43 % sz43 % sz



Valproate (add on)Valproate (add on)

920 mg920 mg

JanowskyJanowsky

20032003


41% sz41% sz



Topiramate (add on)Topiramate (add on)

202 mg202 mg

ReidReid

19811981

1010 OveractivityOveractivity

50% sz50% sz

Double blind, Double blind, controlled, controlled, crossovercrossover

Carbamazepine Carbamazepine

(add on)(add on)

AntidepressantsDeb, Journal of Intellectual Disability Research, 2007

• Review of Literature • <1990-2005• >18• IQ <70• Behavior Problem (aggression, SIB, hyperactivity,

stereotypical movements)• N >/= 10• Before & after outcome (any measure)

• 10 studies (Clomipramine, Fluoxetine, Paroxetine, Fluvoxamine)Fluvoxamine)

• 1 RCT - Clomipramine• 5 negative – Fluoxetine (2), Paroxetine (3)

YearYear nn BehaviorBehavior Type of Type of StudyStudy

RxRx

LewisLewis

19951995

1010 Stereotype SIBStereotype SIB

CompulsiveCompulsive

RCTRCT Clomipramine Clomipramine

225 mg225 mg

BodfishBodfish

19931993


SIBSIB

compulsivecompulsive


CohortCohort


FluoxetineFluoxetine

20-80 mg20-80 mg

TroisiTroisi

19951995


100% sz100% sz


LongitudinalLongitudinal



20 mg20 mg

CookCook

19921992

1010 Preserverative Preserverative SIBSIB

Prospective Prospective OpenOpen



20-80 mg20-80 mg

MarkowitzMarkowitz

19921992


SIBSIB

OCD behaviorsOCD behaviors

ProspectiveProspective

Open Open UncontrolledUncontrolled

Fluoxetine (add on)Fluoxetine (add on)

20-80 mg20-80 mg

YearYear nn BehaviorBehavior Type of StudyType of Study RxRx

La MalfaLa Malfa

20012001

6060 AggressionAggression ProspectiveProspective

Case series Case series


FluvoxamineFluvoxamine

250 mg250 mg

La MalfaLa Malfa

19971997


SIBSIB

ProspectiveProspective

Case series Case series


FluvoxamineFluvoxamine

250 mg250 mg

JanowskyJanowsky

20052005


SIBSIB


Case SeriesCase Series


Paroxetine (add on)Paroxetine (add on)

10-40 mg10-40 mg

DavanzoDavanzo

19981998

1515 SIBSIB Prospective Prospective



Paroxetine (add on)Paroxetine (add on)

35 mg35 mg

BranfordBranford

19981998

3333 PerseverationPerseveration

AggressionAggression

SIBSIB




Paroxetine (add Paroxetine (add on)on)

20-40 mg20-40 mg

Monitoring Treatment Effects Expert Consensus Guidelines, 2004

• Evaluate Treatment Effects

• Identify specific target behavior/symptoms

• Collect baseline data before start medications

• Track specific behaviors/symptoms• Frequency count, time sample, interval spoilage, rating scales

(aberrant behavior checklist)• Summarize this data by time periods and/or by drug and dose

condition

• Collect outcome data

Summary• Important to determine the etiology of challenging

behavior in individuals with ID• Psychiatric Illness• Behavioral Phenotype• Medical Illness/Side effects/Pain• Function: Attention, Escape, Access, Sensory

• First step in treatment is to determine etiology!!

Challenging Behavior in Adults with Intellectual Disability

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