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/
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
DSM 4:IQ: 20-25 to 35-40 Mental Age: 3-6yrs
Little understanding of written language or concepts
Limited spoken language. Single words.
Support for all activities
Profound
DSM 4:IQ: 20-25 to 35-40 Mental Age: 3-6yrs
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
Overview• Definitions
• Etiology, Epidemiology
• Challenging Behavior
• Etiology of Challenging Behavior
• Assessment of Challenging Behavior
• Treatment of Challenging Behavior
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”
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
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
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
Behavioral Phenotype DM-ID
PKUPrader-Willi Rubinstein-TaybiSmith MagenisTuberous Sclerosis Complex
Velocardiofacial
Angelman Cri-du-chatDownFetal Alcohol Fragile XWilliams
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
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
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
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
Overview• Definitions
• Etiology, Epidemiology
• Challenging Behavior
• Etiology of Challenging Behavior
• Assessment of Challenging Behavior
• Treatment of Challenging Behavior
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
Overview• Definitions
• Etiology, Epidemiology
• Challenging Behavior
• Etiology of Challenging Behavior
• Assessment of Challenging Behavior
• Treatment of Challenging Behavior
Step 1: Determine Reason for Behavior
• Psychiatric Illness• I’m depressed. I am manic. I am anxious. I am hearing voices.
• 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 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
1515 AggressionAggression
SIBSIB
Prospective Prospective Uncontrolled Uncontrolled
QuetiapineQuetiapine
300-1200mg300-1200mg
YearYear nn Target Target BehaviorBehavior
Type of Type of StudyStudy
RxRx
ThalyasingamThalyasingam
(2004)(2004)
2424 AggressionAggression
(psychosis)(psychosis)
Retrospective Retrospective
UncontrolledUncontrolled
ClozapineClozapine
485 mg485 mg
Boachie & Boachie & McGinnityMcGinnity
19971997
1717 AggressionAggression
(psychosis)(psychosis)
Retrospective Retrospective
UncontrolledUncontrolled
ClozapineClozapine
640 mg in ♀640 mg in ♀
357 mg in ♂357 mg in ♂
JanowkyJanowky
20032003
2020 AggressionAggression
SIBSIB
RetrospectiveRetrospective
UncontrolledUncontrolled
OlanzapineOlanzapine
9.1 mg9.1 mg
GualtieriGualtieri
19901990
1212 SIBSIB Prospective Prospective UncontrolledUncontrolled
FluphenazineFluphenazine
1-15mg1-15mg
MaltMalt
19951995
3434 AggressionAggression
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
5252 AggressionAggression
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
2828 Aggression, Aggression, SIBSIB
28% sz28% sz
Prospective Prospective
UncontrolledUncontrolled
Valproate (add on)Valproate (add on)
1345 mg 1345 mg
RuedrichRuedrich
19991999
2828 Aggression, Aggression, SIBSIB
43 % sz43 % sz
RetrospectiveRetrospective
UncontrolledUncontrolled
Valproate (add on)Valproate (add on)
920 mg920 mg
JanowskyJanowsky
20032003
2222 Aggression, Aggression, SIBSIB
41% sz41% sz
RetrospectiveRetrospective
UncontrolledUncontrolled
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
1616 AggressionAggression
SIBSIB
compulsivecompulsive
Prospective Prospective
CohortCohort
UncontrolledUncontrolled
FluoxetineFluoxetine
20-80 mg20-80 mg
TroisiTroisi
19951995
1919 AggressionAggression
100% sz100% sz
Prospective Prospective
LongitudinalLongitudinal
UncontrolledUncontrolled
FluoxetineFluoxetine
20 mg20 mg
CookCook
19921992
1010 Preserverative Preserverative SIBSIB
Prospective Prospective OpenOpen
UncontrolledUncontrolled
FluoxetineFluoxetine
20-80 mg20-80 mg
MarkowitzMarkowitz
19921992
2020 AggressionAggression
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
UncontrolledUncontrolled
FluvoxamineFluvoxamine
250 mg250 mg
La MalfaLa Malfa
19971997
1414 AggressionAggression
SIBSIB
ProspectiveProspective
Case series Case series
UncontrolledUncontrolled
FluvoxamineFluvoxamine
250 mg250 mg
JanowskyJanowsky
20052005
1414 AggressionAggression
SIBSIB
RetrospectiveRetrospective
Case SeriesCase Series
UncontrolledUncontrolled
Paroxetine (add on)Paroxetine (add on)
10-40 mg10-40 mg
DavanzoDavanzo
19981998
1515 SIBSIB Prospective Prospective
Case SeriesCase Series
UncontrolledUncontrolled
Paroxetine (add on)Paroxetine (add on)
35 mg35 mg
BranfordBranford
19981998
3333 PerseverationPerseveration
AggressionAggression
SIBSIB
RetrospectiveRetrospective
Case SeriesCase Series
UncontrolledUncontrolled
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