Inform patients of interventions and support options
Inform patients of psychological interventions and supports available from the interprofessional team or community. Ensure that supports to access these services are provided (eg, transportation) and include the active participation of an IDD-informed support person.108
Recommended
Expert
When people with IDD experience emotional distress, various individual or group interventions are effective (eg, counseling, CBT, positive behaviour support, psychotherapy, trauma-informed therapies, mindfulness practices).108, 252, 290 Adaptations to the needs of people with IDD and supports can improve access to these therapies.
Consider disorder-specific medications
When a psychiatric diagnosis is confirmed by comprehensive assessment, consider indicated, disorder-specific psychotropic medication along with other possible interventions as outlined below.252, 263
Strongly Recommended
Empirical Ecosystem Expert
Psychotropic medications can be effective, along with other psychological therapies, when a psychiatric disorder (eg, ADHD, anxiety and mood disorder) is confirmed by comprehensive assessment.216, 252, 263, 303 Psychotropic medications, however, should be used judiciously with people with IDD. Some might be taking multiple medications and thus be at increased risk of adverse drug-drug interactions (see Polypharmacy and Long-term use of Medication), have atypical responses and have adverse reactions or unwanted effects even at low doses. Adults with IDD might be unable to describe harmful or distressing effects other than through changes in their behaviours.264, 304-307
Consult prescribing guidelines
Consult prescribing guidelines for psychiatric disorders in IDD.88, 263, 267
Strongly Recommended
Empirical Ecosystem Expert
Psychotropic medications can be effective, along with other psychological therapies, when a psychiatric disorder (eg, ADHD, anxiety and mood disorder) is confirmed by comprehensive assessment.216, 252, 263, 303 Psychotropic medications, however, should be used judiciously with people with IDD. Some might be taking multiple medications and thus be at increased risk of adverse drug-drug interactions (see Polypharmacy and Long-term use of Medication), have atypical responses and have adverse reactions or unwanted effects even at low doses. Adults with IDD might be unable to describe harmful or distressing effects other than through changes in their behaviours.264, 304-307
Refer to medication algorithms
Refer to medication algorithms for specific diagnostic categories, eg, ADHD, anxiety, mood.216, 303
Strongly Recommended
Empirical Ecosystem Expert
Psychotropic medications can be effective, along with other psychological therapies, when a psychiatric disorder (eg, ADHD, anxiety and mood disorder) is confirmed by comprehensive assessment.216, 252, 263, 303 Psychotropic medications, however, should be used judiciously with people with IDD. Some might be taking multiple medications and thus be at increased risk of adverse drug-drug interactions (see Polypharmacy and Long-term use of Medication), have atypical responses and have adverse reactions or unwanted effects even at low doses. Adults with IDD might be unable to describe harmful or distressing effects other than through changes in their behaviours.264, 304-307
Start low, go slow with medication dosing
Start low and go slow in initiating, increasing, or decreasing doses of medications.88, 305
Strongly Recommended
Empirical Ecosystem Expert
Psychotropic medications can be effective, along with other psychological therapies, when a psychiatric disorder (eg, ADHD, anxiety and mood disorder) is confirmed by comprehensive assessment.216, 252, 263, 303 Psychotropic medications, however, should be used judiciously with people with IDD. Some might be taking multiple medications and thus be at increased risk of adverse drug-drug interactions (see Polypharmacy and Long-term use of Medication), have atypical responses and have adverse reactions or unwanted effects even at low doses. Adults with IDD might be unable to describe harmful or distressing effects other than through changes in their behaviours.264, 304-307
Seek informed consent
Seek and document informed consent using adapted tools, such as the Informed Consent Checklist 32 (see Capacity for Decision Making).88
Strongly Recommended
Empirical Ecosystem Expert
Psychotropic medications can be effective, along with other psychological therapies, when a psychiatric disorder (eg, ADHD, anxiety and mood disorder) is confirmed by comprehensive assessment.216, 252, 263, 303 Psychotropic medications, however, should be used judiciously with people with IDD. Some might be taking multiple medications and thus be at increased risk of adverse drug-drug interactions (see Polypharmacy and Long-term use of Medication), have atypical responses and have adverse reactions or unwanted effects even at low doses. Adults with IDD might be unable to describe harmful or distressing effects other than through changes in their behaviours.264, 304-307
Get feedback from patients and caregivers
Educate and arrange to receive feedback regularly from patients and their caregivers during medication trials.252, 303
Strongly Recommended
Empirical Ecosystem Expert
Psychotropic medications can be effective, along with other psychological therapies, when a psychiatric disorder (eg, ADHD, anxiety and mood disorder) is confirmed by comprehensive assessment.216, 252, 263, 303 Psychotropic medications, however, should be used judiciously with people with IDD. Some might be taking multiple medications and thus be at increased risk of adverse drug-drug interactions (see Polypharmacy and Long-term use of Medication), have atypical responses and have adverse reactions or unwanted effects even at low doses. Adults with IDD might be unable to describe harmful or distressing effects other than through changes in their behaviours.264, 304-307
Review response to drugs every three months
Review response, adverse drug reactions, or unwanted effects every 3 mo (see Polypharmacy and Long-term use of Medication). Review the psychiatric diagnosis and appropriateness of prescribed medications whenever there is nonresponse, worsening of symptoms, behavioural change, or patient or caregiver request.88, 263, 306
Strongly Recommended
Empirical Ecosystem Expert
Antipsychotic medications are commonly prescribed to adults with IDD despite the absence of a diagnosis of a psychotic or mood disorder.83, 264 Adverse drug reactions and unwanted effects can be considerable. Antipsychotic medications increase the risk of CNS effects (eg, sedation, behavioural disturbance), extrapyramidal symptoms (eg, parkinsonism, akathisia, tardive dyskinesia), anticholinergic effects (eg, swallowing difficulties, bowel dysfunction), cardiovascular effects (eg, orthostatic hypotension, tachycardia), and endocrine effects (eg, metabolic syndrome, sexual dysfunction), as well as longer-term adverse effects.267, 308
Monitor and address drug reactions
Monitor and address adverse drug reactions and unwanted effects of antipsychotics, such as those listed in the background.88
Strongly Recommended
Empirical Ecosystem Expert
Antipsychotic medications are commonly prescribed to adults with IDD despite the absence of a diagnosis of a psychotic or mood disorder.83, 264 Adverse drug reactions and unwanted effects can be considerable. Antipsychotic medications increase the risk of CNS effects (eg, sedation, behavioural disturbance), extrapyramidal symptoms (eg, parkinsonism, akathisia, tardive dyskinesia), anticholinergic effects (eg, swallowing difficulties, bowel dysfunction), cardiovascular effects (eg, orthostatic hypotension, tachycardia), and endocrine effects (eg, metabolic syndrome, sexual dysfunction), as well as longer-term adverse effects.267, 308
Consider dose reduction, tapering or switching medications
If adverse drug reactions or unwanted effects are present, consider dose reduction, tapering or switching medications.263, 308
Strongly Recommended
Empirical Ecosystem Expert
Antipsychotic medications are commonly prescribed to adults with IDD despite the absence of a diagnosis of a psychotic or mood disorder.83, 264 Adverse drug reactions and unwanted effects can be considerable. Antipsychotic medications increase the risk of CNS effects (eg, sedation, behavioural disturbance), extrapyramidal symptoms (eg, parkinsonism, akathisia, tardive dyskinesia), anticholinergic effects (eg, swallowing difficulties, bowel dysfunction), cardiovascular effects (eg, orthostatic hypotension, tachycardia), and endocrine effects (eg, metabolic syndrome, sexual dysfunction), as well as longer-term adverse effects.267, 308
Encourage a healthy lifestyle
Educate patients and caregivers to incorporate a healthy diet, physical activity and good sleep habits into their lifestyles.88
Strongly Recommended
Empirical Expert
Other therapeutic interventions include environmental modification with attention to sensory hypersensitivities and hyposensitivities; education and skill development; communication aids; behaviour support; art, drama and music therapies; healthy lifestyle and physical activity interventions; and caregiver support, training, and stress-reduction practices.124, 126, 252
Refer to other professionals, agencies, and community
Advocate for and consider referral to professionals, agencies, and community programs that can be of therapeutic benefit, especially those that can be adapted to the needs of people with IDD.252
Strongly Recommended
Empirical Expert
Other therapeutic interventions include environmental modification with attention to sensory hypersensitivities and hyposensitivities; education and skill development; communication aids; behaviour support; art, drama and music therapies; healthy lifestyle and physical activity interventions; and caregiver support, training and stress-reduction practices.124, 126, 252
Decision-Making Checklist
The Informed Consent in Adults with Developmental Disabilities & Informed Voluntary Consent Checklist, developed by the Developmental Disabilities Primary Care Initiative at Surrey Place (Toronto, 2011), helps primary care providers assess the person’s capacity for giving and refusing consent
Learn how to implement these guideline recommendations into your practice from selected articles in the special issue on primary care of adults with intellectual and developmental disabilities in Canadian Family Physician, Vol 64 (suppl 2): S1-78, April 2018:
HELP for behaviours that challenge in adults with intellectual and developmental disabilities
32. Gillis G, Gitta M, Heng J, Korossy M, Leong R, Sullivan WF, et al. Informed consent in adults with developmental disabilities & informed voluntary consent checklist and sample questions. In: Sullivan WF, Developmental Disabilities Primary Care Initiative [DDPCI], editors. Tools for the primary care for people with developmental disabilities. Toronto: MUMS Guideline Clearinghouse;Surrey Place; 2011. p. 11-7.
83. Cobigo V, Ouellette-Kuntz HMJ, Lake JK, Wilton AS, Lunsky Y. Chapter 6: Medication use. In: Lunsky Y, Klein-Geltink JE, Yates EA, editors. Atlas on the primary care of adults in Ontario. Toronto: Centre for Addiction and Mental Health and Institute for Clinical Evaluative Sciences; 2013. p. 117-36.
88. Branford D, Bhaumik S. Chapter 2: Prescribing practice. In: Bhaumik S, Branford D, Barrett M, Gangadharan SK, editors. The Frith prescribing guidelines for people with intellectual disability. 3rd ed. Chichester, West Sussex ; Hoboken, NJ: John Wiley & Sons Inc.; 2015. p. 11-9.
108. Beail N, Faculties for Intellectual Disabilities of the Royal College of Psychiatrists and the Division of Clinical Psychology, British Psychological Society. Psychological therapies and people who have intellectual disabilities. United Kingdom: The British Psychological Society, Division of Clinical Psychology; 2016.
124. Ogg-Groenendaal M, Hermans H, Claessens B. A systematic review on the effect of exercise interventions on challenging behavior for people with intellectual disabilities. Res Dev Disabil. 2014;35(7):1507-17.
126. Carraro A, Gobbi E. Exercise intervention to reduce depressive symptoms in adults with intellectual disabilities. Percept Mot Skills. 2014;119(1):1-5.
216. Bhaumik S, Branford D, Barrett M, Gangadharan SK, editors. The Frith Prescribing Guidelines for People with Intellectual Disability. 3rd ed. Chichester, West Sussex ; Hoboken, NJ: John Wiley & Sons Inc.; 2015.
252. National Institute for Health and Care Excellence – NICE. Mental health problems in people with learning disabilities: Prevention, assessment and management – methods, evidence and recommendations: Final version. UK: The British Psychological Society and The Royal College of Psychiatrists; 2016 September.
263. Alexander RT, Branford D, Devapriam J. Psychotropic drug prescribing for people with intellectual disability, mental health problems and/or behaviours that challenge: Practice guidelines. London, UK: The Royal College of Psychiatrist; 2016 April.
264. Sheehan R, Hassiotis A, Walters K, Osborn D, Strydom A, Horsfall L. Mental illness, challenging behaviour, and psychotropic drug prescribing in people with intellectual disability: UK population based cohort study. BMJ. 2015;351:h4326.
267. Branford D, Bhaumik S. Chapter 3: Physical and health monitoring. In: Bhaumik S, Branford D, Barret M, editors. The Frith prescribing guidelines for adults with learning disability. 3rd ed. Wiley; 2015. p. 21-30.
290. Mevissen L, de Jongh A. PTSD and its treatment in people with intellectual disabilities. A review of the literature. Clin Psychol Rev. 2010;30(3):308-16.
299. Boardman L, Bernal J, Hollins S. Communicating with people with intellectual disabilities: A guide for general psychiatrists. Advances in Psychiatric Treatment. 2014;20(1):27-36.
303. Ji NY, Findling RL. Pharmacotherapy for mental health problems in people with intellectual disability. Curr Opin Psychiatry. 2016;29(2):103-25.
304. Bradley E, Cheetham T. The use of psychotropic medication for the management of problem behaviours in adults with intellectual disabilities living in canada. Advances in Mental Health and Intellectual Disabilities. 2010;4(3):12-26.
305. Eady N, Courtenay K, Strydom A. Pharmacological management of behavioral and psychiatric symptoms in older adults with intellectual disability. Drugs Aging. 2015;32(2):95-102.
306. Emerson E, Einfeld SL. Chapter 10: Pharmacotherapy. In: Challenging behaviour. 3rd ed. Cambridge, UK ; New York: Cambridge University Press; 2011. p. 94-101.
307. Scheifes A, Walraven S, Stolker JJ, Nijman HL, Egberts TC, Heerdink ER. Adverse events and the relation with quality of life in adults with intellectual disability and challenging behaviour using psychotropic drugs. Res Dev Disabil. 2016;49-50:13-21.
308. De Kuijper G, Mulder H, Evenhuis H, Visser F, Hoekstra PJ. Effects of controlled discontinuation of long-term used antipsychotics on weight and metabolic parameters in individuals with intellectual disability. J Clin Psychopharmacol. 2013;33(4):520-4.
