Assessment and Treatment of Neuropsychological Disorders for Individuals with Developmental Disabilities

Educational Objectives

The goal of this program is to improve management of neuropsychological disorders and developmental disabilities. After hearing and assimilating this program, the clinician will be better able to:

1. Explain methods that can be used to treat nonverbal patients with developmental disabilities.
2. Gather history and other information when assessing a patient with developmental disabilities.
3. Optimize management of developmental disabilities through appropriate prescribing of medications.

Summary

Introduction: [Dr. Susan Goldwasser speaking] individuals who consult psychiatrists are many; it is usually because of behaviors, such as concerns about aggression, destruction of property, or mood changes, including withdrawal, crying, and loss of interest in previously enjoyable activities, and changes in sleep patterns; many families say that they cannot find psychiatrists or clinics for treatment because their child is nonverbal; this is not logical because, eg, pediatricians treat children who are nonverbal, and many neurologists treat, eg, aphasic stroke victims who cannot speak; mental health workers are capable of evaluating patients with or without the capacity of verbal communication

Case examples from speaker’s practice: 1) 16-yr-old nonverbal patient with autism, intellectual disability, attention-deficit/hyperactivity disorder (ADHD), history of aggression and impulsivity, and recent dramatic escalation in violence; 2) 42-yr-old woman with Down syndrome and limited verbal skills is threatening her housemate with forks; cannot follow directions

Preparation for assessment: assessment is the same whether patient is verbal or not; with nonverbal individuals, collateral information is required from family member or care provider; nonverbal status does not mean patient cannot understand care provider; alternative methods of communication (eg, writing, typing) are valid; gathering information (eg, school information, results of Conners Behavior Rating Scale, laboratory results) prior to assessment results in better use of time

Meeting location: meeting place does not have to be an office; speaker has met with a patient for 8 yr in the parking lot because he will not leave the car; after trust was established, patient re-entered school and Applied Behavior Analysis (ABA) therapy; speaker also meets patients in the waiting room; “meet people where they need to get met”

Assessment: with patient’s and family’s permission, important to invite others (eg, behaviorist, teachers, respite workers) to help gather information; gain trust so patient and family know people want to help them; identify the target symptoms; identify triggers, frequency, duration, and the location of the behavior (important if behavior is only, eg, at school or at home); review past psychiatric history, including treatments and outcomes, sexual or physical abuse, and trauma; medical history also critical

Medical history: should include neurologic, gastrointestinal (GI), genitourinary, sleep, dental, and substance abuse history; case examples — speaker treated 7-yr-old boy making no academic gains despite ABA therapy, who was not toilet trained, and was agitated, irritable, and aggressive; he also exhibited pica behavior; patient had chronic diarrhea so speaker obtained a stool culture; it was positive for campylobacter and enteropathic Escherichia coli; the diarrhea was treated and the boy’s behavior improved; another patient of the speaker was a 14-yr-old boy who was excessively aggressive and agitated; speaker witnessed the boy placing his father’s finger in his mouth and she determined by speaking with the boy’s mother he had not visited a dentist in ≥5 yr; patient was treated for abscess and behavior improved

Other history: family members often neglect to mention drug or alcohol use; important to ask; ask about medication; the chart might not be accurate; compliance is sometimes an issue; ask about potential side effects, and medication history; pregnancy and developmental history critical; self-care skills should be noted; social history is another important information to collect; aggressive patients with access to weapons are cause for concern; food insecurity can also be an important factor; education history is important to discover; some families will not take advantage of adult day programs for fear of abuse; this results in lack of cognitive stimulation, socialization, or vocational training; mental status examination allows the health care providers to better assess conditions such as mood or psychotic symptoms; critical to get help from family member or care provider to assess cognitive decline from baseline in nonverbal patients; they can help determine if there is loss of self-care skills; depression and anxiety in these patients can be ascertained during assessment through, eg, facial expressions, reports of withdrawal from activities

Categories in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition): [Dr. Richard Goldwasser speaking] ADHD is now categorized as a neurodevelopmental disorder; ≈33% of patients with neurodevelopmental disorders have some degree of ADHD; motor disorders include self-injurious behavior; fetal alcohol syndrome classified as neurodevelopmental disorder; in schizophrenia spectrum and other psychotic disorders, there is discussion of genetic polymorphisms and common markers that raise risk for autism spectrum disorders (ASD), schizophrenia, and bipolar disorders; higher frequency of mood disorders in individuals with developmental disabilities; depressive disorders include dysthymia, premenstrual dysphoric disorder, and disruptive mood dysregulation disorder (DMDD); DMDD was created to include children diagnosed a decade ago with bipolar disorder “outgrew it”; it is used to classify patients with prolonged rages with explosive outbursts and general irritability; anxiety disorders include separation anxiety, social anxiety, generalized anxiety, and panic; obsessive compulsive disorder is no longer in the anxiety category, but has overlap with other disorders; posttraumatic stress disorder is overrepresented in people with developmental disabilities; reactive attachment disorder can appear similar to autism, especially in children exposed to drugs and alcohol in utero; similarly, patients suffering from early abuse, trauma, and neglect show a mix of ASD with reactive attachment disorder; dissociative disorders, somatic symptom disorder, and conversion disorder refer to people with nonepileptic seizures and connected to trauma; other categories include feeding disorders, elimination disorders, sleep-wake disorders, sexual dysfunction, and gender dysphoria; gender dysphoria is more common among people with ASD; includes transgender and nonbinary individuals; there are also neurocognitive disorders, eg, Alzheimer disease; medication-induced movement disorders include tardive dyskinesia, which can be associated with antipsychotic medications

Treatment: antipsychotics (risperidone, aripiprazole, quetiapine [Seroquel], lurasidone [Latuda], pimozide, haloperidol) are used for ASD; are not curative, but can reduce irritability and hyperactivity and help with mental focus; they can help with aggression and hyperactivity; ADHD medications include 2 types of stimulants, methylphenidate-based drugs (Concerta) and dextroamphetamine drugs (Adderall); such drugs improve attention span, frustration tolerance, and hyperactivity; for depression, SSRIs, and selective serotonin-norepinephrine reuptake inhibitors (SNRIs; eg, mirtazapine, trazodone, atomoxetine [Strattera]) helpful with sleep but too sedating to use as primary antidepressant; buproprion (Wellbutrin) not for use with patients who have history of seizure; for anxiety, SSRIs and SNRIs, as well as antipsychotic drugs, are useful; buspirone is good for generalized anxiety disorder but not helpful with depression; benzodiazepines make a difference in patients occasionally; mood stabilizers used for bipolar disorder are lithium, and anti-epileptic drugs (eg, valproic acid, carbamazepine, lamotrigine), as well as antipsychotics; for tic disorders both antipsychotic (pimozide, haloperidol, risperidone, and aripiprazole) and ADHD medications are favored; enuresis is primarily treated with tricyclic antidepressants (imipramine, desmopressin)

Off-label use of medication: some patients have illness that cannot be categorized; in such cases medication is prescribed based on efficacy; with aggression, impulsivity, and irritability, it is reasonable to begin with ADHD medications; bipolar disorder and mood lability indicate use of antipsychotics; if patients show symptoms of aggression and irritability but not impulsivity, anti-epileptics and lithium could be prescribed; antihypertensive medications (eg, prazosin) appears to be most helpful in treating posttraumatic stress disorder (PTSD); for help with sleep, pediatricians use trazodone and mirtazapine (the latter increases appetite); gabapentin helpful with sleep and restless leg syndrome; nonprescription options include valerian, melatonin, diphenhydramine (Benadryl), and cannabidiol-2

Side effects: ≈25% of people develop side effects at first, and they improve after some time; those that do not improve can be managed; sedation, insomnia, weight gain are common with antipsychotics; good evidence that metformin can be used to reduce weight gain and the risk for diabetes that result from antipsychotics; mirtazapine useful for decreased appetite; important to manage GI side effects; often behavioral issues improve as a result; patients rarely volunteer such information so it is important to ask; emotional flattening should be addressed; dropout rate is ≈10%; worsening mood or behavior can occur (rare); akathisia is associated with antipsychotics; any drug can cause agitation; suicidal ideation is often seen (1%-2%) with anti-epileptics, antidepressants, and atomoxetine; patients with bipolar disorders, family history of mood lability, or history of abuse, trauma, and neglect are at greater risk for suicidal ideation from medication

Conclusion: psychiatric conditions are common in this population; recent study suggested that ≥33% of patients have comorbid psychiatric conditions

Readings

Carvalho AF et al. The safety, tolerability and risks associated with the use of newer generation antidepressant drugs: a critical review of the literature. Psychother Psychosom. 2016;85:270-288; doi: 10.1159/000447034; Mayes SD et al. Disruptive mood dysregulation disorder symptoms by age in autism, ADHD, and general population samples. J Ment Health Res Intellect Disabil. 2017;10:345-359; doi: 10.1080/19315864.2017.1338804; O'Neal MA et al. Treatment for patients with a functional neurological disorder (conversion disorder): an integrated approach. Am J Psychiatry. 2018;175:307-314; doi: 10.1176/appi.ajp.2017.17040450; Pietz CA, Mattson CA. Violent offenders: understanding and assessment. Oxford ; New York : Oxford University Press. 2015. doi: 10.1111/bjop.12149; Selten JP et al. Risks for non-affective psychotic disorder and bipolar disorder in young people with autism spectrum disorder. JAMA Psychiatry 2015;72:483-489; doi: 10.1001/ jamapsychiatry.2014.3059; Weitlauf AS et al. Interventions targeting sensory challenges in autism spectrum disorder: a systematic review. Pediatrics 2017; 139:e20170347; doi: 10.1542/peds.2017-0347.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose. In their lecture, Dr. Susan Goldwasser and Dr. Richard Goldwasser present information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Susan Goldwasser, and Dr. Richard Goldwasser was recorded at Developmental Disabilities: Update for Health Professionals, held March 5-7, 2021, in San Francisco, CA, and presented by the University of California, San Francisco School of Medicine and UCSF School of Nursing. For information on future CME activities from this sponsor, please visit meded.ucsf.edu. Audio Digest thanks the speakers and the University of California, San Francisco for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

NE121702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.