- Email: [email protected]
7.5 Pharmacotherapy for Co-Occurring Psychiatric Conditions in Intellectual Disability and Autism Spectrum Disorder
INSTITUTES 7.5 — 7.7
approaches is also described. Case examples illustrating behavioral and pharmacological interventions and their coordinated application will be presented. Results: In the context of deficits in communication, adaptive behavior, and intellectual functioning associated with IDD, problem behavior can emerge and come to be strengthened by reinforcement in the environment. Decades of research show that in at least two-thirds of cases, problem behavior is maintained by socially mediated variables (e.g., problem behavior functions to escape tasks, access attention, gain access to preferred items). Behavioral treatments based on an understanding of the behavioral function are highly effective in reducing problem behavior and teaching adaptive skills, but in many cases, problems with emotion regulation also necessitate the use of medications. Conclusions: Problem behavior in persons with IDD can have a range of determinants, including environmental, biological, and psychiatric variables. Functional behavioral assessment procedures can precisely identify environmental variables maintaining problem behavior and thus help delineate what remaining dimensions of the clinical presentation seem biological and would require psychopharmacologic intervention. Singlecase design methodologies used to evaluate behavioral intervention effects are also ideally suited to objectively evaluate psychopharmacological interventions.
CBT, DBD, ID http://dx.doi.org/10.1016/j.jaac.2017.07.562
7.5 PHARMACOTHERAPY FOR CO-OCCURRING PSYCHIATRIC CONDITIONS IN INTELLECTUAL DISABILITY AND AUTISM SPECTRUM DISORDER Robert L. Findling, MD, MBA, Kennedy Krieger Institute and Johns Hopkins University, [email protected] Objectives: The goal of this session is to provide a review of what is known (and what is not known) about the pharmacological treatment of co-occurring psychiatric conditions in patients suffering from intellectual disability (ID) and autism spectrum disorder (ASD). Furthermore, medication treatment data on neurogenetic syndromes that are associated with ID/ASD will also be considered. The clinical relevance of the extant research data and evidence-based treatment approaches will be discussed. Methods: For this presentation, data from published clinical trials for ID and ASD will be reviewed. In addition, information from relevant scientific meetings will be considered. Results: In patients with ID, the most methodologically stringent data suggest that symptoms of ADHD may improve with methylphenidate. Similarly, the cautious use of antipsychotic drugs may be beneficial for children with ID and substantive and impairing disruptive behavior disorders (DBDs). Data for patients with ID and other psychiatric conditions are limited. For patients with ASD, there is evidence to support the assertion that patients with ADHD and DBDs may benefit from certain pharmacotherapies. Selective serotonin re-uptake inhibitors do not have the data to support their efficacy in reducing repetitive behaviors in ASD. Conclusions: More rigorous study is needed to examine what role, if any, medication management may have in youths with ID who are suffering from mood and anxiety disorders. In addition, for patients with ID, there are limited data on the long-term safety and effectiveness of treatment with psychotropic agents. Compared with patients with ID, more is known about the medication treatment of patients with ASD. For this reason, evidence-based decisions about prescribing psychiatric agents to these vulnerable patients with ASD can be made more frequently. However, most studies that have reported efficacy for medications in those with ASD are generally of short duration. As a result, the ability to draw definitive conclusions about long-term tolerability or effectiveness is limited.
CM, ID, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.563
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
7.6 FAMILY INTERVENTIONS FOR CHILDREN WITH NEURODEVELOPMENTAL DISABILITIES AND CO-OCCURRING BEHAVIORAL AND MENTAL DISORDERS Elisabeth Dykens, PhD, Vanderbilt Kennedy Center and Vanderbilt University Medical Center, elisabeth.dykens@ Vanderbilt.Edu Objectives: The goals of this sessions are to do as follows: 1) discuss key findings on the health and mental health vulnerabilities of parents of offspring with neurodevelopmental disorders, including autism spectrum disorders, Down syndrome, rare genetic syndromes, and mental illness; and 2) demonstrate the need for novel interventions that directly address the stress and distress of these parents. Methods: This presentation will summarize research on family care providers and the nascent literature on effective interventions for them, including cognitive behavioral therapies, thematic and informational groups, and mindfulness practices. Results: Neurodevelopmental disorders are the most prevalent chronic health conditions among our nation’s children, and the health and mental health problems in parents of these children now have become an urgent public health concern. Beyond elevated stress, depression, anxiety, sleep, and health problems, these parents also show reduced immune function, shorter telomere length, and blunted diurnal cortisol trajectories—all indicative of stress chronicity. Results will be shared from our large, randomized clinical trial in parents of children with autism and other disabilities comparing mindfulness-based stress reduction to an intervention based on principles of positive psychology. Our trial demonstrated significant effects of both mindfulness and positive psychology practices in reducing these problems in the short- and long-term. Mindfulness practices led to more immediate reductions in depression and anxiety, with large effect sizes. Findings also demonstrated the utility of using trained, supervised peer mentors to deliver treatments. Conclusions: Interventions are sorely needed that reduce parental distress and enhance their health and well-being. As most adults with intellectual and other disabilities co-reside with their aging parents, such interventions can position parents to more effectively care for their children in the long-term. New disability policies are needed to support such efforts.
FAM, ID, PAT http://dx.doi.org/10.1016/j.jaac.2017.07.564
7.7 LEGAL, ETHICAL, AND FORENSIC ISSUES IN INTELLECTUAL AND DEVELOPMENTAL DISABILITIES Ludwik S. Szymanski, MD, Boston Children’s Hospital and Harvard Medical School, [email protected] Objectives: This presentation will review legislation, legal entitlements, techniques of forensic psychiatric assessment in criminal and civil proceedings, and ethical issues pertinent to persons who have an intellectual and developmental disability (ID/DD). Methods: Both federal and state legislations and laws, as well as case law, are pertinent here; thus, their principles will be reviewed. Although state laws may differ from one another, the important underlying principles are usually similar and will be discussed and illustrated with case examples Results: Persons with ID may be involved in civil proceedings, which may include determining general legal competence; need for guardianship; assessment of competence to enter into a contract, including marriage, to provide informed consent (such as for medical treatment or participation in a research study); and parental competence in child protection and custody cases. The diagnosis of ID does not automatically imply legal incompetence, which has to be determined through court decision, usually based on assessment by a clinical team, focused on a person’s ability to make rational and informed decisions. Assessment in criminal proceedings may include determination of competence to stand trial, criminal responsibility, and competence to testify as a witness. Psychiatric testimony on whether the
www.jaacap.org
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approaches is also described. Case examples illustrating behavioral and pharmacological interventions and their coordinated application will be presented. Results: In the context of deficits in communication, adaptive behavior, and intellectual functioning associated with IDD, problem behavior can emerge and come to be strengthened by reinforcement in the environment. Decades of research show that in at least two-thirds of cases, problem behavior is maintained by socially mediated variables (e.g., problem behavior functions to escape tasks, access attention, gain access to preferred items). Behavioral treatments based on an understanding of the behavioral function are highly effective in reducing problem behavior and teaching adaptive skills, but in many cases, problems with emotion regulation also necessitate the use of medications. Conclusions: Problem behavior in persons with IDD can have a range of determinants, including environmental, biological, and psychiatric variables. Functional behavioral assessment procedures can precisely identify environmental variables maintaining problem behavior and thus help delineate what remaining dimensions of the clinical presentation seem biological and would require psychopharmacologic intervention. Singlecase design methodologies used to evaluate behavioral intervention effects are also ideally suited to objectively evaluate psychopharmacological interventions.
CBT, DBD, ID http://dx.doi.org/10.1016/j.jaac.2017.07.562
7.5 PHARMACOTHERAPY FOR CO-OCCURRING PSYCHIATRIC CONDITIONS IN INTELLECTUAL DISABILITY AND AUTISM SPECTRUM DISORDER Robert L. Findling, MD, MBA, Kennedy Krieger Institute and Johns Hopkins University, [email protected] Objectives: The goal of this session is to provide a review of what is known (and what is not known) about the pharmacological treatment of co-occurring psychiatric conditions in patients suffering from intellectual disability (ID) and autism spectrum disorder (ASD). Furthermore, medication treatment data on neurogenetic syndromes that are associated with ID/ASD will also be considered. The clinical relevance of the extant research data and evidence-based treatment approaches will be discussed. Methods: For this presentation, data from published clinical trials for ID and ASD will be reviewed. In addition, information from relevant scientific meetings will be considered. Results: In patients with ID, the most methodologically stringent data suggest that symptoms of ADHD may improve with methylphenidate. Similarly, the cautious use of antipsychotic drugs may be beneficial for children with ID and substantive and impairing disruptive behavior disorders (DBDs). Data for patients with ID and other psychiatric conditions are limited. For patients with ASD, there is evidence to support the assertion that patients with ADHD and DBDs may benefit from certain pharmacotherapies. Selective serotonin re-uptake inhibitors do not have the data to support their efficacy in reducing repetitive behaviors in ASD. Conclusions: More rigorous study is needed to examine what role, if any, medication management may have in youths with ID who are suffering from mood and anxiety disorders. In addition, for patients with ID, there are limited data on the long-term safety and effectiveness of treatment with psychotropic agents. Compared with patients with ID, more is known about the medication treatment of patients with ASD. For this reason, evidence-based decisions about prescribing psychiatric agents to these vulnerable patients with ASD can be made more frequently. However, most studies that have reported efficacy for medications in those with ASD are generally of short duration. As a result, the ability to draw definitive conclusions about long-term tolerability or effectiveness is limited.
CM, ID, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.563
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
7.6 FAMILY INTERVENTIONS FOR CHILDREN WITH NEURODEVELOPMENTAL DISABILITIES AND CO-OCCURRING BEHAVIORAL AND MENTAL DISORDERS Elisabeth Dykens, PhD, Vanderbilt Kennedy Center and Vanderbilt University Medical Center, elisabeth.dykens@ Vanderbilt.Edu Objectives: The goals of this sessions are to do as follows: 1) discuss key findings on the health and mental health vulnerabilities of parents of offspring with neurodevelopmental disorders, including autism spectrum disorders, Down syndrome, rare genetic syndromes, and mental illness; and 2) demonstrate the need for novel interventions that directly address the stress and distress of these parents. Methods: This presentation will summarize research on family care providers and the nascent literature on effective interventions for them, including cognitive behavioral therapies, thematic and informational groups, and mindfulness practices. Results: Neurodevelopmental disorders are the most prevalent chronic health conditions among our nation’s children, and the health and mental health problems in parents of these children now have become an urgent public health concern. Beyond elevated stress, depression, anxiety, sleep, and health problems, these parents also show reduced immune function, shorter telomere length, and blunted diurnal cortisol trajectories—all indicative of stress chronicity. Results will be shared from our large, randomized clinical trial in parents of children with autism and other disabilities comparing mindfulness-based stress reduction to an intervention based on principles of positive psychology. Our trial demonstrated significant effects of both mindfulness and positive psychology practices in reducing these problems in the short- and long-term. Mindfulness practices led to more immediate reductions in depression and anxiety, with large effect sizes. Findings also demonstrated the utility of using trained, supervised peer mentors to deliver treatments. Conclusions: Interventions are sorely needed that reduce parental distress and enhance their health and well-being. As most adults with intellectual and other disabilities co-reside with their aging parents, such interventions can position parents to more effectively care for their children in the long-term. New disability policies are needed to support such efforts.
FAM, ID, PAT http://dx.doi.org/10.1016/j.jaac.2017.07.564
7.7 LEGAL, ETHICAL, AND FORENSIC ISSUES IN INTELLECTUAL AND DEVELOPMENTAL DISABILITIES Ludwik S. Szymanski, MD, Boston Children’s Hospital and Harvard Medical School, [email protected] Objectives: This presentation will review legislation, legal entitlements, techniques of forensic psychiatric assessment in criminal and civil proceedings, and ethical issues pertinent to persons who have an intellectual and developmental disability (ID/DD). Methods: Both federal and state legislations and laws, as well as case law, are pertinent here; thus, their principles will be reviewed. Although state laws may differ from one another, the important underlying principles are usually similar and will be discussed and illustrated with case examples Results: Persons with ID may be involved in civil proceedings, which may include determining general legal competence; need for guardianship; assessment of competence to enter into a contract, including marriage, to provide informed consent (such as for medical treatment or participation in a research study); and parental competence in child protection and custody cases. The diagnosis of ID does not automatically imply legal incompetence, which has to be determined through court decision, usually based on assessment by a clinical team, focused on a person’s ability to make rational and informed decisions. Assessment in criminal proceedings may include determination of competence to stand trial, criminal responsibility, and competence to testify as a witness. Psychiatric testimony on whether the
www.jaacap.org
S149