Intellectual Disabilities: Behavioral Problems
Theodore A. Kastner
Kevin K. Walsh
I. Description of the problem.
A. Terminology. The term used to describe children and adults with what we have known as “mental retardation” is in a state of flux. The phenomenon of changes in terminology in this field is well-known, as terms over time often acquire negative connotations. The term “mental retardation” is rapidly being replaced by the term “intellectual disability” in America; in other countries, other terms have been selected. For example, in Great Britain, the term used to describe this group is “learning disability.”
B. Epidemiology. The incidence of behavioral disorders in children with intellectual and other developmental disabilities is greater than in children without them, because any brain damage or dysfunction appears to increase the likelihood of behavioral or psychiatric disorders.
Forty percent of people with intellectual disabilities experience a period of disturbed behavior and function at some time in their lives.
The epidemiology of behavioral problems among children with intellectual and related developmental disabilities is unknown because of their cognitive and communicative limitations, and because appropriate diagnostic tools are not yet available.
It is estimated that diagnosable psychiatric disorders exist in 5% to 10% of children with intellectual and developmental disabilities.
C. Etiology. There are four major causes of severe, challenging behaviors in children with intellectual disabilities: adaptive dysfunction, psychiatric disorders, medication side effects, and organic causes. In many cases, the etiology is of multiple origins (e.g., a psychiatric disorder accompanied by family dysfunction).
1. Adaptive dysfunction is a mismatch between the needs, abilities, and goals of the child and that of the environment (usually the school and/or family unit). In this model, the potential communicative nature of the behavior is often considered. For example, does a behavioral outburst always accompany a request to accomplish difficult tasks? In this case, the behavioral problem may be due to unrealistic environmental expectations or poor adaptive skills of the child or both. Adaptive dysfunction can often be distinguished from mental illness or an organic cause by a lack of vegetative signs (weight loss or sleep problem) and a consistent relationship between the behavior and various setting events.
2. Psychiatric disorders are more common in children with intellectual disabilities than in the general population. The most common psychiatric disorders associated with intellectual disabilities in children may be the mood disorders, such as depression and bipolar disease (often in atypical forms, e.g., rapid cycling and chronic mania). Mood disorders in children with intellectual disabilities can often be recognized by the presence of a sleep disturbance, change in weight or eating habits, overactivity or motor restlessness, mood lability (crying or laughing), and a behavioral history of cycling. Less commonly, anxiety disorders, psychosis, Tourette syndrome, attentiondeficit/hyperactivity disorder (ADHD), and obsessive-compulsive disorder are seen.
3. Medication side effects are a common cause of behavioral morbidity among children with intellectual disabilities. For example, in a study of 209 people with mental retardation who presented with behavioral complaints, undiagnosed medication side effects were noted in 7%. These included akasthisia, tardive dyskinesia, and other side effects typically associated with the use of major tranquilizers.
4. Health-related causes. Occult medical illnesses have been found in about 20% of behaviorally disordered children with intellectual and developmental disabilities. The high prevalence is due to their greater healthcare needs, communication barriers around symptomatology, and a lack of effective healthcare services. Perhaps the most common medical cause of disturbed behavior is unrecognized or poorly treated epilepsy, especially partial complex seizures. Interictal irritability, for example, can exacerbate aggressive or self-injurious behaviors. Other undiagnosed medical causes
of behavioral problems include thyroid dysfunction, premenstrual syndrome, and cardiac disease.
Table 51-1. Formulating a diagnosis in individuals with intellectual disabilities and behavioral problems
1. Rule out the presence of a medical disorder.
2. Evaluate the presence of environmental supports and stressors.
3. Look for a complex of behavioral symptoms.
4. Establish a psychiatric diagnosis using standard or modified criteria.
5. Develop treatment goals.
6. Monitor treatment with a predetermined methodology.
7. Establish a treatment end point.
II. Making the diagnosis.
A. Signs and symptoms. Behavioral problems in children with intellectual disabilities include aggression, self-injury, overactivity, disruptive behaviors, and sleep disturbances. In addition, rumination, elopement, property destruction, and other behaviors are occasionally seen.
B. Behavioral questionnaires. Inventories or behavioral scales can be used to facilitate the evaluation of behavioral problems in children with intellectual disabilities. These include the Reiss Screen for Maladaptive Behavior, the Reiss Scales for Children’s Dual Diagnosis, the Psychopathology Instrument for Mentally Retarded Adults (PIMRA), and the Aberrant Behavior Checklist. There are also many specialized tools for specific disorders such as the Childhood Autism Rating Scale or the Vanderbilt ADHD Diagnostic Scales (parent and teacher versions). It is frequently of benefit to use two or more inventories and to have more than one caregiver complete the instrument.
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