12 Intellectual disability12.4 Clinical
12.4.4 Psychiatric treatment and multidisciplinary care
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Written by Resident Doctor Committee · Published
Treating a formulation, not a behaviour
State what you are treating, the proposed mechanism, the intended benefit and the review date.
Self-injury may be driven by pain, depression or distress at a changed routine, and each cause needs its own response.
Adapting psychological therapy
Adapted cognitive behavioural therapy (CBT) suits mild intellectual disability with good verbal skills. It uses simpler language, pictures, shorter sessions, more repetition and a supporter between sessions.
Match the work to the person's abilities while respecting their chronological age and adult identity.
Behavioural approaches
Positive behaviour support
Positive behaviour support is the framework favoured in UK services for behaviour that challenges.
It starts from a functional assessment that charts antecedents and consequences to find what the behaviour achieves.
The plan then makes proactive changes to the setting, teaches new skills including communication, and sets agreed reactive strategies.
The psychiatrist keeps medical causes under review and judges the plan on quality of life, not on sedation or fewer incidents.
Pica
Pica needs iron deficiency and lead toxicity excluded first.
It is then usually maintained by what it gives the person, often sensory stimulation.
A functional assessment guides behavioural treatment by enrichment, restricted access and reinforcement of alternative behaviour.
Stammering
Prolonged speech is the fluency-shaping technique used in the direct treatment of stammering. It retrains speech production with a slow rate, gentle voicing onset and smooth joins.
Communication interventions
Intervention | For whom | How it works |
|---|---|---|
Intensive interaction | Pre-verbal people | The partner follows the person's lead, joining their own behaviour in shared enjoyable exchanges that build eye contact, turn-taking and attention to another person |
Social story | Developed by Carol Gray for autistic people | A personalised text with pictures describes a coming situation, what others will do and how the person might respond |
Talking Mats | People with limited speech; from the University of Stirling | Picture symbols are sorted under a visual scale of feelings in a low-tech framework, so people give their views and take part in decisions |
In a social story, descriptive sentences outnumber directive ones.
Prescribing for a stated indication
Follow guidance for the diagnosed illness, starting lower and titrating more slowly while still reaching an effective dose.
Review epilepsy, interactions, movement disorders, swallowing, constipation and the person's ability to report adverse effects.
A licence does not establish that a drug suits this patient.
Drugs for specific problems
Drug | Use in intellectual disability | Points to know |
|---|---|---|
Lithium | Aggressive behaviour and intentional self-harm; first-line bipolar maintenance | Its UK licence covers aggression and self-harm, so this use is on-licence, unlike drugs used off-label; add a baseline electroencephalogram (EEG), as epilepsy is much commoner and lithium can provoke seizures |
Valproate | Mania | Avoid in women of childbearing potential because of teratogenic and neurodevelopmental risk |
Carbamazepine | Episodic dyscontrol: brief out-of-character rages without trigger in poorly controlled temporal lobe epilepsy | Some evidence; part of the benefit may come from better seizure control |
Selective serotonin reuptake inhibitor (SSRI), such as sertraline | Depression, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder (treated as in the general population) | Usual first drug for depression once hypothyroidism, a common mimic in Down syndrome, is excluded |
Methylphenidate | Attention deficit hyperactivity disorder in children | First-line, but responses are smaller and side effects commoner, so raise the dose slowly |
Naltrexone | Self-injurious behaviour | Weak, inconsistent evidence from small studies and case reports; use has declined; kept for self-injury that has failed other approaches |
Cyproterone acetate | Sexual offending that persists despite adapted psychological and behavioural treatment | Blocks androgen receptors and lowers testosterone, reducing sexual drive; needs informed consent, specialist oversight and monitoring of liver function, mood and bone density |
Antipsychotics for behaviour that challenges
The National Institute for Health and Care Excellence (NICE) allows an antipsychotic when other interventions have not helped within an agreed time, treating coexisting illness has not reduced the behaviour, or risk is very severe.
Review at 3 to 4 weeks and stop if there is no response by 6 weeks; continuing use needs multidisciplinary review at 3 months, then 6-monthly.
In a trial of 86 non-psychotic adults with aggression, the haloperidol, risperidone and placebo groups all improved, with the largest median reduction on placebo.
STOMP and STAMP press for the right indication, dose and duration across psychotropics, not a blanket ban.
Sedation can reduce visible behaviour while the person functions worse, and new agitation may be akathisia rather than undertreated illness.
Drug-induced dysphagia
Drug class | How it impairs swallowing |
|---|---|
Benzodiazepines | Sedation, reduced muscle tone and poorer oropharyngeal coordination |
Antipsychotics | Mainly dopamine D2 blockade causing drug-induced parkinsonism, which slows the oral and pharyngeal phases; sedation adds to it |
The team and crisis planning
NICE recommends a keyworker for people with intellectual disability and serious mental illness.
An accessible crisis plan sets out triggers, warning signs, helpful responses, contacts and escalation.
Assess safeguarding concerns alongside clinical causes when behaviour changes.