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Dr. Eileen Trigoboff
RN, PMHCNS-BC, DNS, DABFN
Practical Considerations Related
to Pharmacology and
Developmental Disabilities
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■ Common presentations of DD
■ Assessment strategies with individuals with DD
■ Typical medications for this population
■ Pharmacology options
■ Behavior changes and possible explanations
■ Communication barriers with clients
■ Communication tools for clients and caregivers
■ Coping with resistance to assessment and treatment
Outline
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■ Originates during the developmental period
(conception through age 18 years)
■ Significantly sub-average general intellectual function
deficits in functional life skills
■ Diagnosis - intelligence quotient (IQ) score of at least
2 standard deviations (SD) below the mean IQ of 100
(i.e., IQ <70).
■ Equivalent deficits in at least 2 areas of functional life
skills or adaptive skills
Intellectual Disability (ID) or Mental
Retardation (MR)
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■ Self-direction
■ Functional academic skills
■ Work
■ Leisure
■ Health
■ Safety
■ Communication
■ Self-care
■ Home living
■ Social and interpersonal
skills
■ Use of community
resources
2 areas of deficits in the functional life skills of:
Adaptive Skills
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CategoryIQ(SDs below mean)
IQ scoreEducational
Level
Intensity of
supports
required
Prevalence
in total
population
Mild 2-3 55 to 70 Educable Intermittent 0.9-2.7%
Moderate 3-4 40 to 54 Trainable Limited 0.3-0.4%
Severe 4-5 25 to 39 Non-trainable Extensive 0.3-0.4%
Profound >5 <25 Non-trainable Pervasive 0.3-0.4%
Mild 2-3 55 to 70 Educable Intermittent 0.9-2.7%
Needs Title
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Ranges from 1.6-3% of the population
United States Frequency of
ID of All Degrees
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Health problems interfere with quality of life:
■ Epilepsy
■ Immobility
■ Significant Oral Motor Incoordination/
Dysphagia/Aspiration
■ Respiratory disease is the most prevalent cause of
death among individuals with profound ID
■ Mild cognitive impairment life expectancy is not
known to differ from that of the general population.
Health & ID
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■ Diagnosed more frequently
■ Schizophrenia may have a prevalence of 3%
■ Bipolar illness has a 2- to 3-fold greater prevalence in the cognitively
impaired than in the general population
■ Attention deficit/hyperactivity disorder (ADHD) is diagnosed in 8-15% of
children and 17-52% of adults with ID
■ Self-injurious behaviors require treatment in 3-15%, particularly in the
severe range of ID
■ Major depression, autistic spectrum disorders, obsessive-compulsive
disorder, anxiety disorders, conduct disorder, tic disorders, and other
stereotypic behaviors are diagnosed more commonly
Comorbid Psychiatric Conditions
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■ 5 times the rate of emotional or behavioral disorder
■ ID compounded by epilepsy can increase the risk of a
psychiatric problem to over 50%
■ Occult visual and auditory deficits occur in 50% of
those with ID
■ STDs, Hepatitis B, and Helicobacter pylori infection
(H. Pylori) are increased significantly
Emotional/Behavioral Problems
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■ 1 in 5 also has cerebral palsy (CP)
■ As many as 20% have seizures
■ GI complications: feeding dysfunction, excess
drooling, reflux esophagitis, and constipation
■ GU complications: urinary incontinence and poor
menstrual hygiene
■ Profound social morbidity: lost wages, dependence
on social services, impaired long-term relationships,
and emotional suffering.
Emotional/Behavioral Problems
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■ Before psychopathology can be
identified, infants and toddlers with
ID are more likely to have
■ Difficult temperaments
■ Noncompliance
■ Hyperactivity
■ Disordered sleep
■ Colic
■ Poor social skills
■ Delays in play skills
■ Aggression
■ Self-injury
■ Defiance
■ Inattention
■ Hyperactivity
■ Anxiety
■ Depression
■ Sleep disturbances
■ Stereotypic behaviors
Psychopathology
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■ Language delay - Many infants are thought to be deaf
due to lack of expressive language & environmental
inattention.
■ Fine motor/adaptive delay - Significant delays in self-
feeding, toileting, and play skills are typical
■ Prolonged and messy finger feeding
■ Lack of interest in age-appropriate toys and delays in
imaginative play & reciprocal play with age-matched
peers.
Other Clinical Observations
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■ Odd, repetitive behaviors often replace imaginative
play with symbolic toys.
■ Clumsiness
■ Prevalence of ID is increased among children with
seizure disorders, microcephaly, macrocephaly,
history of intrauterine or postnatal growth
retardation, prematurity, and congenital anomalies.
Other Clinical Observations
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The Overlapping Symptoms
of Developmental Disabilities
and Other Psychiatric Disorders
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Overlapping Symptoms
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■ No treatments are available specifically for cognitive
deficiency
■ Pharmacologic enhancement of cognition is an area
of interest
� Research on such nootropic (i.e., knowledge-enhancing)
compounds is limited
Treatment
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■ Complex habilitation plan
■ Special educators
■ Language therapists
■ Behavioral therapists
■ Occupational therapists
■ Community services that provide social support and
respite care for families
Treatment
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■ Target psychiatric disease/behavioral disturbances
■ Vitamin/mineral therapies are popular, but efficacy has not
been established
■ Antioxidant supplements with Down Syndrome is of
theoretical benefit, but has not yet been tested vigorously
■ CNS stimulants (psychostimulants methylphenidate and
dextroamphetamine appear to enhance dopamine and
norepinephrine activity in the CNS) - The most common class
of drugs prescribed with as many as 50% ADHD/ADD
Medications
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■ To understand the basics of psychiatric medications
(psychopharmacology)
■ To recognize likely treatment options for a set of
symptoms or problems
■ To be able to plan for main effects and side effects
that are possible with psychiatric treatment
Why We’re Talking About Medications
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■ Help the client have
better control over
impulses
■ Help the client feel
better
■ Help keep functioning
from slipping away
■ Help minimize
depressive symptoms
■ Help clarify thinking
■ Help reduce anxiety
Examples of Why Psychiatric
Medications May be Necessary
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■ Inattention
■ Excitability
■ Focus
■ Aggression
■ Sleep problems
■ Depression
■ Psychosis
■ Disorganized thinking
Medicate the Symptom
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Assessment Strategies and Tools
for Behavioral Assessment
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■ Hallucinations, Delusions, Disorganization,
Depression, Mood Variations, and Anxiety all affect:
� Activities
� Interactions
� Sleep
� Eating
Behavioral Problems Accompany
All Symptoms
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■ Schizophrenia
■ Depression
■ Bipolar Disorder
■ Anxiety
Assess for Symptoms of Major Mental
Illness
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The reason so many people do not like to take their medications as prescribed
Side Effects
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Side Effects Seen Particularly with Psychiatric Medications
Extra Pyramidal Side Effects
(EPSE)
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■ Dystonia
■ Akathisia
■ Drug-induced Parkinsonism
ExtraPyramidal Side Effects (EPSE)
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The Clinical Impacts of EPSE are far reaching and
durable. Experiences with EPSE:
■ Contribute to lack of trust in the treatment provider
■ Contribute to lack of trust in the medication
■ Enhances a less collaborative attitude toward
treatment in general.
Extra Pyramidal Side Effects (EPSE)
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■ TD Late onset (after at least 3 months of treatment)
during the course of treatment with antipsychotics
■ TD Frequently associated with irreversible abnormal
movements, or a neurological syndrome.
Tardive Dyskinesia (TD)
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Generally Drying in Physiologic Effect
Anticholinergic
Side Effects
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■ Neuroleptic Malignant Syndrome (NBS)
■ Sexual Dysfunction
■ Sleep Disturbances
■ Weight Gain – waist circumference, BMI,
metabolic syndrome, diabetes,
hypertension, hypercholesterolemia
Additional Side Effects
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■ A side effect called QT
Prolongation or QTc Prolongation
affects the length of time it takes
for the heart to go through its
electronic and mechanical cycle.
■ Most antipsychotics cause this
Mellaril is the most problematic
Side Effect
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■ Intensive case management
■ Atypical antipsychotic drugs
� Especially clozapine in high hospital utilizers
■ Rehabilitation therapy
■ Family treatment
■ Social skills training
Interventions that Improve Recovery from
Schizophrenia
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Break
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Mood Disorders
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Depression
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Depression is more common in those with DD than for the general population
CALLED THE COMMON COLD OF
MENTAL HEALTH ISSUES
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Manic Depression
Bipolar Illness
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■ An estimated: 5.7 million Americans have BPI.
■ Bipolar illness has a 2- to 3-fold greater prevalence in
the cognitively impaired than in the general
population
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D Distractibility
I Insomnia
G Grandiosity
F Flight of ideas
A Agitation
S Speech
T Thoughtlessness (Impulsivity)
Manic Symptoms
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■ Lithium (LiCO3)
■ Anticonvulsants
■ Atypical Antipsychotics
Mood Stabilizers
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Starting Maintenance
On a Mood Stabilizer
Earlier
Predicts Greater Improvement.
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■ Individuals who are taught coping skills to anticipate
potential problems are likely to do better at handling
stressful situations.
■ Education on self-monitoring can be an important
tool for the individual adjusting to a new
environment.
Stress & Relapse
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Anxiety and the Medications
to Address It
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■ At low to moderate levels, anxiety
can be motivating, instructive, and
provide cues to the environment.
■ When anxiety passes these stages
and proceeds to excess, high anxiety
and panic can occur.
■ Extreme feelings of anxiety are not
motivating—in fact they are
immobilizing and learning is not
possible.
Anxiety
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Anti-Anxiety medications include tranquilizers
■ Benzodiazepines such as Valium, Librium, Ativan,
Xanax, and Versed
■ Non-benzodiazepines such as Ambien and Sonata
Anxiolytics (Anti-Anxiety Meds)
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■ Medicating such that higher levels of anxiety are
prevented allows the individual to have enough anxiety in
a given situation to manage that anxiety with the coping
skills taught, and to gauge their effectiveness.
■ If antianxiety medications are given without regard to the
actual anxiety level and the learning of the individual, it is
possible to obliterate the need to learn to cope with
stress. The client learns instead to rely on the medication
to cope.
Anxiolytics (Anti-Anxiety Meds)
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Strategies to Overcome
Communication Barriers and
Resistance To Treatment
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■ Difficulty adjusting to new routines is a
feature of Developmental Disabilities
(DD). In the weeks prior to the
beginning of a change, gradually move
into the schedule that is necessary for
that change. This might mean shifting
bed time, meal times, chores,
interactions, TV, etc.
Establish Routines
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You can help make waking up earlier in the
morning easier. For many people with any DD, it
is important that they also have morning
routines. This may reduce some of the
challenging mornings. For example, if client
Joshua has been in the habit of eating breakfast
in his pajamas and watching his favorite
television show for an hour prior to getting
dressed in one setting, it would be advisable to
modify his routine several weeks prior to the
change in setting.
Routines
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■ Establish some quiet time routines by getting into the
habit of doing quiet activities at a specific time and
place every day. This could be time for reviewing
previously mastered skills, doing silent reading,
journal writing, crossword puzzles, and similar
activities.
Quieting the Storm
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■ Plan on using external motivational systems in order
to be able to implement these changes. People with
DD rarely see our agenda as necessary or important.
This can often involve the use of activities/items we
often give away freely (watching TV shows, playing
favorite games, errand to favorite store,
points/tokens exchangeable for something s/he
wants). Remember, the key to motivation is that the
reinforcer must be powerful and immediate!
Communicate & Motivate
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■ Give the person with DD time to get
used to wearing new clothes. In some
cases, it may be helpful to wash them
several times with fabric softener to
lesson the sensory challenges. Plan
wearing his/her new clothes for
gradually longer periods of time, over
the course of several days.
Address Issue of Clothes
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Consider how a flexible attitude on your part can
make all tasks and issues run a lot more smoothly.
Set the Stage for a Good Relationship
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■ The development of positive social relationships is
essential but requires planning. Prior to the start of
any new social situation, target one or two people
who will be involved in a social activity with the DD
person. Usually, successful social experiences are
easiest to structure with one person at a time, rather
than a group.
Orchestrate a Few Social Gatherings
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■ People with DDs need an advocate - which is a never-
ending job! There is always so much to teach and so
much to do. Usually, there are stressors - not only for
people with DDs, but their caretakers as well.
Remember to make some effort to take care of your
own needs in order to have the time and energy to
attend to the needs of others.
Plan a Relaxing Adult Day
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■ Common presentations
■ Assessment strategies
■ Typical medications
■ Communication tools
■ Coping with resistance to assessment and treatment
What We’ve Covered . . .
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Question 1: One of your recipients, who has always been self stimulating,
begins to significantly scratch and cut herself as well. This could mean which of
the following?
(a) The recipient is having emotional problems
(b) The recipient may have a new physical complaint
(c) The recipient’s blood pressure has changed
(d) The recipient’s medications need to have Gradual Dose Reduction (GDR)
Answers: 1. (a) + (b)
2. (c)
3. (d)
4. (b)
Correct Answer: 1. (a) + (b)
Poll Questions
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Question 2: Assessment of a newly admitted recipient with
developmental disabilities takes into consideration:
� (a) The recipient’s communication skills
� (b) The recipient’s functional level
� (c) The recipient’s living environment
� (d) The recipient’s physical status
Answers: 1. (b) + (c)
2. (c)
3. (a)
4. All of the above
Correct Answer: 4. All of the above
Poll Questions
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Question 3: You are conducting a group with five recipients who
have developmental disabilities and one recipient suddenly and
for the first time is screaming, acting out, and aggressive. The
most likely explanation could be:
(a) Dementia
(b) Infection
(c) Environment
(d) Allergy
Answers: 1. (b) + (c)
2 (c)
3. (a)
4. All of the above
Correct Answer: 2. (c)
Poll Questions
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Question 4: When giving directions to recipients with
developmental disabilities and they are resisting assistance:
� (a) Repeat what they should be doing until they comply.
� (b) Distract with something they like to do then slowly reintroduce
assistance.
� (c) Express approval verbally and with appropriate facial expressions.
� (d) Carefully explain three problems with what they are doing.
Answers: 1. (a)
2. (b)
3. (c)
4. (d)
Correct Answer: 2. (b)
Poll Questions
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Question 5: Regarding medications commonly used with people
with developmental disabilities:
� (a) There are a variety of medications specifically indicated for treatment of
developmental disabilities.
� (b) Medications treat the various symptoms but are not indicated for the
disability.
� (c) Indications are not relevant when discussing medications.
� (d) No medications are commonly used exclusively for those with
developmental disabilities.
Answers: 1. (a)
2. (b)
3. (c) + (d)
4. (d)
Correct Answer: 2
Poll Questions
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At the conclusion of the webinar, please fill out the
survey that will pop up in your internet browser.
If you don’t see the survey, please follow the link in the
follow-up email that you will receive tomorrow.
Evaluation Survey
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Lisa Zimmerman
(518) 449-2976
Questions / Comments?