A Review of Support Staff Perception of and Training on Psychotropic Medication and Challenging Behavior in Adults With Intellectual and Developmental Disabilities

Learning disabilities: Interventions and clinical issues

The use of psychotropic medications in United States foster care children is an issue of growing concern among clinicians, child serving agencies, and legislators. Although pharmacologic interventions are accepted as part of multi-modal treatment strategies for many symptoms of mental illness, the relatively high use of psychotropic agents in this population, as well as the limited data on efficacy and both short and long-term adverse effect risks, have led to increased scrutiny. In addition to safety, issues of concern include indications for use, overdiagnosis, appropriate consent for treatment, oversight/monitoring of psychotropic prescribing and psychiatric consultation, and the availability of medication information for clinicians, foster parents, and care givers.

Many people with intellectual and developmental disabilities (IDD) are treated with psychotropic medications, and polypharmacy is common. Although few studies address psychotropic side effects in the population, people with IDD have been found more likely to experience side effects than others who do not have IDD. Because many individuals with IDD may not report side effects reliably, there is risk that side effects may be missed. Psychotropic use and side effects of 71 adults with IDD admitted for a 30-day crisis stay to a Systemic, Therapeutic, Assessment, Resources, and Treatment (START) Resource Center were reviewed. START is a specialised behavioural health outreach, training and crisis programme for individuals with IDD. During crisis stays, centre nurses administer the Matson Evaluation of Drug Side Effects screen, a psychometrically established psychotropic medication side effects screen developed for use with people with IDD. Data reviewed were de-identified data used to inform day-to-day practices and assess outcomes for individuals START served. The average age was 28years, and 56% of the sample was male. All individuals were taking at least one psychotropic, while 79% were taking three or more. The average number of psychotropics used was 3.94. Antipsychotics were the most commonly prescribed medications taken by 85% of the sample; 49% of whom were not reported to have psychosis. Although the overall number of psychotropics did not correlate with Matson Evaluation of Drug Side Effects scores, the average scale scores for all participants was high in contrast to prior studies of people with IDD not taking psychotropics, with central nervous system side effects being the most commonly reported. In the present study, data for individuals experiencing a crisis were reviewed and indicated high rates of psychotropic polypharmacy and side effects rates higher than previously reported for people with IDD not taking psychotropics. Prospective study in larger samples is needed to determine if missed or under-appreciated psychotropic side effects may play a role in behavioural health challenges of some people with IDD.

There is a high prevalence of psychotropic medication use in adults with Intellectual Disabilities (ID), often in the absence of psychiatric disorder, also associated with challenging behaviour. Previous research has focused on specific sample frames or data from primary care providers. There is also a lack of consistency in the definition of challenging behaviour used. We adopted a total population sampling method. Medication data on 265 adults with ID were classified according to the Anatomical Therapeutic Chemical classification system. The Behaviour Problems Inventory - short form classified challenging behaviours. We examined the association between challenging behaviour and the use of psychotropic medication, and whether any association would still be present after accounting for socio-demographic and clinical characteristics. 70.57% of adults with ID were prescribed at least one class of any medication (mean per person =2.62; range 0-14). Psychotropic medications were used by 37.73% of participants with antipsychotics the commonest type used by 21.89% of individuals. Polypharmacy and high dosages were common. Generalised Linear Models indicated significant associations between psychotropic medication and the presence of a psychiatric diagnosis, challenging behaviour, older age and type of residence. Male gender was additionally associated with antipsychotic medication. The use of a total population sample identified via multiple routes is less likely to overestimate prevalence rates of medication use. Current challenging behaviour was a predictor of medication use after controlling for other variables. Data indicate that there may be differences in prescribing patterns associated with different topographies of challenging behaviours.

Longitudinal data on medication use in adults with intellectual disability (ID) are scarce. We describe the longitudinal use of and factors associated with psychotropic medication prescribing in adults with ID living in the Australian community. Longitudinal data were obtained from adults with ID in the community in Queensland, Australia, between 1999 and 2015. Participant characteristics and medication use information were extracted from baseline questionnaires and health check booklets. Logistic regression was used to investigate the associations between participant characteristics and psychotropic medication use, commencement or cessation. Longitudinal data were available for 138 participants on 697 reviews. The proportion of participants prescribed psychotropic medications increased from 43% to 54% between 1999 and 2015. The rates of commencement and cessation of psychotropic medications between consecutive time periods ranged from 9% to 18% and 7% to 15%, respectively. Challenging behaviour was associated with psychotropic medication use (adjusted odds ratio=4.1; 95% confidence interval: 2.1-7.9). Presence of challenging behaviour, either consistent or newly identified, was positively associated with ongoing use or commencement of psychotropic medications. Psychotropic medications are commonly prescribed to adults with ID. Challenging behaviour is positively associated with ongoing use and commencement.

Objective: The use of psychotropic medication to address challenging behavior in individuals diagnosed with intellectual disabilities is common practice; however, very few studies have examined how multiple medication use (or combination treatment) impacts the behaviors these medications are prescribed to treat.Method: The current study followed eight individuals over a two-year period as they experienced changes in their psychotropic medication regimens. During that time, data from functional analyses and indirect assessments of challenging behavior were collected.Results: The results suggest that changes in psychotropic medication regimens can produce changes in functional assessment outcomes, suggesting a need for continued behavioral assessment to better inform medication practices and behavioral treatment. Of the eight participants in the study, five participants’ behaviors varied in rate of responding in functional analysis (FAs) across all medication changes. Additionally, three participants’ FAs produced changes in outcomes; however, those changes were not consistent across all medication changes, that is, not every medication change yielded different outcomes from previous assessments.Conclusion: This study demonstrates how the outcome of an FA can be used to monitor the effects of psychotropic medication changes, specifically when medications are combined, on challenging behavior in individuals with intellectual and developmental disabilities.

Accessible summary Family members often support people with intellectual disabilities who display challenging behaviour. Family carers should be listened to and included in important decisions. We asked family carers how professional services had helped their relative with challenging behaviour. Family carers said that the care of people with intellectual disabilities who display challenging behaviour can be improved. Family carers sometimes felt left out of decisions and said that they needed more information. Listening to parent carers' experiences can help to improve the services that are provided to people with intellectual disabilities and their families. AbstractBackgroundThere is relatively little published data that report the experiences and views of family carers of people with intellectual disabilities who display challenging behaviour who are prescribed psychotropic medication.Materials and methodsAn online structured questionnaire was created by the Challenging Behaviour Foundation, a UK charity, and family carers of people with intellectual disability. Questions concerned the management of challenging behaviour and asked family carers about their experiences and views on the use of psychotropic medication. Responses were gathered between August and October 2016. Results are summarised using descriptive and inferential statistics and descriptive analysis of free‐text comments.FindingsNinety‐nine family carers completed the survey. Family carers reported gaps in the holistic and proactive management of challenging behaviour. Whilst some felt involved in decisions around psychotropic medication prescribing, others described feeling marginalised and lacking information and influence. The decision to prescribe psychotropic medication evoked complex emotions in family carers and medication use was associated with mixed outcomes in those prescribed. Family carers identified areas of good practice and those areas where they believe improvements are needed.ConclusionsPsychotropic medication should be only one option in a multimodal approach to challenging behaviour, but this may not always be reflected in current practice. Greater effort needs to be made to ensure that services are equipped to provide optimum care and to embed shared decision‐making into routine practice.

The paper provides a Canadian perspective on the use of psychotropic medication in the management of problem behaviours in adults with intellectual disabilities in Canada. Psychotropic medication and intellectual disabilities were explored in the context of Canadian health and social services, clinical practices, medical training and factors that have shaped these over the past few decades. Informal physician intellectual disabilities networks and the newly formed Canadian Network of the National Coalition on Dual Diagnosis provided the opportunity to survey the use of psychotropic medication for problem behaviours across the country. Geographic, political, cultural and other influences on the development of health and social services are described, as well as training requirements for physicians. Survey responses were received from all provinces and represented clinicians in mental health multidisciplinary teams, health and social services ministry representatives, agency staff (up to executive director level) and family members of individuals with intellectual disabilities. Psychiatry and family medicine perspectives of the authors from working in Canada and the UK with people with intellectual disabilities presenting with problem behaviours are described. In Canada there are no national, provincial or territorial policies or guidelines on use of psychotropic medication for the management of such behaviours. There are no requirements for physicians prescribing these medications to have training in the care of people with intellectual disabilities. Services for people with intellectual disabilities and behaviour problems in Canada appear to be more crisis‐reactive than those in the UK.

Children and adolescents with autism spectrum disorder (ASD) frequently present with mental health comorbidities and behavioral crises, necessitating inpatient care. However, evidence-based guidelines for psychotropic medication use in specialized inpatient settings remain limited, particularly in non-Western contexts. This study examined the clinical characteristics and prescribing patterns among 269 hospitalized ASD patients (2012-2023), with a focus on how intellectual disability (ID) influences medication decisions. A retrospective analysis was conducted using electronic medical records to assess mental disorders, behavioral challenges, and psychotropic medication use at discharge. Logistic regression analyses was performed to examine factors associated with medication prescribing patterns, including the impact of ID status. Psychotropic medication use was highly prevalent (96.7%), with antipsychotics (89.96%) being the most frequently prescribed class, followed by anxiolytics (35.32%) and antidepressants (33.09%). ID was significantly associated with distinct prescribing patterns: patients with ID had 63% lower odds of antidepressant use (aOR = 0.37, p = 0.001) and 80% lower odds of ADHD medication use (aOR = 0.20, p = 0.009), while being more likely to receive antipsychotics (aOR = 2.74, p = 0.049) and experience polypharmacy (aOR = 1.89, p = 0.028). Additionally, disruptive behaviors and age were key predictors of antipsychotic use, whereas suicidal thoughts/attempts or SIBs independently predicted antidepressant prescribing. These findings suggest that ID status plays a critical role in shaping psychotropic prescribing practices beyond symptom severity alone, potentially reflecting diagnostic overshadowing and safety concerns. Future research should focus on developing tailored clinical assessment tools and treatment protocols for ASD populations with and without ID, while enhancing individualized medication monitoring to optimize therapeutic outcomes.

152 R studies have documented a substantial increase in the use of psychotropic medications by children and adolescents. Use of antidepressants by youths tripled between 1988 and 1996 (1), and similar increases have been seen in their use of other psychotropic medications (3). However, no data are available on the proportion of total mental health costs accounted for by use of psychotropic medications by youth. This column presents 1998 cost estimates from more than 100,000 privately insured children in all census regions. Costs were calculated from claims data from 28 large employers. In 1998 mental health expenditures for children with private insurance totaled some $5.5 billion, excluding services provided by state and local agencies and not paid for by private insurance. Expenditures for psychotropic medications for children covered by private insurance were approximately $670 million, or 11.9 percent of total expenditures. As Figure 1 shows, the proportion varied across age groups for children. About 4.3 percent of children received psychotropic medications, compared with 4.7 percent of adults (data not shown). As Figure 2 shows, stimulants were the most common medication prescribed in all age groups among children. Antidepressants accounted for 50 percent of the total costs for psychotropic medications among those aged 12 to 17, compared with 10 percent among oneto five-year-olds and 28 percent among children aged six to 11. We found that both the rates of use of psychotropic medications and their costs were lower among children and adolescents than among adults, despite the increased use of these medications among youths. At the same time, psychotropic medications now represent an appreciable part of children’s total mental health costs. Most of the cost for these medications are for the use of antidepressants by adolescents and stimulants by younger children.

As youth with intellectual and developmental disabilities (IDD) are transitioning from the school systems and special education supports, many of them are moving into the adult service system (e.g., Vocational Rehabilitation, Home and Community‐Based Services). Thus, in addition to adolescence being a source of many psychological and behavioral needs, the change in service systems often leads to uncertainty and anxiety. Psychotropic medications tend to be used to treat challenging behavior and psychological conditions (e.g., depression, anxiety, psychosis). This study used National Core Indicators‐In‐Person Survey 2020–2021 data to explore the prevalence of psychotropic medication use among two groups of people with IDD: disability service users of transition age (18–25 years) and disability service users of adult age (26–45 years) and the role of residential settings (where one lives) as related to psychotropic medication use. The results indicated that adults (aged 26–45 years) are more likely to be prescribed psychotropic medications. This appears to be driven by the larger number of transition‐aged adults who still live with family, where prescription rates are much lower. Psychotropic drug use is an important issue due to its potential to lead to unintended negative consequences that affect health, social inclusion, and self‐determination if not carefully and effectively administered.

Clinical considerations with use of psychotropic medications in COVID-19 patients

Previous research has reported higher prevalence rates of anxiety and depression among musicians, compared to the general workforce. We compared the use of psychotherapy and psychotropic medication with other major occupational groups, and expected to find higher use among musicians. Musicians from the Norwegian Musicians’ Union ( n = 1,607) answered an online questionnaire about demographic characteristics, mental health, use of healthcare services and use of psychotropic medication. They were compared to a sample of the Norwegian workforce ( n = 2,550) from the Norwegian survey of level of living. Based on chi-square and logistic regression analysis, adjusted for age, sex, education, and cohabitation status, we found that musicians reported higher use of psychotherapy and psychotropic medication. Use of psychotherapy was reported most frequently among vocalists, while rock musicians reported the most widespread use of psychotropic medication. Overall, musicians had three-fold higher odds of use of psychotherapy and 50% higher odds of use of psychotropic medication compared to the general workforce. This is consistent with previous findings indicating high rates of sleep-difficulties and psychological distress among musicians. The results underline the importance of investigating both the content and quality of services provided.

The Impact of COVID-19 on Individuals With Intellectual and Developmental Disabilities: Clinical and Scientific Priorities.

In long-term care (LTC) settings, use of psychotropic medications to manage behavioral and psychological symptoms of dementia and use of cognitive enhancers are commonplace. It is important that these medications are properly used to ensure resident well-being, and thus, it is paramount to understand use of these medications in contemporary practice to develop appropriate quality improvement initiatives. To characterize psychotropic and cognition-enhancing medication use LTC residents and current trends in documentation. Cross-sectional chart review of residents aged >65 years with dementia receiving psychotropic medications and/or cognitive enhancers. From 180 residents, 84 (82% female) met inclusion criteria (average age 86 years). The prevalence of psychotropic medication use was as follows: cognitive enhancers, 71%; antidepressants, 98%; antipsychotics, 61%; sedative hypnotics, 23%. Quetiapine was the most commonly used antipsychotic (48%), followed by risperidone (28%) and olanzapine (15%), all of which were dosed within accepted guidelines. The duration of therapy ranged from 2 to 5 years for antipsychotic medications and 1¼ to 3 years for antidepressants. Documentation documentation rates were hightest for psychotropics versus cognitive enhancers. There was no documentation of attempts to lower doses or discontinue psychotropic medications or cognitive enhancers. Many, but not all psychotropics used were acceptable choices. The duration of therapy appears to be excessive for antipsychotic medications. Documentation of ongoing need for medications varied and could be improved on to better assess residents' medication regimens. Further research will inform efforts to enhance the care of these residents.