Treating aggression in patients with intellectual disability?

[chajjohnson]

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A while ago I sat in with a patient in a psych clinic who had intellectual disability and a history of aggressive behavior. The patient's caretakers were coming in asking if anything can help with the aggression. If I remember correctly the resident prescribed Risperidone and I have no follow-up to see if that helped at all.

Just wondering if anyone knows of some data or has personal experience with pharmacological treatment of aggression in patients with ID. I looked around on pubmed and found a few trials and reviews, but nothing I would call high-quality data. Seems like Risperidone does have the best evidence, as well as some favoring mood stabilizers, mostly lithium. Anyone have any other thoughts?

 

[michaelrack]

Propranolol

 

[WisNeuro]

It's pretty much either taking the time for behavioral training/shaping or just snowing them with chemical restraints. The pharma agents don't do a great job for the aggression, they just get amped up to the dose where they are too sedated to do much of anything, let alone be aggressive.

 

[chajjohnson]

Propranolol

I only saw case reports of propranolol success.

I agree, the best evidence seems to support some sort of psychotherapy depending on the level of ID, whether CBT or behavioral or something else.

 

[erg923]

I only saw case reports of propranolol success.

I agree, the best evidence seems to support some sort of psychotherapy depending on the level of ID, whether CBT or behavioral or something else.

"Psychotherapy" is unlikely to be effective if the individual is more the mild ID. Positive Behavior Support Plans, behavior plans, contingency management, etc should be developed in the person place of living/dwelling. Chemical restraints alone are not really fair to patients.

 

[wolfvgang22]

I've had some success with oxcarbazepine.

 

[Liquid8]

Have used very low doses of risperidone or valproate in this population. Behavioural interventions and support staff training for those living in supported accommodation can also be very effective, but the logistics of this can be a challenge. When I worked on a government service that offered this kind of training for free, you'd still get resistance from homes to allow their staff to attend the training during working hours.

 

[hamstergang]

In general, for kids with aggression (with or without intellectual disability, with or without autism), Risperdal has the best evidence of any medication. You could use mood stabilizers, but the antipsychotics require less lab monitoring and so are typically easier.

Of course, meds shouldn't be the place to start (unless very severe aggression, possibly). Working on the environment and those in authority over the kid (parents, teachers, possibly others) is most important and is a better long term strategy. Getting these elements addressed properly is often a challenge, however.

I've had some success with oxcarbazepine.

Is there any evidence supporting this in the literature?

 

[PistolPete]

Agreed with above. Risperidone has best evidence. Abilify can be used too (of course it’s FDA approved for irritability in autism which I’d argue is largely on a similar spectrum to aggression in ID).

I’ve had some success with decreasing impulsivity and self-harm behaviors with SSRI’s. Some success with Li/Depakote.

Benzos are last resort and only for the most severe of cases, where parents are about to call 911 and put them Inpatient

 

[psychattending]

There are data on lithium as well as depakote. I have seen significant effects with lithium in multiple patients.

 

[psyguru]

Clonidine and tenex are options. If there is tbi you can consider inderal. I worked in a state school and the ABA therapist did a great job graphing their behaviors to determine what meds worked as half my patients were non verbal.

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[milesed]

I usually start with behavioral therapy, then move onto the same meds used for this w/o intellectual disability.