مدیریت دارویی رفتار چالش انگیز افراد دارای معلولیت ذهنی

In many Westernized countries, including Australia, concerns about the use of psychotropic drugs to manage the challenging behavior of individuals with intellectual disability have resulted in the development of legislative and procedural controls. Although these constraints may limit indiscriminate use, employing medication remains a common practice. This study examined information about 873 individuals (566 males, 307 females) who were the subjects of reports to the Intellectual Disability Review Panel in March 2000 concerning the use of chemical restraint. A high proportion of people with intellectual disability were reported to have received drugs for purposes of behavioral restraint. The range of drugs was extensive, although those from the antipsychotic class were the most frequently reported. Many individuals concurrently received more than one type of drug or more than one drug from the same drug class. More males than females and more older than younger individuals were administered medication. A relationship between gender and age was apparent, with younger males but older females dominating. The use of drugs to mange the behavior of people with intellectual disability may at times be warranted. However, it is important that the extent and type of drug use, as well as the characteristics of those who are medicated, be subject to ongoing scrutiny.

The widespread use of psychotropic drugs among people with intellectual disability has been well-documented and even 20 years ago there were claims that this population was one of the most medicated groups in society (Aman, 1984). In addition to the treatment of specific psychiatric symptoms, these drugs have been used to control the behavioral disturbances that commonly occur among people with intellectual disability (e.g., Emerson et al., 2000). The potential of some drugs to alleviate certain behavioral and emotional disturbances has been recognized (Reiss & Aman, 1998). However, the significant risk of side effects in the absence of diagnostic precision and clear efficacy has prompted serious concerns regarding use (Brylewski & Duggan, 1999; Matson et al., 2003). In many Westernized countries, including Australia, these concerns have resulted in the development of legislative and procedural controls on the use of psychotropic drugs to manage challenging behavior. In the state of Victoria, Australia, the Intellectually Disabled Persons Services Act (IDPS Act) (1986) mandates circumstances and requirements for the use of drugs to restrain the behavior of individuals with intellectual disability. Although the requirements of the IDPS Act and related policy documents have probably limited the indiscriminate use of psychotropic drugs, the use of medication to restrain behavior remains a common practice (Intellectual Disability Review Panel, 2001). The extent and type of drug use, as well as the characteristics of the individuals who are medicated is important and should be subject to ongoing scrutiny. Although the difficulties inherent in distinguishing between psychiatric illness and challenging behaviors in people with intellectual disability are acknowledged (Emerson, Moss, & Kiernan, 1999; Jenkins, Rose, & Jones, 1998; Sturmey, 1995), there are now many studies confirming that the psychopharmacological management of challenging behavior in this population is widespread (Deb, Thomas, & Bright, 2001; Emerson et al., 1997 and Emerson et al., 1997; Kiernan, Reeves, & Alborz, 1995; Molyneux, Emerson, & Caine, 1999; Robertson et al., 2000). Aggression, for example, appears to be the primary source of psychiatric referral of individuals with intellectual disability for psychotropic medication (Fleming, Caine, Ahmed, & Smith, 1996; Kiernan et al., 1995). The neuroleptics (major tranquilizers, antipsychotics) are the most common pharmacological agents prescribed to people with intellectual disability in the United States (Aman & Singh, 1991), the United Kingdom (Branford, 1996 and Robertson et al., 2000) and Australia (IDRP, 1989; Jauerning & Hudson, 1995; Ryan, 1991 and Sachdev, 1991). A wide range of other types of medication, however, have also been reported (e.g., Molyneux et al., 1999 and Robertson et al., 2000). Several of these studies have indicated that both gender and age may have an impact on the nature and extent of drug use. This situation may arise from differences in the incidence of challenging behaviors or it may be related to prescribing practices. The impact of gender on the incidence and nature of challenging behaviors is equivocal. Emerson et al., 1997 and Emerson et al., 1997, for example, reported a predominance of males among individuals with challenging behaviors. In contrast, Deb et al. (2001) reported that female gender was significantly associated with behavioral disorders. In both studies there was an association between females and self-injurious behavior, although others (e.g., Callacott, Cooper, Branford, & McGrother, 1998) have reported no such association. Gender differences in particular types of behavior problems have been reported by Dudley, Ahlgrim-Delzell, and Calhoun (1999). Females, for example, were found to have had more frequent and severe temper tantrums and screaming episodes and more frequent withdrawal and asocial behavior than males. Males have been reported to show significantly higher levels of physical aggression (Borthick-Duffy, 1994 and Davidson et al., 1994; Emerson et al., 1997 and Emerson et al., 1997; McClintock, Hall, & Oliver, 2003). The association between gender and challenging behavior may thus depend on the type of behaviors under consideration. The association between gender and the administration of psychotropic drugs is also unclear. Some evidence exists that a greater proportion of females receive psychotropic medication than males (Kirman, 1975 and Tu, 1979). These two studies, however, included sedatives and antidepressants in addition to antipsychotic drugs, and it is possible that these prescribing practices reflected the greater prevalence of anxiety and mood disorders evident among females within the general population (Astbury & Cabral, 2000). A recent study by Lunsky (2003) confirmed that women with intellectual disability are particularly vulnerable to depressive disorders. In a study of only antipsychotic drug use, Wressel, Tyrer, and Berney (1990) reported that males comprised 63% of their sample of 243 who were receiving medication. Interestingly, female residents received a significantly higher mean daily dose of medication than males. The authors suggested that this may result from a tendency for males to receive neuroleptics for lower levels of disturbance on the basis of risks associated with their physical strength and size. As noted by Robertson et al. (2000), the high predictive association between Body Mass Index (BMI) and the decision to administer psychotropic medication may be a factor in the trend for more males than females to be administered medication. In contrast, females may not receive drugs until they are displaying a greater degree of disturbance, ultimately requiring higher doses (Wressel et al., 1990). The longevity of people with intellectual disability has increased in association with general population trends, due to better standards of health care and living conditions (Cooper, 1999). There remains, however, a differential survival rate in older people with intellectual disability, with those who live longer tending to be more able (Janicki, Dalton, Henderson, & Davidson, 1999). On the basis that challenging behaviors may be more common in more severely disabled individuals (Crews, Bonaventura, & Rowe, 1994; Deb et al., 2001), it would be expected that challenging behavior may be less prevalent in older groups. A decline in energy level associated with aging could also serve to reduce the occurrence of at least the more physical of the challenging behaviors. Several studies have shown that after 40 years of age there is a marked decrease in aggressive and challenging behavior among people with intellectual disability (e.g., Joyce, Ditchfield, & Harris, 2001; Kiernan et al., 1995 and Quereshi, 1993). Others have suggested however, that an increased susceptibility to psychiatric disorders and dementia increases the likelihood of behavior disorders with increasing age (Cooper, 1997a; Cooper & Prasher, 1998; Thorpe, Davidson, & Janicki, 2001). According to Cooper (1997b), a high rate of dementia was associated with aging in individuals with all types of intellectual disability and was particularly prevalent in females. Furthermore, dementia was associated with a high prevalence of aggression, a lack of cooperativeness and disturbed sleep (Cooper & Prasher, 1998), suggesting that intellectually disabled individuals with dementia may present a considerable challenge to careers.