What medications are used to manage impulse control in patients with mild intellectual disability (Intellectual Disability, ID)?

From the Guidelines

Risperidone is the most effective medication for impulse control in individuals with mild intellectual disability, with a recommended dose of 0.5-2mg daily. This recommendation is based on the most recent and highest quality study available, which found significant improvements in behavior problems with risperidone compared to placebo 1. The study, published in the Journal of the American Academy of Child and Adolescent Psychiatry in 2020, included 38 children with intellectual disability, with a mean dose of 2.9 mg/d for 6 weeks, and found significant improvements on all scales, including CGI-S, OAS-M, ABC, and EPRS.

Key Considerations

• The choice of medication depends on the specific symptoms, comorbid conditions, and individual response 1
• A comprehensive approach should include behavioral therapy, environmental modifications, and regular follow-up appointments to assess effectiveness and adjust treatment as necessary 1
• Individuals with intellectual disabilities may be more sensitive to medication side effects and require careful monitoring 1
• Non-pharmacological interventions, such as behavioral therapy, may also be effective in reducing behaviors that challenge in people with intellectual disabilities, with small intervention effects found in a systematic review and meta-analysis of randomized controlled trials 1

Medication Options

• Risperidone: 0.5-2mg daily, with significant improvements in behavior problems compared to placebo 1
• Aripiprazole: 5-15mg daily, although less evidence is available for its use in individuals with mild intellectual disability
• Mood stabilizers, such as valproic acid and carbamazepine, and selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine and sertraline, may also be considered, although the evidence for their use in individuals with mild intellectual disability is limited 1

From the FDA Drug Label

The efficacy of RISPERIDONE in the treatment of irritability associated with autistic disorder was established in two 8-week, placebo-controlled trials in children and adolescents (aged 5 to 16 years) who met the DSM-IV criteria for autistic disorder. The ABC-I subscale measured the emotional and behavioral symptoms of autism, including aggression towards others, deliberate self-injuriousness, temper tantrums, and quickly changing moods.

Risperidone may be used to treat impulse control issues associated with autistic disorder, as it has been shown to improve scores on the Aberrant Behavior Checklist (ABC) and the Clinical Global Impression - Change (CGI-C) scale. However, the label does not specifically address mild intellectual disability. 2

From the Research

Medication for Impulse Control due to Mild Intellectual Disability

• Individuals with mild intellectual disability are at high risk of co-occurring mental health conditions, including impulse control disorders 3.
• Aripiprazole has been found to be effective in managing schizophrenia and challenging behavior in individuals with intellectual disabilities, and may be a useful treatment option for impulse control disorders 4.
• Low impulse control and aggressive response generation have been identified as predictors of aggressive behavior in children with mild intellectual disabilities and borderline intelligence 5.
• Second-generation antipsychotics, such as risperidone, olanzapine, and aripiprazole, have been used off-label to treat impulse regulation disorders, including attention-deficit and disruptive behavior disorders, tic disorders, and substance use disorders 6.
• However, the use of these medications in individuals with mild intellectual disability requires careful consideration of potential side effects, such as metabolic changes, weight gain, and sedation 6.

Treatment Approaches

• A biopsychosocial approach, incorporating medication, behavioral therapy, and environmental supports, may be effective in managing impulse control disorders in individuals with mild intellectual disability 4, 6.
• Applied behavior analysis (ABA) has been suggested as a useful approach for addressing challenging behaviors, including impulse control disorders, in individuals with intellectual disabilities 3.
• Trauma-informed and person-centered care, as well as the promotion of self-determination, are important considerations in the treatment of individuals with mild intellectual disability and impulse control disorders 3.

Future Directions

• Further research is needed to determine the long-term efficacy and safety of second-generation antipsychotics in individuals with mild intellectual disability and impulse control disorders 6.
• A more differentiated system of support, taking into account individual and environmental variables, may be necessary to provide effective care for individuals with mild intellectual disability or borderline intellectual functioning 7.