From the Guidelines
Behavioral concerns in individuals with cerebral palsy and intellectual disability should be addressed through a comprehensive approach combining non-pharmacological interventions as the first line of treatment, with pharmacological interventions used only when necessary and with careful monitoring. This approach is supported by the most recent and highest quality study, a systematic review and meta-analysis of randomized controlled trials published in The Lancet Psychiatry in 2023 1. The study found that non-pharmacological interventions, such as applied behavior analysis, positive reinforcement strategies, communication aids, sensory integration therapy, and environmental modifications, are effective in reducing behaviors that challenge in people with intellectual disabilities.
When medications are needed, options include risperidone (0.25-3 mg/day) or aripiprazole (2-15 mg/day) for aggression and irritability; methylphenidate (0.3-1 mg/kg/day) for attention issues; and SSRIs like sertraline (25-200 mg/day) for anxiety or repetitive behaviors, as suggested by general clinical practice guidelines 1. Antiepileptic medications such as valproate (10-60 mg/kg/day) may help with mood stabilization. It is essential to start with low doses and gradually increase them while maintaining regular follow-ups to assess effectiveness and monitor for side effects, particularly metabolic changes with antipsychotics.
Key components of successful management include:
- A thorough assessment to identify specific triggers and underlying causes of behaviors
- Family education and support
- Coordination between healthcare providers, therapists, educators, and caregivers to ensure consistency across all settings
- Regular monitoring for side effects and adjustments to treatment as needed
- A "start low, go slow" approach to medication dosing, as recommended for managing psychiatric illnesses in individuals with 22q11.2 deletion syndrome 1.
By prioritizing non-pharmacological interventions and using pharmacological interventions judiciously, individuals with cerebral palsy and intellectual disability can receive effective treatment for behavioral concerns while minimizing the risk of adverse effects.
From the Research
Treatment Approaches
- Behavioral interventions are commonly used to address challenging behaviors in individuals with intellectual disabilities, including those with cerebral palsy 2.
- Pharmacological interventions, such as topiramate, may also be effective in reducing behavioral problems and seizure frequency in patients with epilepsy and intellectual disability, including those with cerebral palsy 3.
- Stepping Stones Triple P (SSTP) and Acceptance and Commitment Therapy (ACT) have been shown to be effective in reducing behavioral problems in children with cerebral palsy 4.
Diagnosis and Assessment
- Diagnosis of mental disorders in individuals with cerebral palsy can be challenging due to the combination of physical, speech, and sensory disorders, requiring a differentiated approach 5.
- Assessment of behavioral problems in children with cerebral palsy can be done using tools such as the Eyberg Child Behavior Inventory (ECBI) and the Strengths and Difficulties Questionnaire (SDQ) 4.
Rehabilitation and Management
- A comprehensive system of rehabilitation, including medical, social, and psychological-pedagogical correction of cognitive, emotional, and behavioral disorders, is recommended for individuals with cerebral palsy 5, 6.
- Multidisciplinary management involving a team of rehabilitation, orthopedic, psychologic, and social care providers is necessary for effective management of cerebral palsy 6.
- Cortexin has been shown to compensate for cognitive impairment and improve social adaptation in children with cerebral palsy 5.