Efficacy of atypical antipsychotic medication in the management of behaviour problems in children with intellectual disabilities and borderline intelligence: A systematic review

Abstract

The use of medications to manage problem behaviours is widespread. However, robust evidence to support their use seems to be lacking. The aim was to review research evidence into the efficacy of atypical antipsychotic medication in managing problem behaviour in children with intellectual disabilities and borderline intelligence. A systematic review was conducted for placebo-controlled randomised double-blind trials. The included studies (N = 6) showed that risperidone was significantly more effective than placebo in managing problem behaviours. However, most studies highlighted adverse events primarily somnolence and weight gain. There is now some evidence in favour of the use of risperidone. However, because of possible adverse events, these medications have to be used with caution.

Introduction

The rate of problem behaviours in people with intellectual disabilities (ID) seems high (Deb et al., 2001, Smith et al., 1996). Furthermore, it has been reported that 20–45% of people with ID are receiving psychotropic medication and 14–30% of them are receiving medication to manage a problem behaviour such as aggression or self-injurious behaviour in the absence of a diagnosed psychiatric disorder (Clarke, Kelley, Thinn, & Corbett, 1990). As much as two thirds of psychotropic medications prescribed to people with ID are antipsychotics (Spreat, Conroy, & Jones, 1997). Studies suggest that problem behaviours are both prevalent and persistent in people with ID (Einfeld and Tonge, 1996, Emerson et al., 2001a, Emerson et al., 2001b, Green et al., 2005). It is, therefore, suggested that it may be necessary to start interventions earlier rather than later to prevent behaviours from becoming more serious and to reduce the number of emergent behaviours.

The rate of prescription of psychotropic medication for the management of problem behaviours is already a source of concern in light of the poor evidence with regards to their effectiveness and adverse events in people with ID (Deb and Unwin, 2007, McGillivray and McCabe, 2004). Whilst there are suggestions that certain behaviours in people with ID may be managed with antipsychotic medication, there are several concerns expressed with regard to their effect on quality of life of the individuals (Aman & Gharabawi, 2004).

Among psychotropic medications, atypical antipsychotics, particularly risperidone, are used most commonly to manage problem behaviours in people with ID (Unwin & Deb, 2008). In a review of six studies it has been concluded that although evidence is mounting, there is, as yet, not enough to make generalisations as to the use of risperidone in all groups for all problem behaviours (Singh, Matson, Cooper, Dixon, & Sturmey, 2005). In contrast, it has also been concluded that when looking specifically at the effect of risperidone on agitation and aggression not previously responding to non-pharmacological interventions, the use of atypical antipsychotics should be considered (De Deyn & Buitelaar, 2006). However, Grey and Hastings (2005) suggest that although the evidence regarding the rapid effects of risperidone in children with problem behaviours is growing, the adverse effect of somnolence in bringing about these improvements has not been clarified.

The Cochrane Collaboration published a systematic review of risperidone for autism spectrum disorder (Jesner, Aref-Adib, & Coren, 2007). Only three randomised-controlled trials (RCTs) were identified through their review. The authors conclude that whilst their meta-analysis suggests that risperidone may be effective for the treatment of irritability, repetition and social withdrawal, further research needs to be conducted to establish the effectiveness of risperidone and to investigate the longer term effects including adverse events, especially weight gain.

The present systematic review was conducted in the context of developing a national guideline (in the UK) to provide good practice recommendations on the use of medication in the management of problem behaviours in adults with ID (Deb, Clarke, & Unwin, 2006). A systematic review of the evidence for effectiveness of antipsychotics for behavioural problems in adults with intellectual disabilities, conducted as part of the guideline development revealed only one RCT of risperidone in adults and one cross-over RCT involving both adults and children (Deb, Sohanpal, Soni, Unwin, & Lenôtre, 2007). Whilst one cannot assume that results from studies with children will be equivalent for adults, owing to the paucity of evidence in adults, we felt it pertinent to investigate the evidence base for use of antipsychotics in children. The guideline emphasises the importance of a thorough assessment and formulation prior to prescribing medication to manage problem behaviours. Furthermore, it highlights the importance of the constant consideration of non-pharmaceutical interventions and the withdrawal of medication.