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Keywords:

  • Epilepsy;
  • Intellectual disabilities;
  • Mental retardation;
  • Antipsychotic drugs

Summary

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

Behavioral disorders are common in people with epilepsy and intellectual disability. Although in some genetic disorders behavioral problems are part of the established phenotype, they may also be a manifestation of underlying physical or mental illness, or may be unrecognized seizure activity. In light of this, assessment of behavioral disorders should take into account person factors such as the physical health and mental state of the person and environmental factors such as the quality of their interactions with carers and their living conditions. Video–electroencephalography ( EEG) is recommended where possible. We review potential pharmacologic and behavioral management strategies for behavioral disorders in people with intellectual disability.

People with intellectual disabilities frequently have some forms of behavioral disorders that may manifest as stereotypies, difficult or disruptive behavior, aggressive behaviors toward other people, behaviors that lead to injury of the self or others, and destruction of property (Lowe et al., 2007; Smith & Matson, 2010a). These lead to difficulties for the individual themselves and are often problematic for those who work with and care for them. A joint report by the Royal College of Psychiatrists, British Psychological Society & Royal College of Speech and Language Therapists (2007) defined behavior as challenging when:

…it is of such an intensity, frequency or duration as to threaten the quality of life and/or the physical safety of the individual or others and is likely to lead to responses that are restrictive, aversive or result in exclusion.

A large study conducted in South Wales (United Kingdom) found that 10% of the intellectual disability population manifested some form of serious challenging behavior, with disruptive behavior being the most prevalent. Multiple forms of challenging behavior in the same person were common (Lowe et al., 2007). These figures were convergent with earlier studies that also found self-injury, destructiveness, aggression, and disruptive behavior to be prevalent in 10% of the intellectual disability population (Emerson et al., 2001). Earlier studies of a broader range of behavioral problems, including problems such as verbal aggression and temper tantrums, in the intellectual disability population have suggested prevalence between 22.5% and 55% (Deb & Joyce, 1999; Cooper et al., 2007).

Recent community studies of epilepsy in the intellectual disability population have suggested prevalence between 26% and 40% (McGrother et al., 2006), and it is widely accepted that even higher rates of epilepsy are found in individuals with more severe intellectual disability (Bowley & Kerr, 2000). Although challenging behaviors are commonly observed in people who have both epilepsy and intellectual disability, there is some disagreement within the scientific literature as to whether the presence of epilepsy in a person with intellectual disability is suggestive of higher levels of problematic behavior. In some studies, the prevalence of behavioral disorders in this population has not been found to be higher than that found in individuals with an intellectual disability alone (Deb & Joyce, 1999; Espie et al., 2003). However, a recent study has found lower rates of psychopathology in people with epilepsy and intellectual disability when compared to people with intellectual disability alone, and have suggested that the effect of anticonvulsant medications may account for this finding (Arshad et al., 2011). A number of epilepsy-related factors have been linked to increased rates of behavioral disorder including high seizure frequency, presence of tonic–clonic seizures, and polypharmacy (Espie et al., 2003; Scheepers & Kerr, 2004), suggesting that behavior disorders in some patients with ID might be modified by appropriate management of the epilepsy when both conditions coexist. In a prospective study of the impact of seizure activity on the development of psychiatric disorders, people with epilepsy and intellectual disability were found to have a sevenfold increase in risk of developing psychiatric disorders over those with intellectual disability only (Turky et al., 2011). The presence of autism spectrum disorder in people with intellectual disability is thought to be related to increased rates of behavioral disorder (Smith & Matson, 2010a,2010b). A recent study found that the combination of epilepsy and autism in individuals with intellectual disability was significantly associated with higher rates of disruptive behavior and self-injurious behavior (Smith & Matson, 2010a), and epilepsy has also been observed at higher rates in people with more severe autistic phenotypes, who have poorer verbal and nonverbal communicative abilities (Bolton et al., 2011).

Review Methodology

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

Research papers were identified for this review through the search engines PubMed and Ovid. The following Key words were used: epidemiology; aetiology; epilepsy; behavioral disorder; learning disability; intellectual disability; mental retardation; psychopathology; RCT. Reference mining of the relevant papers was also conducted to identify further articles of relevance.

Etiology: Challenging Behavior as a Social Construct

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

The joint report by the Royal College of Psychiatrists, British Psychological Society & Royal College of Speech and Language Therapists (2007) considers challenging behavior to be a social construct. They suggest that challenging behavior represents the interaction between person factors, (e.g., degree of intellectual functioning, sensory, motor, or communication difficulties, or underlying mental health problems) and environmental factors (e.g., staff numbers and training, quality of material environment, opportunities for social engagement). According to this perspective, challenging behavior can result from a mismatch between the person's individual needs and the environment. This view posits challenging behavior as a response to a poor environment and as such suggests a role for approaches such as functional analysis with appropriate environmental changes in managing behavioral problems.

Etiology: Challenging Behavior as a Medical Disorder

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

Abnormal behavior, either continuous or episodic, is a clinical manifestation of multiple medical conditions, including psychiatric (psychoses, personality disorders, depression, anxiety disorders, among the most common), medical (metabolic derangements, intoxication), and neurologic (epilepsy, acquired, and congenital brain damage, dementia, sleep disorders, and stroke among others). In the population of patients with intellectual disability and epilepsy, abnormal behavior might represent a symptom of the underlying condition, a comorbid association with a medical or a psychiatric disorder (De Winter et al., 2011; Turky et al., 2011), an effect of antiepileptic medication, or a periictal (preictal, ictal, and postictal) manifestation.

Recent scientific advances in the field of immunology have begun to highlight the importance of immune-mediated epilepsies where significant behavior problems and epilepsy present together (Irani et al., 2011). For example, anti-N-methyl-d-aspartate (NMDA)-receptor encephalitis follows a typical, phased course (Wandinger et al., 2011). There is an initial flu-like prodromal period, followed by bizarre behavioral and psychiatric problems, and memory difficulties, which is followed by a deterioration in the patient's condition characterized by seizures, decreased consciousness, and autonomic instability (Benarroch, 2011; Wandinger et al., 2011). Aggressive immunotherapy should be implemented in these patients (Wandinger et al., 2011). Although patients with intellectual disability have equally subtle organic injury/damage, it is important to understand how our understanding of intellectual disability may be influenced in the future by knowledge of immune-mediated epilepsies.

Individuals who have an unclassified intellectual disability and epilepsy syndrome frequently present with behavioral disorder or autism. Furthermore, there are a number of genetic syndromes in which both seizures and specific behavioral patterns are part of the phenotype. Examples are Angelman's syndrome (Gasca et al., 2010), Prader Willi syndrome (Woodcock et al., 2011), and Rett syndrome (Temudo et al., 2011), which are all known to feature stereotypic hand movements (see below). Prader Willi syndrome is also known to be associated with characteristic problematic food seeking behavior, repetitive and self-injurious behaviors, temper outbursts, and mood disturbances. Some of these characteristics are thought to be related to specific cognitive impairments in this syndrome (Woodcock et al., 2011).

Phenomenology

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

Stereotyped behaviors

There are a number of conditions that have stereotypies as a core feature including Angelman's syndrome, Rett syndrome, and autism spectrum disorder. They are characterized as apparently purposeless repetitive movements that may affect the hands, limbs, face, or whole body (Bodfish et al., 1999; Muthugovidan & Singer, 2009), which can become problematic when they develop into self-injurious behavior, or are performed to the detriment of other more social behaviors. Early researchers in the area, who mostly worked with individuals who had been institutionalized in conditions of sensory deprivation have suggested that these behaviors emerge as a form of self-stimulation to supplement the poor opportunities for external stimulation in the environment. More recent work has focused on the possibility of stereotypies as a movement disorder involving dysfunction of dopaminergic pathways in the basal ganglia (Roebel & MacLean, 2007), or as dysfunction of executive control mechanisms in the frontal lobes (Sayers et al., 2011).

Aggressive behavior

High rates of aggressive and rebellious behaviors have been reported as a feature of psychopathology in people with intellectual disability (Kishore et al., 2005). The joint report by the Royal College of Psychiatrists, British Psychological Society & Royal College of Speech and Language Therapists (2007) has suggested four ways in which challenging behavior may be related to psychiatric disorder. Different patterns of behavior disturbances can be observed in patients with psychiatric conditions. Aggressive behavior is a common manifestation of psychoses, including schizophrenia, and may be observed in personality disorders. Less common, aggression is present in bipolar disorders, depression, and anxiety disorders. Substance abuse can cause aggressive behavior both during phases of acute intoxication and deprivation. In each case the etiology is usually identified by careful psychiatric evaluation.

AED-related behavioral problems

In general terms, they include hyperactivity, irritability, and aggressive behavior (Smith & Matson, 2010a,2010b) and appear to be associated with polytherapy and severity of epilepsy (Mula & Monaco, 2009). This is particularly evident with γ-aminobutyric acid (GABA)ergic drugs such as barbiturates (Vining et al., 1987) and vigabatrin (Bhaumik et al., 1997). Although an audit study conducted in a tertiary referral epilepsy center reported aggressive behavior in 7% of patients with intellectual disabilities and epilepsy taking levetiracetam (Mula et al., 2004a2004b), such prevalence is similar to that described in previous clinical studies involving a general population of patients with epilepsy (Mula et al., 2003). In this regard, it has to be taken into account that, if patients who have been disabled by frequent seizures suddenly become seizure free without being sedated, the consequence may be an increased propensity to misbehave (Besag, 2004). This condition is also known as the “release phenomenon” and “forced normalization” and can occur with several AEDs that are effective in controlling seizures with a low sedative potential (e.g., lamotrigine; Clemens, 2005).

Assessment: People with Intellectual Disability

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

Assessment of behavioral disorder or psychopathology in people with intellectual disability can be problematic due to cognitive or communicative deficits (Smith & Matson, 2010b). Behavioral problems are commonly assessed through direct observation by family members or paid carers, which may be revealed through a detailed clinical history (Kerr, 2002). Functional analysis may be useful to clarify the circumstances under which problem behaviors may arise, or the purpose of that behavior (Kerr, 2002). In addition to this a number of tools have been researched and validated for use by carers and professionals working with people with intellectual disability, for example, the Aberrant Behaviour Checklist in adults (Kerr, 2002).

The joint report by the Royal College of Psychiatrists, British Psychological Society & Royal College of Speech and Language Therapists (2007) advises that a comprehensive assessment of an individual with challenging behavior should include the collection and evaluation of “relevant information about the person, the social, interpersonal and physical environment” in addition to careful exploration of the behavior in question (see Table 1 for a summary of factors relevant to assessment).

Table 1. Important factors in assessment of challenging behavior
Behavior
Nature of behavior
Severity of behavior
Frequency of behavior
Obvious triggers to behavior
Underlying medical and organic factors
Medical examinations and investigations
Symptoms of physical illness (e.g., headache, tooth ache, gastric pain)
Current medication
Specific disabilities or syndromes
Sensory problems
Communication problems
Mobility problems
Psychological and psychiatric factors
Mental health problems
Communication style
Social and environmental factors
Staffing
Numbers
Training
Quality of staff-person interactions
Quality of environment
Opportunities for social interaction
Current restrictions/demands on individual

In particular they advise functional analysis with appropriate environmental adaptation in the management of challenging behaviors in people with intellectual disability. Functional analysis is a technique that aims to explore why an individual may be behaving in the way they are behaving, with the intention of adjusting the environmental pressures on the individual accordingly. Underlying this approach is an assumption that challenging behaviors are functional to the individual performing them, and that unlocking what that function may be will provide the key to managing the behavior appropriately. There are three stages to this method:

  1. Hypothesis development—all available information is employed to develop a hypothesis about why an individual may behave as they do.
  2. Hypothesis testing—direct observation and detailed interviews are used to assess the hypothesis within the context that the individual is living.
  3. Hypothesis refining—experimental analysis may be used to refine working hypotheses/direct move to interventions that may shed light on the function of the behavior.

Although the report works on the assumption that challenging behavior is a functional response to a mismatch between the person and their environment, they do note that in some individuals challenging behavior may be associated with psychiatric disorder.

Assessment: Issues Specific to Epilepsy

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

For the clinician some specific epilepsy questions arise in the context of challenging behavior. For example, De Toledo et al. (2002) found in a video-EEG study of individuals living in institutions that there was frequent diagnostic confusion between self-stimulation, self-abuse, and ataxia and seizures. The first is diagnostic and an evaluation is needed as to whether the behavior is in fact a seizure. Although rare, some behaviors associated in particular with frontal lobe seizures and nonconvulsive status epilepticus can mimic non–epilepsy-derived behaviors. The second issue is seizure timing-related events such as postictal confusion or psychosis. The third are seizure control–related behavioral changes such as deteriorations when control worsens or in more rare cases behavior change associated with seizure improvement. A detailed clinical history, supplemented where possible by video footage of the events (ideally video-EEG) can be effective in differentiating challenging behavior from seizure activity (Kerr, 2002). In certain genetic epilepsies such as ring chromosome 20 syndrome, periods of nonconvulsive status can affect behavior and last hours and days (e.g., Kamoun et al., 2012). Absence status rarely can persist for days, sometimes presenting as prolonged episodes of confusion, without recognition of their epileptic origins (Genton et al., 2008).

The epileptologist is ideally placed to conduct an assessment of potential psychiatric symptoms in an individual with epilepsy and intellectual disability. The social situation of people with intellectual disability can, however, result in difficulties in this process as these individuals may be accompanied to consultations by carers or drivers who are do not know them well and thus can provide little observational information about seizures and behavior. Families and institutions should be strongly encouraged to send accompanying persons who are well known to the individual, and who may be able to both enable communication between the individual and the clinician, and provide additional observational information. In many areas access to these specialist services may be limited, which provides a further challenge to achieving an accurate diagnosis for these individuals.

Treatment Considerations

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

When considering treatment options for behavioral problems in people with intellectual disability, we are faced with a poverty of evidence. There are few randomized controlled trials conducted specifically with people with intellectual disability, and although those that are conducted are of good quality, they tend to have smaller sample sizes than trials conducted with a non–intellectual disability population (Scheifs et al., 2011). With this in mind, we review the current evidence on the use of psychotropic medication and behavioral techniques in the management of behavioral disorder in people with intellectual disability (see Fig. 1 for a simple treatment pathway for behavior problems).

image

Figure 1. Treatment approaches to behavior disorder in people with epilepsy.

Download figure to PowerPoint

Pharmacologic Interventions

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

People with intellectual disability who display challenging behaviors are frequently prescribed antipsychotic medications in an attempt to control this behavior. However, the evidence for the use of these medications in this context are at best mixed (Deb et al., 2008). A randomized controlled trial by Tyrer et al. (2008) concluded that antipsychotic drugs should not be used as routine treatment for aggressive behavior in people with intellectual disability after finding no differences between treatment groups prescribed either risperidone or haloperidol, and a placebo group. Participants were mostly male, and had mild to moderate intellectual disabilities. They were randomly allocated to one of the three groups, and assessments of aggressive and challenging behavior, quality of life, and adverse drug effects were conducted. Aggressive behavior scores (as measured by the Modified Overt Aggression Scale) improved for all three groups over the trial, and no group was seen to show significant improvements over the others. Furthermore, there were no significant differences in challenging behavior, quality of life, or any other secondary measure across groups. In general terms, the tendency is away from using traditional neuroleptics, to using the atypical antipsychotic drugs, not least for their potential effect on negative symptoms and because of the reduced risk for long-term development of extrapyramidal motor symptoms, which are much less likely to occur with atypical molecules.

Pharmacologic Issues Specific to Epilepsy

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

Because seizures and antiepileptic drugs may play a role in behavior disturbances in patients with intellectual disability and epilepsy, this potential relationship should be addressed in each patient. A careful clinical history might reveal a particular pattern of behavior worsening related to seizure occurrence; in this case improving seizure control might result in improvement of behavior. In other cases an antiepileptic drug might be suspected of causing or worsening a patient's behavior, either because it is known to cause this type of side effect (especially barbiturates and benzodiazepines), or because there is a relationship with the time of introduction of the new agent and the onset of behavior derangement or worsening (Huber et al., 2009).

Epileptologists have to be aware that the dose of neuroleptics has to be always tailored to the patient's response because in almost all cases enzyme inducers reduce the plasma levels of these drugs (Mula et al., 2004a,2004b). In particular, the use of clozapine has to be carefully monitored because its metabolism has a high interindividual and intraindividual variability and, especially in combination with valproate, interactions are difficult to predict (Mula & Monaco, 2002).

Among possible adverse effects of antipsychotic drugs, it has to be acknowledged that weight gain and sedation could be emphasized by some AED combinations (e.g., valproate, barbiturates). The association of clozapine with AED characterized by bone marrow suppression (e.g., carbamazepine, oxcarbazepine and so on) is highly contraindicated (Mula et al., 2004a,2004b). Traditional antipsychotics have long been recognized as a class of drugs that can increase the risk of seizures. However, data usually come from psychiatric samples, thus limiting the applicability of such findings to the population of patients with epilepsy. In particular it is still unknown whether different epileptic syndromes have different risks for psychotropic-induced seizures. In general terms, chlorpromazine and clozapine are considered proconvulsant in patients with epilepsy—the former only at high doses (1,000 mg/daily) and the latter at medium and high doses (>600 mg/daily; Alldredge, 1999). Clozapine may cause epileptiform EEG changes and seizures even at therapeutic doses. Such effects seem to be dose-dependent and titration-dependent (Langosch & Trimble, 2002). EEG abnormalities have been reported in 1%, 2.7%, and 4.4% of patients for doses <300, 300–600, or 600–900 mg/daily, respectively (Devinsky et al., 1991). However, the prevalence of seizures, in subjects without a previous history of epilepsy, seems to be much lower and in the region of 0.9%, 0.8%, and 1.5% for the same range of doses of the previous study (Pacia & Devinsky, 1994). Seizures are often myoclonic but also generalized tonic–clonic or partial depending on the individual patient. New antipsychotic drugs are usually well tolerated and can be considered reasonably safe as compared to clozapine and chlorpromazine. In particular, olanzapine and quetiapine showed a seizure rate of 0.9% and risperidone an even lower risk of seizures (about 0.3%; Alper et al., 2007).

Behavioral Interventions

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

There are a number of behavioral interventions available including cognitive behavioral therapy, functional analysis, and multidisciplinary team approaches. A recent randomized controlled trial by Hassiotis et al. (2009) compared the effect of a community-based specialist behavior therapy team with the standard treatment received by a group of people with intellectual disability in a residential setting. The behavioral therapy team consisted of a team coordinator, five full-time behavioral therapists, two part-time behavior-associate practitioners, and an administrator. They used a multidimensional approach including applied behavior analysis and positive behavioral support on a one to one basis with participants and their carers. The standard treatment involved access to a multidisciplinary team who were able to provide pharmacotherapy, occupational, speech and language therapy, and nursing support. They found significant differences in scores from the Aberrant Behaviour Checklist such that the specialist behavioral therapy team was thought to be more effective in reducing challenging behavior than the standard treatment currently offered to these individuals.

Conclusions

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

The occurrence of psychiatric symptoms or problematic behavior in people with intellectual disabilities and epilepsy may be due to a number of underlying causes including unrecognized physical or mental illness, seizure activity, communication difficulties, issues surrounding the individual's physical or social environment, or early stages of autoimmune encephalopathy. As such it is important that the assessment of these symptoms is conducted with consideration of these factors, and appropriate management should be implemented at the earliest opportunity.

Disclosure

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References

The authors have no conflicts of interest to disclose. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. The contents of this supplement reflect the opinions of the individual authors and do not necessarily represent official policy or position of the ILAE.

References

  1. Top of page
  2. Summary
  3. Review Methodology
  4. Etiology: Challenging Behavior as a Social Construct
  5. Etiology: Challenging Behavior as a Medical Disorder
  6. Phenomenology
  7. Assessment: People with Intellectual Disability
  8. Assessment: Issues Specific to Epilepsy
  9. Treatment Considerations
  10. Pharmacologic Interventions
  11. Pharmacologic Issues Specific to Epilepsy
  12. Behavioral Interventions
  13. Conclusions
  14. Disclosure
  15. References
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