Hi, everyone. Good morning. Can everyone hear me okay? I'm going to be wearing my mask, so just if you need me to project, just raise your hand. I think we're going to get started in the interest of time. Thank you all so much for coming. Welcome to the EPA. My name is Elizabeth Wise. I'm a psychiatrist from Baltimore, and I'll be presenting with Dr. Wisner Carlson, another psychiatrist from Baltimore. So thank you so much. Just to start, neither of us have any relevant financial disclosures. Thanks Lizzie. Good to be here. Hope everyone's enjoying New Orleans so far. Again, my name's Bob Wisner Carlson. I'm the chief of the Outpatient Autism and Neurodevelopmental Program at Shepard Pratt, and we're going to be presenting about the psychiatric treatment of individuals with intellectual disability and autism, adults. So intellectual disability and autism are neurodevelopmental disorders that start in early childhood, but they are lifelong. And that is one of the main reasons that adult psychiatrists, psychiatrists who treat adults, need to know about these. And not only are they lifelong, but they also have a high comorbidity of psychiatric problems. So individuals with intellectual disability and autism have a high degree of psychiatric comorbidity, and they have special characteristics that lead to unique challenges that the psychiatrist needs to know about to effectively treat these individuals. Now before I go further, I'd just like to ask a couple questions. How many people right now are treating individuals with intellectual disability and or autism in their practice? Excellent. Now, how many of those, how many of you are doing that in a public setting? Got it. How about in a organized health system, a hospital system or the like? How about in private practice? Okay, great. All right. So you might have some things also to add about this. Intellectual disability is a neurocognitive disorder characterized by deficits in general mental abilities and adaptive functioning. The IQ on formal testing must be at least two standard deviations below the mean. So for the Wechsler, the standard deviation is 15, two standard deviations below the mean is 30, so a cutoff score of 70. But along with that, the individuals must have significant impairments in adaptive functioning. Adaptive functioning are the things that we do to run our lives. So paying bills, getting up in the morning, bathing, eating, working, taking public transportation, knowing when a situation is unsafe, knowing what areas not to go into, for example. Those are all part of adaptive functioning. The prevalence of intellectual disability in the general population overall is about 1%, with severe intellectual disability being about 6 per 1,000. It is a little bit more prevalent in males. And there are a multitude of genetic conditions, diseases, and exposures that can cause intellectual disability. For our purposes, I think of three burdens for individuals with ID in regards to psychiatric issues. One is the burden of intellectual disability itself. So individuals with intellectual disability have trouble abstracting, and because of that, they have trouble problem solving. And with that, they are more prone to be overwhelmed by the stressors of life, the provocations that come upon all of us. And that can cause adjustment disorders, catastrophic reactions. Another issue is that individuals, another burden is that individuals with intellectual disability have a higher degree of comorbid psychiatric problems and behavior problems. And then a third burden really rests on us, and that is that one has to take special consideration in making the diagnosis, making a psychiatric diagnosis in individuals with intellectual disability and other developmental disabilities. So part of this presentation is to help alleviate that third burden. Related to this, there are special aids to diagnosing psychiatric issues in individuals with developmental disabilities. Probably the primary one is the Diagnostic Manual of Intellectual Disability, second edition, which is a textbook that correlates to the DSM-5 and explains how to make the diagnosis of various psychiatric conditions in individuals with intellectual disability and autism. Autism. Autism was first described by Leo Kanner in 1943 at Johns Hopkins in Baltimore and by Hans Asperger in 1944 in Austria. Autism, now referred to as Autism Spectrum Disorder or ASD, is a neurodevelopmental disorder starting in the early developmental period, characterized by persistent deficits in social communication coupled with restricted, repetitive behaviors, interests or activities, and sensory problems. And we call those RRBs or RRBIs. These are the diagnostic criteria. And what I will point out is that in the B criteria, there are a number of things which become burdens also for individuals with autism. Being inflexible in routines, having difficulties with sensory input, especially being hyperreactive to these. And those are important to know, especially for individuals who take care of people with autism. So the most recent CDC data, autism occurs in more than 2% of 8-year-olds in the United States. There's no overall difference in racial or various racial or ethnic groups, although in this particular survey, several sites showed that the percentage of Hispanic children identified with ASD was lower compared to white or black children. Boys are four times more likely to be identified as girls. And the key word is identified, because we think that autism is under-identified in girls. And among 8-year-old children, autism was more than one-third associated or had comorbid intellectual disability. Autism is highly genetic. The current heritability estimate is 83%. Autism is associated with, syndromic autism is associated with genetic syndromes, and we'll talk about a few of those in a minute. And these are genetic syndromes that also cause intellectual disability. However, common genetic variation is thought to contribute the greatest risk, the greatest portion of the risk for autism. Autism is highly associated with epilepsy, and epilepsy and autism co-occurs in epilepsy, both at about 30%. And there's an increased incidence of other medical conditions. Autism and intellectual disability are not uniform conditions. And part of that is because they occur in the context of other disorders often, including various genetic syndromes, and we'll look at those in a minute. Another concept in this regard that's important is that of the behavioral phenotype. So behavioral phenotype is, so just like there is a phenotype to go along with the genotype, right, for different genetic conditions, so the faces, the height, the, you know, et cetera. There are behavioral phenotypes, and that was first described by William Nyan of Lesh Nyan fame in the early 1970s, the behavioral phenotype of self-injury in individuals with Lesh Nyan syndrome. So a behavioral phenotype is a characteristic pattern of motor, cognitive, linguistic, and social observations that is consistently associated with a biologic disorder. Hyperphagia in Prader-Willi syndrome is another example of a behavioral phenotype. So this and the next slide, and these slides are available, I should say, on the app. So in order to save trees and the climate, there wasn't a push for paper printouts. So what I want, so these are available, and of course there's a lot of information here. What I want to point out is that understanding the psychiatric comorbidities, the behavioral phenotype, and the medical comorbidities may well inform the psychiatrist who's seeing an individual with intellectual disability or autism who's coming in for an evaluation. Most of the time, it's family or a caretaker who's bringing the individual in, and they are doing that because of a change in behavior. So for example, with Down syndrome, which we'll hear more about later, say a young adult in their 20s is brought in because they're anadonic. They're not interested in the things they used to be interested in. Their energy is poor. They are sleeping more, right? They're irritable. And there's a question, are they depressed? And they well could be depressed, and depression can definitely occur in Down syndrome and may occur at a higher rate. But they might also have hypothyroidism, which occurs more frequently. They might have obstructive sleep apnea. They might even have a deterioration in a previous cardiac condition. And they're more likely to have these, a 20-year-old with Downs, than the general population. So individuals with intellectual disability and autism have special characteristics and special needs. And a couple of these affect the psychiatric interview and the process of psychiatric diagnosis. So language can be a problem. Some individuals, especially those with autism it seems, have assistive communication devices. And so that can help in an interview, right? But almost always, one is going to have collateral informants. And that's very important. In the interview, in the exam, it's important for the psychiatrist to realize that individuals have concrete thinking and problems abstracting. And so one must talk in simple sentences with simple vocabulary, not compound sentences, no complex grammar. And you may not realize that the individual with intellectual disability is not understanding you because they've lived a life where perhaps they haven't understood everything that's going on in an interaction. And so they just agree, yes, yes, doctor, they agree to what you're saying. And you're not getting good information. Metaphorical language can be problematic in individuals with autism. And so that is to be avoided. In the mid-1980s, Sopner and Hurley identified a number of these problems and gave them terms. And we've talked about this, psychosocial max scheme, intellectual distortion, baseline exaggeration. I'll point out that, well, the definitions are here. I'll point out a couple things. One is the tendency to attribute behaviors that are really coming from an underlying medical or psychiatric condition to attribute those to the intellectual disability or core symptoms of autism, diagnostic overshadowing. And another is baseline exaggeration. So individuals with intellectual disability and autism often have challenging behaviors. And those behaviors can come from a number of different things. And those can be exaggerated in the setting of a psychiatric condition. And I'm going to hand it over to Dr. Weiss. Thank you. Can everyone hear me okay? Yes? Okay, great. So with that background, thank you, Dr. Wisner-Carlson, I want to go over how we elicit the psychiatric history for specific disorders. And we'll be identifying different psychiatric disorders with specific cases that we've seen. I think we're a good combination. I work mostly in the outpatient setting, and Dr. Wisner-Carlson primarily has an inpatient unit. So we'll be illustrating cases through that. So first I want to start with one of my patients. This is Ryan. He's a 44-year-old with Down syndrome, whose mother brought him to the clinic because he was less communicative. His family history was notable for alcohol use disorder, and his father, who also, it was in remission at the time, who also developed ALS and passed away from that. Ryan went to high school. He was born and raised in the D.C. area. He went to high school in a special education program, got his certificate at age 21. And before the pandemic, he had been attending a day program. He lives with his mother. He has a medical history of hypothyroidism. As Dr. Wisner-Carlson mentioned, there's a high comorbidity of hypothyroidism with Down syndrome, as well as psoriasis. His mom brought him to the clinic because he had been much more tearful. He wasn't eating and drinking as much. He was refusing his medications in the morning, wasn't sleeping very well, would be up pacing. And this all started about four to five weeks after his father had passed away. So when we saw him, we made sure to do a medical workup, making sure that his thyroid function was intact. We reviewed prior neuropsychological testing he had. He had a full-scale IQ of 47 on the WAIS-IV, the Wechsler scale. His mother did not think that there was any change in his functioning or cognitive concerns. So for him, we thought it was pretty consistent with a depressive episode, given the neurovegetative signs. We started sertraline and slowly titrated that, and he actually did better. So even though Ryan was pretty clear-cut, given the onset after his father's death and the neurovegetative symptoms of depression, making the diagnosis of psychiatric disorders, as he alluded to, can be very challenging. For one, as you can imagine, self-report can be difficult. We're very used to our patients coming in and reporting their mood. However, many of our patients may not have the language skills or the insight into how they feel to report how they feel. In addition, there are overlapping symptoms, signs and symptoms, between psychiatric disorders and developmental disabilities. For instance, in autism, some people might have constricted affect, don't like being around others, and so we want to be careful not to mistake this or to think that this is just their autism when they might be depressed. Further, psychiatric disorders have unique phenotypes, and this is kind of different than the behavioral phenotypes, but more like atypical presentations. So they don't always fit well with the DSM-5 criteria for our major affective and anxiety disorders. As Dr. Wisner-Carlson was saying, we often have to rely on collateral informants and really take the time to get to know our patients to diagnose psychiatric disorders or rule them out. And finally, we lack the standard assessments that some of us may use when diagnosing psychiatric disorders in the general population. So just broadly, to build upon what he was saying, it's so important when meeting an individual to identify their baseline. So really getting to know what their daily routine is like, when they're doing well, so that if there's a change from that, we can assess if something else is going on. Identifying what their sleep and eating habits are like. Some people might only need five hours of sleep a night, kind of as in the general population. Getting a baseline is key here. And really identifying how social they are. So even though people with autism may have challenges in socializing and communicating, many people desire social relationships and are like being around others. So not just assuming that if somebody has autism, they're asocial, right? Because if somebody is social at baseline and then all of a sudden they're less interested in being around others, that may key us in that there's a psychiatric problem. So talking to family, caregivers, day program staff, if they're still in the school setting, educational staff as well. Understanding any medical history and workup that's been done, constipation. So I also do geriatric psychiatry. So there's a lot of overlap with geriatrics. Constipation is key. And we want to make sure that there's no GI problems that could be complicating or exacerbating what we're seeing. Dental problems as well is a big one that we can see. A lot of times people have trouble keeping up with their dental hygiene and have abscesses. And so some of the challenging behaviors we might see could be related to medical problems like that, which we would intervene differently rather than adding a psychiatric medication. We also want to make sure that there's nothing in the environment that's causing what we're seeing. And so similar again to geriatrics and dementia care, really talking to the caregiver and assessing how they're approaching the patient. Because maybe something that they're doing could be modified and could help with the patient's presentation. And finally, both in the inpatient and outpatient setting, it's really important to collect objective data on sleep, frequency of challenging behaviors, how often they're engaging in self-injury, what their food intake is like. But just trying to get objective data because it sometimes can be hard to get that subjective data. And I brought here this little, probably hard to see, but I just love this, this was from a patient, this is a sleep chart, a sleep log, I don't know if any of you collect these from your patients, show of hands, yeah. A lot of times people in group homes will have awake overnight staff, and they go in and check on the individual every hour, and then they write if they're awake, asleep, using the bathroom, agitated, and so on. And so I ask my patients, caregivers, to bring these to their appointments so that I can get a sense of how many hours, on average, they're getting a night, and where kind of the problems lie. Because it's so easy for people to just rely on, oh, what happened the last week, whereas we want to look at overall trends rather than just blips. So moving just to specific psychiatric disorders, so depression, so exact estimates of depression in IDD vary, depending on the sample source, whether it's drawn from the clinic or community setting, what type of diagnostic instrument is used, how we're assessing for depression. But it's generally thought that people with IDD are as likely, if not more likely, than the general population to experience depression. So depending on the study, the rates range from either 2.2 to almost 16%. You'll see in the next couple of slides that there's a wide variety. It's thought that people with autism have an even higher frequency of depression. So this bullet here is from a recent meta-analysis that looked at several studies of depression and found that at the time of study, there was a current prevalence of 23% in autism, and over the course of people's lifetime, there was a 37% prevalence of depression. In intellectual disability, one study found a two-year incidence of 7.2%. So even though these rates sound high, it's quite possible that they are underestimated. People with intellectual and developmental disabilities may not self-report, so we might not be seeing them in the general setting. We as clinicians, unfortunately, lack experience and training in recognizing psychiatric problems. And caregivers, whether it's family or paid caregivers, they do not receive specialized training in the recognition of mental health problems. A lot of the caregivers who accompany our patients to appointments are getting minimum wage for a very difficult job. They're working several jobs, and so even though we wanna get a lot of information from them, we have to realize that there are limitations there as well. So depression in intellectual and developmental disability can have, as you see on the left, kind of basic DSM-5 criteria. They can present with sadness. They may even be able to tell us they feel sad. Anhedonia, so this may present as people becoming aggressive when they are asked to engage in their usual activities or going to their day program. They might become more withdrawn or don't wanna participate. They may have psychomotor slowing as well as changes in neurovegetative signs or symptoms like we saw with Ryan. And then there are atypical presentations, so people might be a lot more irritable, have an angry facial expression, angry affect. They may cry more frequently, and they're not able to tell us, but crying several times a week unprompted. If at baseline, if they engage in self-injury, it may be increased or they may develop self-injury de novo. In addition, we can see unexplained skill loss, so people may have been able to dress themselves, do all the adaptive skills that they're used to, but all of a sudden have some regression. They might become incontinent, and this in association with other symptoms can lead us to think maybe there's a depression. Specifically for autism, they might have worsening of their core symptoms, so their preoccupations or their restricted interests might change in character or content. So the example I like is, somebody who's very interested in space may all of a sudden start talking about the deep, dark hole of space and become very fearful that they're going to fall into that deep, dark hole. So these can cue us into symptoms of depression. In the literature, common precipitants of depression in IDD are similar to what we might see in the general population, but there's also unique features, as many of these individuals are very sensitive to changes in the environment. As you can imagine, there's a lot of turnover in terms of group home staff, and unfortunately, many individuals bond with their group home staff, and when a staff member leaves to go to a new job or gets promoted, the individual might perceive that as a personal affront, and it may lead to a reduction in self-attitude and depression. Further, they may have what we call existential crises or concerns related to their disability. There's seats in front if you'd like to come up. So they might notice, feel like their disability is causing meaninglessness or not having a purpose. They may feel very isolated. A lot of them, if they've got physical comorbidities, may have to rely on others for a lot, and they might feel like a loss of control really dominates their day-to-day experience. And then finally, excuse me, they might recognize the differences between themselves and their peers. So one of my patients gets very depressed and demoralized when her sister was getting married, and her realizing, you know, I'm not going to be able to get married, have children, move out of the family home. And it's been shown that individuals with higher verbal and cognitive abilities, as well as more insight into their deficits, have lower perceived social competence and higher rates of depression. And I think just in thinking about this, even in individuals with reduced cognition or intellectual disability, we want to avoid the assumption that they're not capable of experiencing these struggles just because of their intellectual disabilities. So this was a Norwegian study that actually looked at, well, what is the association between type, number, and intensity of negative life events with depression? So they looked at almost 600 adults with intellectual disability in the community. About 2 3rds of them had either mild or moderate intellectual disability with an average age of 41. And they used two informant-based measures. A lot of the research in this area relies on informant-based, for better or worse. And in order to measure depressive symptoms, they used the psychopathology checklist for adults with ID. And then they also administered the life event checklist for adults with ID, which looked at four major negative life events, loss, illness, bullying, and change. And they found that 41% of the individuals had been exposed to one or more negative life events in the past year. And then after adjusting for things like age, gender, level of intellectual disability, they found that bullying and loss in the past year were most significantly associated with depression, whereas change in living arrangements and social routines were not associated, or was not associated with depression. They also found that higher quality community care, which was kind of interestingly based on the caregivers, the caregivers rated it themselves, but nonetheless, they found that that may decrease the risk for depression in individuals who had been exposed to bullying, suggesting that these individuals do well when they are able to form meaningful relationships. So for all these reasons, it's very important to evaluate for suicidal ideation, being careful, just noting that some people are suggestible and they know, or they may have learned as we see in the, unfortunately, in the emergency department, saying your suicidal gets a reaction. So just taking that caveat, but it's generally thought that rates of suicide in people with intellectual disability are probably lower than in the general population. And as you can imagine, it's more common in people with mild intellectual disability compared to moderate or severe. This was a small study done in Europe, a community sample of almost 100 adults who had either borderline intellectual disability or moderate. And at the time of the structured interview, they found that a third had passive death wishes. Nearly a quarter had suffered from suicidal ideation at some point in the past. And almost, I think, 10% had attempted suicide, sometimes passive methods like walking into traffic or jumping from a height. So again, avoiding that assumption that people with intellectual disability aren't able to experience suicidal ideation. In the past several years, it's been recognized that individuals with autism are at higher rates of experiencing suicidal ideation. One study showed that adults with ASD, or sorry, adolescents and adults, are up to nine times more likely to experience suicidal ideation and up to six times more likely to attempt suicide than in the general population. And again, things like higher IQ, low self-esteem, younger age, decreased social supports, lack of access to appropriate mental health care are thought as potential risk factors. So moving on now to anxiety, I want to tell you about a patient, Mary. She's a 32-year-old woman with autism who came to the clinic presenting with agitation or anxiety. As I said, she has autism and intellectual disability. Her full-scale IQ is about 50. She's minimally verbal. At baseline, she's socially indifferent. She engages in stereotypies, including finger-flipping, and she really thrives on routine and likes routine. Her past medical history was only notable for constipation. She lives in a group home and she works in a dollar store stocking shelves. Her group home staff brought her to the clinic because she had been more agitated, very fearful at work, hitting herself in the head when the routine wasn't followed or there was an unexpected change, constantly preoccupied with the timer and the watch. She would always look frightened and pace at doctor's appointments. And so when we saw her, we thought, how can we differentiate this from her autism? Was this just a need for sameness that people experience? But we thought that this was actual fear of change and really anticipatory anxiety in advance of change. Also, we considered that her anxiety and her symptoms were occurring across multiple environments, both at the group home setting and at work. Had her symptoms only been on a particular shift, you know, caregiver shift, like from three to 11, we might've thought maybe this is a systems problem that could be addressed with, you know, talking to the caregiver or adjusting something in the environment. But given how pervasive it was, we diagnosed her with an anxiety disorder. We tried an SSRI, but she had some agitation on that. So we ultimately treated her with low dose of risperidone, as well as using visual schedules so that she could see, you know, at this time, this is when we do this, and giving her rewards for when she engaged in her job and did well without engaging a self-injury. So that was Mary. So anxiety, excuse me, even though anxiety and agitation is a common problem that we see people in the clinic, in the literature, the rates aren't as high as I thought they would be. So this comes from a Scottish study of over a thousand adults with ID using a semi-structured assessment. And they found that there was a point prevalence of almost 4% for any anxiety disorder, specifically generalized anxiety disorder in 1.7% and social phobia in 0.3%. Smaller studies have shown higher rates, up to 17% for GAD. And then in autism, as you can imagine, rates even higher with a very wide range depending on the study, 15 to 76%. And that same meta-analysis that I spoke of earlier, they found that adults with autism at the time of study had 27% experienced anxiety and over the course of their lifetime, 42%. So similarly to depression, we often have to rely on behavioral signs of anxiety because many of our patients aren't going to come tell us that they're worried. So whether this be frightened appearance, you know, getting easily flushed, worsening eye contact in certain situations, clinginess to their parents, their siblings, caregivers, having irritability and outbursts, nail biting and skin picking, which in and of itself is a whole lecture, and avoidance of activities that precipitate anxiety. We can also see a lot of perseveration, repetitive questioning, kind of seeking reassurance rather than them just focusing on their preferred interests, as well as sleep disturbance and disordered eating. And again, in autism, there may be worsening core features. So they might be even more withdrawn from social activities, may have more repetitive behaviors or self-injury. Or for some of our individuals without intellectual disability, when they get in social situations, they may really get confused and kind of have a discomfort that's different than what we see in social anxiety disorder, but more than just what would be expected with autism. And when we try to guide treatment, we want to think about what kind of triggers are there. Are there any comorbidities like ADHD? Is the individual using substances? A lot of, well, not a lot, but several of my patients, when I ask about it, they do drink alcohol in an effort to mitigate anxiety. They are using marijuana. So even though substance use tends to be less common than in the general population, we do want to ask about it and be aware that when an individual can access these substances, they may be using them. In terms of risk factors for anxiety, there's a number of factors that can increase the risk. A Scottish study found that unemployment and having a negative life event, similar to what we saw in that depression study, can be associated with anxiety. Looking at age, it's kind of conflicting. A study of adults with autism found that actually increasing age lowers the risk. So individuals in their 70s to 90s, if you can believe it, had lower rates of social phobia among other psychiatric disorders. However, other studies have found that increasing age and more chronic health problems can be associated with anxiety. Okay, so just want to move on to this case. So this is Dan. He's a 39-year-old man who came to the clinic and he self-reported, the tension is aggravating me. He had no notable family psychiatric history. He met his developmental milestones within normal periods, but around age two, his speech started to regress. His parents said that he did not make eye contact or seek out others. He could sing songs, recite nursery rhymes, but he had echolalia. So he would repeat either immediately what somebody had said or repeat things that he had heard in movies. And he did not engage in conversation with his family. He flapped his fingers, flapped his hands and engaged in flipping of the fingers when he would get excited or have strong emotional reactions. He completed high school with a certificate and actually took some computer classes in community college and did some basic office work. And he lives at home with his parents. He has allergic rhinitis and eagle syndrome. I don't know if anyone knows what that is. Anyone ever heard of it? I'd never heard of it before, Dan. So it's actually elongation of the styloid process that causes some throat pain. And so he had had a bilateral styloidectomy. He was diagnosed with, at the time, because this was in the 1980s, infantile autism when he was three. His full-scale IQ was measured in the low 70s and he had been treated in the past for anxiety and obsessive compulsive disorder with fluoxetine. When he came to see us, he and his parents had just moved to the area to be closer to a sibling because his parents were getting older. And they were concerned because it was taking him up to an hour and a half to finish his meals. He had to eat in a certain way because he was saying that the tension was bothering him. It hurt to swallow. However, he had seen his ENT and this was not thought to be due to the eagle syndrome because the styloid process was no longer elongated. He was also taking an hour with his dental hygiene routine. So kind of the opposite of what we usually see. But it was getting problematic because he was running late, not sleeping enough because he took so much time to engage in these. So we thought his diagnosis was obsessive compulsive disorder. We actually switched fluoxetine to clomipramine and added Abilify to augment when he wasn't doing better on clomipramine alone. We're trying to get him to use a timer to kind of limit the amount of time spent engaging in his routines. And he's receiving occupational therapy and psychotherapy in the clinic. So just briefly, obsessive compulsive disorder, as you can imagine, can be challenging to diagnose in this population in part because people might not have the ability to explain their intrusive thoughts or the reasoning behind their compulsions. Also because of overlap with both autism and the phenotype of Prader-Willi syndrome. In both, we can see ritualistic compulsive symptoms as well as repetitive questioning and insistence on routine. There was a nice population-based study that compared individuals with Prader-Willi syndrome to individuals in just an outpatient OCD clinic. And they found that hoarding and needing, like feeling like you need to tell or ask was more common in the Prader-Willi population, whereas checking was less frequent. So even though we might not be able to get the reasoning behind why somebody's engaging in a compulsion, we can make the diagnosis if the individual seems very distraught when they're engaging in the repetitive behavior, or if they become aggressive when we try to intervene from them engaging in their ritual. So we don't always need to hear that inner experience to make the diagnosis. But we do want to be careful not to over-diagnose OCD because many individuals, or some individuals with developmental disabilities may engage in repetitive behavior that they find rewarding or self-stimulatory. So back to you. Just going to talk about bipolar disorder for a minute. Is at least as common, if not more common, in individuals with intellectual disability, and probably much more common in autism. Yeah. So what I want you to appreciate here, bipolar disorder in intellectual disability in autism, these are based on the DSM-5 criteria, and all of these symptoms, or signs really, are observable, right? So, and even in the general population of individuals, individuals who become manic often tell you they're not manic, right? My mood's fine, it's never been better, but it's fine, right? And what you're looking at is that they're talking fast, they have flight of ideas, they have increased goal-directed activities that are getting them into trouble, et cetera, they're not sleeping at all. Well, these are all observable things, so we don't need to have the person report about their inner experience. We don't have to have the person describe their phenomenal world to be able to make a diagnosis of bipolar disorder. And that's true also for other psychiatric conditions, because there's a change in the vital sense that can be observed. Just quickly, the case of Jane. Jane was 23 years of age at the time she was admitted and treated on our specialty unit at Shepard Pratt. She was admitted through the emergency room. Her background, so she's an individual with mild ID due to fetal alcohol syndrome. The background is she lived with her biologic mother until eight when she was removed for neglect and abuse. She was adopted by a wonderful couple, very supportive, intelligent couple. She needed psychiatric care since elementary school. She was hyperactive, had poor attention, labile mood, poor judgment. As she got into her teens and young adulthood, these symptoms continued and she was highly dependent on male attention and she would become devastated when she felt she was being abandoned by a love interest. She was having trouble, she lived in a group home, a supervised setting. She was having trouble in supported employment activities because she was so erratic. So in the several weeks prior to admission, she was becoming increasingly irritable, her energy was elevated, she had decreased need for sleep, she was hyper talkative, she lost her temper easily, she destroyed property in her bedroom, she was upset about a man her age and her day program. She threatened suicide, she was running into the street. She's being treated with a second generation antipsychotic and a stimulant already by the outpatient team. And as her sleep was deteriorating, she was prescribed trazodone and as that didn't work, the trazodone dose was being increased to doses that really are antidepressant, 200 milligrams and above. And she was felt to have borderline personality disorder. Our treatment team diagnosed her with bipolar disorder, manic without psychotic features, with possible mixed features in the setting of mild intellectual disability due to fetal alcohol syndrome. We stopped the stimulant, we tapered and stopped the trazodone, we started lithium. Her mood stabilized, it's been stable for the last seven or eight years on lithium. She obtained supported employment, which she's very proud of. And we thought that even though... We thought she didn't have a borderline personality disorder. So getting the diagnosis right has a major impact on people. Psychosis also is thought to occur more frequently in intellectual disability and autism. However, in more severe intellectual disability, I think it can be harder to diagnose because one can't access the phenomenal world. The report of what's going on, the person's own report. All right, so moving on to treatment. So just in general, even though I'll be talking about medications, I really want to emphasize that medications are only one part of treatment, as in the general population. Psychosocial interventions are key here. So psychotherapy with modifications, which I will reference, support both in the employment setting as we saw with Jane and some of our other patients, and if the individual is finishing up the school, having support in the school system. Identifying what changes in the home environment can be made if there's a problem with a housemate or the way a particular caregiver or family member is approaching the individual, as well as occupational therapy. Fortunately, our clinic has two dedicated occupational therapists, and they are so helpful for our patients, both in developing independent living skills, getting somebody back to their baseline if they've had an affective episode, and really working on social skills. And ultimately, the goal is to tailor whatever interventions we're using to that individual, either based on their developmental level, their special interests, but really making sure the person-environment fit is there. So looking at psychiatric medications, as you can imagine, we have limited, robust research for the use of medications to treat psychiatric problems in adults with IDD. The only FDA-approved medications for severe irritability associated with autism in the child and adolescent age range are Abilify and Risperidone, but we have no FDA-approved medications for adults. There have been very few large-scale randomized trials, both in autism and IDD, even looking at SSRIs for the treatment of anxiety and depression. So a lot of our experience is based on small, open-label studies. Our clinical experience or extrapolating what we found works in the general population. And unfortunately, and I'm even guilty of this, many of our patients are over-medicated, either being on too many medications, staying on medications too long. We have a tendency not to address whether somebody can come off of their medications. So those are important principles to remember. So I want to show this table. This was from a Medicaid claims data over 60,000. This is children with autism, but I think what it shows can be extrapolated to children and individuals with IDD in general. And the different rows look at different age groups. So even among the age 0 to 2, almost 20% are on psychiatric medications, most commonly anxiolytics and sedatives. And this number just gets higher. So by the time people are in the 18 to 21 age range, 73% are taking a psychiatric medication and a fifth are on three or more. At this point, it becomes a neuroleptic, antidepressant, and anxiolytic. And so as you can imagine, people get put on these medications when they're younger and they stay on them when they come to us as adults. So this table is also from a study looking specifically at adults with autism. What's nice about this study is that all of the individuals had been ascertained with autism 20 years prior. A lot of the problems in this field is that some of the autism diagnosis is self-report, but this was actually people who had received the diagnosis as children. And again, almost 60% were prescribed a psychiatric medication and a third were given two or more. So this is just to remind, and this is helpful even in reminding me that when I see a patient, is there anything that I can try to reduce or remove if somebody's had periods of stability? Many people need the medications, but we also want to make sure that we're not unnecessarily medicating. So again, kind of similar to geriatrics, when we're treating depression, always want to start with SSRIs, but start at low doses and increase slowly. Specifically with autism, we can see behavioral activation. So when people are started on antidepressants, they might get more hyperactive, have insomnia, disinhibition, and this can be concerning for either a bipolar diathesis or just not doing well on an SSRI. So when someone does appear agitated, I tend to remove it and go toward another class. Similarly, for anxiety, again, always want to use SSRIs to start, just given that they have less risk of long-term side effects. However, if somebody presents to us as having unstable mood and they had previously done well on antidepressants, but all of a sudden they haven't been doing well, we may want to consider a mood stabilizer. Many individuals will have comorbid ADHD, and so if they're coming to us with both anxiety and ADHD, unless the hyperactivity is really prominent or seems like the primary problem and is very severe, it's often easier to try to treat the anxiety first because some of the inattention and pacing that we see could get better on anxiety medication before starting a stimulant. So benzodiazepines, of course, we don't want to use first line, but many of my patients need as-needed benzodiazepines before going to doctor's appointments, and we want them to engage in regular preventive care. So I think the benefits here outweigh potential risks. So this table was actually from an autism-specific paper, but I think it, again, can be generalized to other developmental disabilities. I just want to point out that clonidine and guanfacine I hadn't used in my practice much. We tend to use them more, or child and adolescent psychiatrists tend to use them more, but they can be very helpful, both the short and long acting preparations for things like impulsivity, behavioral dysregulation, physiological arousal that is associated with anxiety. And then in just some practical guidelines, so as much as possible, it's helpful to try to assess whether the person can actually consent to treatment or whether they can ascent or if, you know, not show signs of not wanting to be on medication. Always discussing what our formulation is and what the treatment plan is with the patient, their family, and caregivers. Letting them know if we're using a medication outside of its approved indication or kind of off-label use, and really emphasizing to the individual and their caregivers that medication is only one part of the treatment plan. It really needs to be person-centered and holistic. I think people can come to us wanting a medication to help something that may not respond to medication. So really identifying what's a challenging behavior and can respond to other interventions. There are, I'm not sure how many of you are familiar with Applied Behavior Analysis or ABA. So this is a wonderful resource. I wish more people were trained in this, but it's all about, and it's used in the child and adolescent psychiatry world, it's all about focusing on interpreting the reasoning behind somebody's behavior, collecting data on its antecedents, what comes before it, and what seems to reinforce or what are the consequences of that behavior. And then the intervention is manipulating the antecedents and consequences to eliminate or mitigate that behavior. And it has a very large evidence base. So ABA, as much as possible, is a wonderful treatment. If we do need to start a medication for either depression, anxiety, bipolar, etc., we want to identify targets and outcomes so that we can really monitor this along the way. And if it's not working, then remove the medication rather than just adding something in addition. Now moving on to psychotherapy, adults with IDD are less likely to receive psychotherapy than adults without IDD. However, with modifications, it has been shown to be helpful, both in the research and based on clinical experience. A lot of the studies in autism have focused more on individuals without co-occurring intellectual disability. However, there have been some that have shown that behavioral activation can be effective for depression in mild to moderate ID, both in the short term and the long term, as well as mindfulness-based interventions really focusing on emotional awareness and regulation. So just modified CBT or cognitive behavioral therapy for use in this population really focuses more on the B, the behaviors, than the cognitions. As Dr. Wisner-Carlson was saying, people have difficulty with abstracting, and so they might not be able to generalize skills across different environments or situations. And so we want to focus on behavior, so generally recognizing stress, emotions, when we're feeling upset, using concrete language, using visuals like here, the feelings thermometer, asking people to express their feelings or rate the intensity of their feelings using this, and try to incorporate the individual's special interests when appropriate. Again, all about supporting the environment, person fit. Also, as we would do in the general population, focusing on diet, exercise, social skills interventions, and leisure. Just in the remaining couple minutes, I want to go over considerations for the geriatric population. So briefly, this Carl was a 61-year-old who came to the clinic, brought by his sister for anxiety, 61 for autism, I consider geriatric. Family history is notable for late-onset dementia in his mother. He was described as a savant when he was younger. He actually attended the University of Maryland, but dropped out. He had a period of homelessness when his family was less involved, brief jobs of short duration. He actually returned to college in 2016 with his sister's assistance and got his associate's degree in environmental sciences. He was involved with DOORS, which in Maryland is the Division of Rehabilitative Services, helps people get jobs. And he lived alone in an apartment with significant support from his sister. Medically, he had diabetes, high blood pressure. He had had a stroke without residual deficits, sleep apnea, obesity. He had had full-scale IQ testing, which showed a full-scale IQ of 119, so above average, with a relative deficit in PSI processing speed, which is often seen in autism. They have a deficit there compared to the other subscales. So substance use, he would drink one to two Tall Boys, which are, maybe everybody knows, like 16 to 25-ounce beers a couple times a week when he was anxious. So again, always wanting to address, is there any substance use, and not thinking that just because somebody has autism, they're not going to drink. He was actually diagnosed at age 51 with what we used to consider Asperger's by a psychologist, and this was based on difficulty with executive functioning. Looking back in his history, he had a lot of hand flapping when he was younger, overstimulated by crowds, sounds, lights. He didn't have much social awareness. He would grunt, kind of zone out, speak in stock phrases when agitated. So we were treating him with fluoxetine for GAD. His OCD was, he would always check that lights were turned off before he would leave the apartment and it would get in the way of things. And he unfortunately no longer follows with us because he went into a managed care insurance, but he actually re-enrolled in college recently. And I think he identifies a lot of the challenges we see in the geriatric population with ASD. Challenges living alone, his sister had to be highly involved in making sure he paid his rent on time. Also the substance use, which was problematic, as well as the medical comorbidities. So due to advances in health policies and healthcare, the life expectancy has increased in recent years, so just specifically looking at Down syndrome. So in the 1960s, the life expectancy was eight. That was probably a lot due to the congenital heart problems. Now it's, the most recent data, it's 58. So even though people are living longer, they still have higher morbidity compared to the general population. A lot of this is due to barriers in accessing healthcare, limited opportunities for physical activity, social marginalization, and so on. The risk of psychiatric illness and age is less well studied, however. So like I said, we don't really know, are people, as they get older, are they at more risk of psychiatric illness, or do rates tend to decrease? Studies have shown both. We recently looked at the START program, which is a national crisis intervention program for individuals with IDD and mental health needs, and compared, we had over 4,000 individuals, and we compared older adults, age 50 and older, to younger adults, and found that the older adults had lower rates of psychiatric diagnoses, hospitalizations, and emergency department use, yet they were more likely than the younger cohort to take higher numbers of psychiatric medications. And this has been shown in other studies. This was a Swedish study of 600 adults with autism. Over 90% taking a psychiatric medication, but half of them didn't have any registered psychiatric diagnosis, so it's unclear what the medications are treating. And older people were less likely to see a psychiatrist. So similar to what we would do in the general population, always want to consider medical conditions. Is there an untreated sleep apnea or sleep-related breathing disorder? Do they have an infection? Are we seeing fluctuating attention because they're delirious? Is there untreated hypothyroidism? Could there be an underlying genetic condition that hadn't previously been identified? So fortunately, we can send people to the lab to identify single nucleotide polymorphisms that might be, we may find a SNP that's abnormal that could be associated with a medical condition that needs monitoring. And then some individuals may be at risk of early-onset dementia. So specifically, there's been a lot of curiosity about individuals with autism. Are they at increased risk of dementia? Studies of children and adolescents with autism have shown that they have impairments in executive functioning, processing speed, and then we know that in the typical population, as we get older, we have declines in processing speed, working memory, and executive functioning. So this has led a lot of people to wonder, are older adults with autism kind of at a double risk or increased burden of cognitive decline or dementia? And I would say that the answer is unclear at this point. The studies have shown conflicting. Some have shown that they don't have age-related declines compared to the general. Others have shown that they've got more decline in visual memory. A lot of these studies have only focused on individuals with autism without ID, so they're not generalizable. And there really haven't been many longitudinal studies, which I think is so key in this area. I will point out that last year, there was a study that looked at Medicaid claims data and found that even after adjusting for cardiovascular risk factors and psychiatric diagnoses, adults with autism under the age of 65 were 2.6 times more likely to have a dementia diagnosis than the general population. But we do know with Down syndrome, there is that clear risk of dementia, and this is due to the overexpression of amyloid precursor protein on chromosome 21. The risk is almost 50% by the time individuals are 60, and it's the leading cause of death. This is a really interesting study that looked at the order and timing of biomarker changes in a large cohort of adults with Down syndrome, and they separated the bottom graph on the y-axis looks at age, or the x-axis, and then the y-axis looked at scores on a cognitive scale specific to Down syndrome. And they found that even, so separating out mild from moderate ID, changes on scores tend to happen at about age 40, about 10 years before prodromal AD occurs. So what can we do for our families and caregivers and for us? So the National Task Group is a wonderful non-profit organization that's associated with the American Association of Developmental Medicine, and they have a lot of free resources that can help individuals with IDD who have dementia. One of the resources that I've been using, and which is free, is the Early Detection Screen for Dementia, and I just put a little sample of it here. So it is an informant-based, I'll leave it up. It's an observer-based instrument that goes through six different domains. You can see some of them here, ADLs, language communication, and so on. And it asks the informant, are they needing help with certain areas? Has this always been the case? Is it always the case but getting worse? Or is this a new symptom? Or does it not apply? And so it can take about 15 to 60 minutes to complete. The challenge is it has to be completed by somebody familiar with the adult. And given staff turnover, we may not always find that. And there was a recent study that tried to validate it in Down syndrome and found that going against kind of the gold standard of extensive assessments and cognitive evaluations, all domains were able to distinguish between adults with and without dementia. There are limitations in diagnosing mild cognitive impairment, which is kind of nebulous to begin with. But I urge everybody to look up the EDSD if you tend to see older adults. I try to give it to people with Down syndrome once they turn 40, and then other developmental disabilities age 50 and above. Okay, so I hope we have a little bit of time for any questions and comments. Thank you all for coming to our session so early. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. I'm wondering if there's any particular precautions by giving thyroid supplementations to people with Down syndromes who may have septal defects, and that's based on an experience of a family member who had Down syndrome and was in her late teens, and she got thyroid, and she was turning increasingly blue over the next few days and squatting a lot, and then dropped dead. So is there a particular risk for that? Or should they be screened for septal defects first? Can you tell me anything about precautions in that regard? Yeah, well, I'm sorry about that. I don't know medically. You said septal, like of the heart, septum of the heart. I mean, they do have a higher risk of congenital, so I would hope that they get screening for that when they're younger. I don't know the medical guidelines, but they do have higher risks of aspiration, so I'm not sure if they have aspirated. But I think that this goes to the point why primary care is so important and making sure that people access this regularly. But I don't know specifically what the guidelines are for monitoring. It was a primary care physician that started her on the thyroid, but she'd never been screened for septal defects. And I don't think he even really knew she was a Down syndrome person. Oh, really? But she was turning blue a lot, so it might have been that the thyroid was stimulating her pulse and more of a stress on the heart or something like that. Possibly, yeah, I'm sorry. Thank you. I was hoping you were gonna speak a little bit about how to diagnose psychosis in patients with ID and ASD, because I've really struggled with that, working out what's magical thinking versus delusional ideation. And do you have any tips? Thank you. So in people with, you're saying in people with autism? Yeah, probably more autism as the patients. Oh, actually, no, the patient that I struggled with is a guy with an artificial alcohol syndrome, and he's in his 20s, and I don't think he's been diagnosed with autism, but he just has this magical sort of fantasy world, which I don't think is psychotic, but other people have. Right, no, I think, well, so in any patient group, that might be a difficult distinction. So, I mean, I think about, the psychosis tends to have a natural history, right? And does it fit that, is what I go by, but it can be difficult. I don't have anything to add to that. Yeah, no, I think you're right. I think a lot of times they do have some magical thinking and kind of the idiosyncratic unique to them that probably isn't true psychosis. However, if it tends to fluctuate, just monitoring the natural history. You started a woman on respital for anxiety. Mary, I think her name was. Yeah. And when will you relook at that? A year from now, 10 years from now, six months from now? Did you understand this was a state situation for her, or did you understand that something was going on that made her anxious and she needed to be on respital for a little while? Right, so we do wanna see, is this state or trait? So I think given that it was pervasive throughout multiple environments, and we did try antidepressants and more conventional treatments at first, but she became more agitated and they weren't helpful. So generally with my patients, I see them at a minimum once every three months and address whether she needs to be on the risperidone. If somebody has continued stability for at least six months, then I'll try reducing it. But I think for her, given the autism, kind of the irritability and rigidity, the risperidone is helpful for her. And the benefits in keeping her employed and not agitated outweigh the metabolic side effects. Okay, so regarding the treatment of psychosis in IDD, the earliest age, as your slide's showing, six in that age group, compared to erythroprazole and risperidone. Erythroprazole and risperidone, the age group is six. Is it applicable both, like erythroprazole in the age group of six? Yes, so both of those have been FDA approved and studied in those young populations. In the six, age of six, like in six. Comparing these two, which evidence is more predominant compared to in that particular age group, age six, erythroprazole and risperidone? Because we know the risperidone has been approved a long time ago. And it's very proven and we are comfortable. But the age group erythroprazole, there was a hesitation to implement earliest age. But now we are seeing that earliest age, the population can receive erythroprazole. So do you have any recent? So I don't know the specifics for that population. I was really just pointing out that those, that we don't have much data in adults compared to what we have in children. I tend to, are you asking which one I tend to use? So I really, I mean it depends on the person. I find that sometimes abilify can be a little bit, or erythroprazole can be a little activating. However, if the patient is really worried about weight gain or the parents seem worried about the potency of risperidone I might try abilify first. But it really just depends on the individual. I don't know if you have a preference. I don't have a preference. I've seen a lot of people, a lot of adults, be on abilify and gain weight also. So, but we really tend to use all of the antipsychotics for the irritability in autism. And so I think about the risk benefit ratio and the side effect burden of other antipsychotics as I approach the situation. Thank you. Very helpful information. And I'm glad you have that slide up. My question is, Nudextra, have you had any experience using Nudextra for severe irritability and impulsivity in adults with intellectual disabilities? That's a great question. Somebody recently asked, a potential patient asked that, and I personally have not. More in the dementia, in the general population, I haven't had any. And I should look into that because that is coming up more. I don't know if you? I've not. Probably the one medication for the impulse control problems in autism that I think about really is propranolol. And so as a neuropsychiatrist, I recognize that propranolol has been used in traumatic brain injury, for example. Very successfully, there's some studies going on suggesting that's true also in autism. So when I think about it, I think about, is this person a candidate for propranolol? Sometimes the doses have to be quite high, but the body does accommodate to that. So that's one I would point out. I've had some success with Nudextra, but it's an expensive alternative, so it's not available to most. Thanks. Hi, good morning. Thank you for the talk. I'm curious how you incorporate assessing for trauma or abuse in this population given they're more vulnerable, but the person doing the abuse might be their caretaker who is your informant, and how that contributes to psychiatric conditions. That's a great question. Yes, trauma is a huge area. So many of these individuals have experienced more trauma than the general population. So if possible, I try to evaluate the person individually without the caregiver in the beginning just because I don't know how comfortable they are. So if they feel comfortable telling me, but you're right, it is hard, and they might not want to get in trouble, especially if they're gonna have to go home with that caregiver, so they may not tell us. All of our patients see a psychotherapist as well, and so they can assess if we're seeing changes, but you're right, that is a huge area that needs to be evaluated. So thank you for bringing that up. Okay. In the list of the different medications that were tried, guanfacine was on there, but it was down at like a 4%, or the percentages of medications tried, it was really low. I was curious, is there a reason for that, are there certain side effects that come up from the guanfacine, or it's just not tried as often? That's a good question. So I mean, yeah, I don't know this particular study why it wasn't tried as often. I mean, I think, I don't know if adult psychiatrists tend to use it that much. At least in my training, it was more on the child and adolescent world. I find it helpful. It's less sedating than clonidine, but it's not always that effective. I don't know how often you use guanfacine. Use it some. And again, I think you had mentioned it before, it's reducing impulsivity more. Yeah, I mean, I find it helpful, especially if somebody has ADHD, it can be helpful as an adjunct to the stimulants for kind of impulse control, especially the long acting formulations I find helpful. Okay, thanks. Hi, thank you for your presentation first. My question is, since we're seeing the use of antipsychotics at such a young age, have you seen any development of movement disorders such as DAP or TD? And if you have, how are you addressing that? Thank you. Yeah, I mean, so, fortunately, I think a lot of, well, many of them, the younger ones were started on second generation, so it's less of a problem, but in some of my older patients who are on like Prolixin and Haldol, they do have some TD. However, the risk benefit ratio, like I always assess, has this been controlling their symptoms? Are they bothered by the TD? And many times they're not. However, I do use vitamin E. I feel like the evidence, well, I don't have anybody on valbenazine. Actually, I did have a patient who developed pretty significant TD on risperidone. However, the risperidone really controlled his tics and extreme anxiety. And when we tried valbenazine, tetrabenazine, all of that, and it didn't help. And actually, I think a lot of the TD was withdrawal. So his parents were willing to have the TD, knowing that psychiatrically he was better controlled. I don't know if you've seen much. Yeah, I don't know the literature. It seems less than one would expect, but it does happen. And we use the range of treatments, the usual approach to the treatment of TD. Yeah. Good morning. I thought your vignettes were really helpful. So thank you. I work at a large public extended care psychiatric facility in Chicago. And we always have a handful of ID diagnosed patients at our facility, but it's not our specialty. And I always feel like we don't do as well with that population as our general population. And I just wonder if you have any pearls. I noticed that the staff gets really burnt out with the perseverativeness of the patients. And I just don't know. It's really not our background. And so we're sort of making it up as we go along. And I don't know if you have any pearls of how to deal with that specific counter-transference that occurs from the staff. That's a good point. Well, I mean, finding the right staff. Welcome to the state system. So I get what I'm given, you know, so. Yeah, so I mean, right, exactly. And training staff, training staff about behavioral interventions, planned ignoring, et cetera. Understanding the behavioral factors for behaviors. You know, what might be eliciting the behavior? What might extinguish the behavior? I find that helpful. But individuals that is staff with the right temperament is really important. Yeah, and just realizing that these people aren't doing it on purpose, the individuals themselves. So even for me, if I'm feeling like counter-transference, just realizing this is their developmental level, right? And so it's not like they're doing it on purpose. I mean, sometimes they might be, but so just trying to educate staff that like this is part of who they are or they're not doing well, they're out of their routine. And like you said, planned ignoring, rewards for when they're doing well. Right. Yeah, rewarding the behavior you want, right? And ignoring the behavior you want to extinguish. Thank you. Thank you for your talk. I'm local. I hope you guys have a great time in New Orleans. Watch our weather. It comes up quickly. It's supposed to rain tomorrow. Interesting timing. This is not my area of expertise, but I had a patient admitted yesterday to my unit at University Hospital, which is the largest teaching hospital here in town, who 70, 60 years old, on Closeril, was on Closeril for years and years and years. Previously was in the state school for the mentally retarded, which they called them here. I have two other people I've been seeing for years in Alexandria via telemedicine. It's in Alexandria, Louisiana, where the state school historically was, and a lot of people are in group homes now that were stepped down out of the state schools. But the use of Closeril in that population, and all three of them are older than 55, and have been on it for a very long time, except for the woman who fell off of it, because when they discharged her, they did not send her. They couldn't get her in to see anyone who's REMS approved for two months. So anyway, just your thoughts. Yeah, absolutely. We use Closeril in this patient population. It can have dramatic effects. I would say the biggest issue, I think, is constipation, and constipation, constipation, constipation, big problem, and can kill the patient, and that's happened. And then, of course, the other range of side effects. So a clinician who is familiar with the use of Closeril and knows how to monitor these side effects, it's very important. Yeah, I think there's a great evidence base for clozapine, and even though it's scary to start in the outpatient setting, I think it can be very helpful in treating aggression and psychosis, but again, monitoring its side effects and doing the whole REMS side effect. So I have about six or seven patients on clozapine who do very well on it, and with relatively benign side effects, as long as you're monitoring bowel movements and the sialorrhea. That's amazing, two months to get a provider for the REMS. Especially with the neurotic side effects. Right. Okay, yeah? So informed consent. This can be an area of challenge in this population. So if you're treating an individual who you think, in your clinical opinion, is not able to provide informed consent, however, either they don't have a loved one available that can be their guardian, or they do have a loved one available family member, but as we all know, guardianship is an expensive affair. So how do you document? And this gray area becomes even grayer when individual doesn't want or want certain medication, while the family member that they live with, they disagree. So how do you document, how do you protect yourself, yet at the same time, serve your patient? Yeah, you're right. So I'm trying to think how, I don't specifically document informed consent. I mean, I think, you know how in the templates, there's like, did you discuss, yes or no? And I guess I do say no if the patient can't verbalize. However, I'll try to see if there's assent, or if they're not refusing. And if somebody is refusing a medication, which hasn't happened too much in my experience, but if they are, then I tell the patient, their family and caregivers, you can't force the patient to take the medication that's unethical, illegal. And that they'll have, you know, just go back and try to see if the patient will accept it later. Unfortunately, I have had one patient I'm thinking of who no longer sees me because he just refused to take the medication. And so I just have to support the parents. And if it gets to a crisis level, unfortunately you're gonna have to take him to the emergency department, but try other interventions. And I don't know, just an area that we have struggled with in our system is that admitting individual with IDD that has a psychiatric illness that needs inpatient admission, but it's declined because they need extra staff. And they said, I will admit if they come with a sitter. And I think that that's beyond our level. And maybe we need to work at a legislative or some insurance or other benefit level where they are able to provide such sitter or assistance so that these individuals can get help that they need. So just a comment. Thank you. Sure. I'll make it quick. I realize the time, don't worry. Just a quick one on, obviously you had a very clear rationale for people over 50, under 50, medications that they're on. And I wondered about whether you're aware of any, obviously from the UK where I practice, there is a stomp program about reducing the unnecessary use of medication. And they have pharmacists come in and lots of other people to support. I'm wondering if you're aware of any programs nationally here and kind of any success rates around any safe medication rationalization programs. No, and so, yeah, the UK is so much better in this area than we are. So bravo to the UK. And you all actually call it learning disability, don't you? Yeah. And so slum, yeah. I think Deb is actually from the UK. So I'm not aware of any US efforts to reduce prescribing. A lot of what I try to apply is from the UK. So kudos to you all. All right, well, thank you guys. Thank you very much. Bye. Bye. Bye. Bye. Bye.

psychiatric treatment

intellectual disability

autism in adults

comorbidity

depression

anxiety

obsessive-compulsive disorder

suicidal ideation

bipolar disorder

medications

psychotherapy

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