Identifying Behavior Problems vs. Medical Issues
If my child has a new "behavior problem," are there medical causes we should rule out first?
This is a common question that concerned parents often have for their medical and mental-health providers. For a child or adult with Down syndrome who also has an additional "behavioral problem," a doctor will typically complete a number of baseline tests in order to rule out associated medical conditions. Among these, we recommend considering the following:
--Thyroid-function tests can be completed by the primary care provider or by a developmental and behavioral pediatrician or even by a psychiatrist as part of an initial assessment.
-- Sleep-related difficulties need to be evaluated by the primary care provider, developmental-behavioral pediatrician, or psychiatrist as part of an initial assessment, with referral to a sleep-disorders clinic or laboratory as needed, to rule out obstructive sleep apnea. (See further discussion below.)
-- Underlying contribution of constipation or other bowel difficulties also need to be ruled out by the primary care or developmental-behavioral pediatrician, with interventions as necessary and with possible referral to a nutritionist for counsel. This is a great opportunity to use healthy diet as a tool to reinforce positive behaviors.
As part of the comprehensive checklist of potential medical conditions, it's also important to make sure that the child or adult with Down syndrome has been evaluated for hearing (audiology) and vision (ophthalmology) problems, anemia (hematology), and GERD (GI). Finally, in addressing any of the potential medical concerns in the context of treating a "behavioral problem," consider the following caveats:
-- Emotional and behavioral problems in children and adults with Down syndrome occur commonly and are not always due to an underlying medical condition. Nevertheless, to obtain a comprehensive assessment, these medical conditions associated in people with Down syndrome need to be ruled out.
-- The medical conditions, even if they may in themselves not cause the emotional or behavioral problems, may nevertheless exacerbate them, or make the person with Down syndrome resistant to treatment of the problem.
-- Correction of a medical condition such as hypothyroidism may not remove the underlying emotional or behavioral issues, which may still need to be treated concurrently. Therefore, a child or adult with hypothyroidism plus depression is unlikely to respond to treatment of depression with antidepressant medication alone, unless the hypothyroidism is also corrected. In other words, there is an "interaction" between the medical and the emotional and behavioral conditions.
What are the symptoms of generalized anxiety, OCD, and depression in Down syndrome? How are they diagnosed and treated?
Anxiety is the most prominent issue among children and adults with Down syndrome. It manifests as an increased level of both baseline and situational anxiety, with clear-cut stressors for each. Situational anxiety is often apparent during transitions and anticipation of new situations, such as transitions from home to school; during transit and at mealtime or bedtime; as well as in unfamiliar situations where the environment creates uncertain expectations.
Increased levels of restlessness and worry may lead the child or adult to behave in a very rigid manner, even resulting in a state of being "stuck," as is often reported by caregivers; in these situations, the child or adult needs to follow familiar routines. The child or adult may also engage in repetitive, compulsive, and ritualistic behaviors that raise the question of obsessive-compulsive disorder. Under these circumstances, the person with Down syndrome tends to be unhappy or fearful. The two states -- generalized anxiety and obsessive-compulsive behaviors -- can often coexist. The disruptive, oppositional, and inattentive child with Down syndrome may not be unhappy, but rather quite silly, happy, and excited. The problems are challenging for caregivers to navigate, because the person with Down syndrome with generalized anxiety or an obsessive-compulsive profile has a tendency to become stuck, which requires a great degree of negative attention. The attention, in turn, reinforces the difficult behavior, creating a vicious cycle.
Differentiating Anxiety and ADHD Symptoms in Young Children
The restlessness, fidgeting, and compulsiveness associated with a state of generalized anxiety have an identifiable onset with a more intermittent course (in contrast with the behavior of children or adults who have an impulsive, oppositional, and attention-deficit profile). It's important to take a detailed history in all these situations in order to identify the source or environmental triggers that contribute to the anxiety -- for instance, changes in the immediate home, school, or work environment. In such circumstances, assessment of antecedents, behaviors, and consequences (ABCs) and development of a behavioral-modification and management plan are essential. The use of antidepressants or anti-anxiety medications may help, although it should be reserved for a more persistent and serious level of symptoms.
Children and adults with symptoms of depression often show signs of extreme social withdrawal, a feeling of sadness, and an inability to enjoy many activities they used to love. Parents or caregivers often report that these signs are a change from the person's previous demeanor. People in a state of depression or anxiety also commonly have disrupted sleep, which can make it hard to distinguish between the states. A remarkable aspect of depression in people with Down syndrome is its association with noxious environmental triggers. These may include a previously unrecognized medical illness or pain or psychosocial stressors, such as an older sibling moving to college, a sudden or chronic illness in a family member, the death of a beloved household pet, the absence of a teacher (for leave or illness). All these ordinary events seem extraordinary for children and adults with Down syndrome; they have a disproportionate psychological impact, compared with the response of a typical person under similar circumstances.
In summary, people with Down syndrome remain exquisitely sensitive to changes in their environment, which they often perceive unfavorably. Families that anticipate any upcoming negative changes should make sure that supportive counseling services are in place ahead of time to reduce their impact. Without such individual support, it's often futile to attempt to treat persistent depression pharmacologically in the context of ongoing stress. The best course is treatment that combines both psychosocial and pharmacological components. The argument for pharmacological intervention is strengthened if the person with Down syndrome is deemed to already have a biological vulnerability (such as a positive family history, previous episode of depression, or concurrent medical illness).