Other Mental Health Issues Related to Down Syndrome
What are the inattentive, impulsive, hyperactive, and disruptive behaviors in people with Down syndrome? How are they diagnosed and treated?
Children and adults with Down syndrome often have significant processing challenges and remarkable difficulty in keeping their attention on tasks. In children with a greater deficit in cognition and receptive-expressive language, especially children in younger age groups, the attention deficit is often accompanied by impulsive and hyperactive behaviors. This pattern of inattention, impulsivity, and motor hyperactivity is consistent with a diagnosis of Attention Deficit Hyperactivity Disorder. For this reason, many children with such characteristic behaviors are treated with stimulant medications.
The response of children and adults with Down syndrome has not yielded encouraging results. In a sub-population of children and adults with Down syndrome, there is a definite adverse behavioral activation in response to these medications. The most commonly observed adverse effects include irritability, agitation, aggressive behaviors, transitional anxiety, and sleep-related problems. Parents or caregivers need to be forewarned about these adverse effects because they can occur very soon after treatment begins and can be very troubling for them to witness. A small group of children with ADHD symptoms may nevertheless benefit from stimulant medications, but even for them, their anxiety and obsessive-compulsive symptoms may increase. For this reason, treatment of ADHD-like symptoms needs to focus on behavioral and therapeutic strategies to enhance adaptive functioning and performance in the home and classroom settings.
For children with a high-degree of impulsivity and disruptive behaviors, low doses of clonidine have been helpful, but this medication may also be limited in its efficacy because it may lead to daytime drowsiness in some children. It's important to note that the use of clonidine can be effective only in addressing impulsive, hyperactive, and disruptive behavior, and it does not necessarily improve primary attention. Clonidine administered at bed time may also help the child to settle down to sleep.
What are the behavioral concerns commonly associated with chronic sleep difficulties? How are they assessed and treated?
Children and adults with Down syndrome commonly experience a range of sleep-related difficulties either as a primary sleep disorder or as associated with mental-health problems (such as generalized anxiety and mood disturbances). Whatever the cause, sleep difficulties impair the ability of a person with Down syndrome to maintain alertness and attention during the day, and to tolerate frustration. Chronic sleep difficulties in people with Down syndrome need to be evaluated thoroughly by an interdisciplinary team in order to rule out any contributing medical conditions.
Children and adults with Down syndrome, in particular, are at increased risk for development of obstructive sleep apnea with mild to moderate cessation of breathing during sleep that leads to a reduction of oxygen saturation in the blood. If the person's history includes evidence for periods of daytime sleepiness or fatigue, a diagnosis of sleep apnea may be in order. To confirm this diagnosis, however, it is necessary to conduct further tests at a sleep-study or sleep-disorder lab (often available in major medical centers).
What are major environmental triggers of behavioral and emotional difficulties?
Children and adults with Down syndrome are often exquisitely sensitive to psychosocial and environmental stressors. Illness or loss of close loved ones or family is particularly devastating and almost invariably leads to a complicated grief reaction; during this time, the person with Down syndrome may experience regressive change in his ability to think, reason, remember, process information, and learn. The psychosocial and environmental triggers also lead to a state of generalized anxiety, obsessive-compulsive symptoms, and depression and sleep difficulties. They may be associated with weight loss, poor self-care, and inability to be motivated to attend school or go to work placements. If the situation persists and there is no concerted attempt to intervene with psychosocial counseling, treatment with appropriate medications, and behavioral interventions, then the mental state may persist and be associated with longer- term decline in psychosocial and cognitive functioning.
Is oppositional defiant disorder common in children and adults with Down syndrome?
Many children and adults with Down syndrome have a wonderful disposition: They are fun-loving, and their interactions generally involve teasing and making jokes. Their giggly outbursts, however, can also lead to intrusive, uninhibited social behaviors. Their exuberant behavior sometimes becomes out of control and dominates the overall interaction. They can become increasingly oppositional, unable to listen, and markedly single-minded and self-immersed. They might, for instance, sit or lie down and refuse to get up. Or, during transitions or at mealtime, bath time, or bedtime, they might continue in a self-directed activity with disregard for the consequences. The oppositional behaviors occur in individuals with all levels of cognitive and language skills, but it's more difficult to manage in those with greater receptive-expressive communication skills. In the classroom setting, behavioral management and one-on-one help may keep the situation in control. Oppositional behavioral problems in children with receptive-expressive and cognitive limitations also tend to be associated with increased level of impulsive and hyperactive behaviors and often occur alongside ADHD symptoms.
Are mood and bipolar disorders common in children and adults with Down syndrome?
It's important to take a comprehensive approach when assessing a person with Down syndrome who also shows signs of mood instability. It's essential to rule out any underlying medical and neurological conditions, and especially to consider the possibility of adverse effects of medications that may lead to secondary mood instability.
A young child with Down syndrome who exhibits persistent oppositional, impulsive, disruptive, irritable, and aggressive behaviors may have a mood disorder. In our clinical experience, the coexistence of true bipolar disorder and Down syndrome is relatively unknown. The use of anticonvulsant medications (as mood stabilizers) should be considered only under careful supervision. Likewise, the use of atypical neuroleptic medications ought to be considered only as a last resort -- again, with careful monitoring of potential side effects. These latter medications tend to be limited in efficacy and should be used sparingly and in low doses. Because children and adults with Down syndrome are already at increased risk of weight gain over their lifetime, the increased appetite leading to weight gain associated with atypical neuroleptic medications can be destabilizing. Concurrent behavioral and nutritional interventions are therefore always essential.
Are we entering a new age with improved assessment of mental-health concerns in children and adults with Down syndrome?
The assessment of mental health concerns in children and adults has improved considerably in recent years. There is now a wider range of available screening and diagnostic tools for assessment of mental conditions in different age groups. We can better measure nonverbal problem-solving abilities, language and communication, and adaptive and behavioral functioning. Much of our current knowledge is based on clinical experience. Emphasis varies depending on the orientation of each provider -- behavioral modification, pharmacological intervention, and social-skills training -- and parents would be wise to seek a holistic philosophy for integrated care.
Despite the fact that many individuals with Down syndrome experience significant cognitive delays and other associated physical conditions, they have a very wide range of abilities, and each individual develops at her own pace. Even though they may be delayed in their progression, many achieve meaningful developmental milestones and lead enjoyable and highly enriching lives. There is a need to conduct more research in the mental-health aspects of Down syndrome, but the increased awareness of the mental-health issues bodes very well for the future.
Originally featured on National Down Syndrome Society (NDSS.org) and reprinted with permission. Copyright ? 2012 Meredith Corporation.