Lauren Charlot, Ph.D., Karen Shedlack, M.D.
Aggressive behavior in people with mental retardation appears to present with greater frequency than in those without intellectual limitations (Rojhan, Borthwick-Dufy, & Jacobson, 1993). This observation holds true even though most people with an intellectual disability are not aggressive. A number of authors addressing the topic of aggression in individuals with developmental disabilities have suggested that aggression acts as a final common pathway for a wide array of underlying problems (Charlot, 1997; Gardner, 2000). In actuality, understanding the factors that underlie and drive aggression in persons with mental retardation is the essential tool for its management. Treatment of aggression may be most successful when it is based on a comprehensive evaluation; one in which developmental, environmental, psychosocial, medical, psychiatric and behavioral variables are identified (Charlot et al., manuscript in preparation). Developmental effects on psychiatric disorders that may be associated with aggressive behavior in people with developmental disabilities are described in Table 1. In Table 2, developmental effects on aggression are presented. In Table 3 common medical problems that may cause agitation are listed. In Table 4, functional analysis of aggressive behavior is summarized.
Aggression may represent surface features that are diagnostically non-specific, and common across a variety of conditions (Charlot, 1998; Gardner, 2000). In people with significant developmental delays, agitated and aggressive behavior may be a means of expressing frustration, a learned problem behavior, an expression of physical pain or acute medical problem, a means of communication, or a signal of an acute psychiatric problem (Charlot et al., manuscript in preparation; Gardner, 2000; Gunsett, Mulick, Fernald, & Martin, 1989; Ryan & Sunada, 1997; Sovner & Hurely, 1986). It is common for persons with mental retardation who have been stable and well adjusted to exhibit regression in situations of stress, pain, changes in routine, or novelty. Old patterns of aggression may recur or new aggressive behaviors may arise where there had previously been none. Developmental stage, changes in physical strength and size due to growth and maturation, puberty and hormonal changes, and less restrictive supervision in the context of maturation and stability may all set the stage for new issues with aggressive behavior around changes in health or environment. Aging, too, presents with changes in aggressive behavior if there is accompanying dementia, as in Down syndrome, or loss of independence and physical functioning (Cooper, 1999; Pettit, 1997). The death of parents and subsequent residential changes are important psychosocial and environmental factors that can also underlie a downward spiral into aggressive behavioral patterns.
Functional analysis of aggressive behaviors often reveals a variety learned bases for aggressive, self injurious, and other agitated behaviors (yelling, threatening, throwing or breaking objects) including: escape and avoidance of unwanted demands or situations, seeking staff attention, communication of pain or discomfort, and self stimulation (Horner, 1994). At times there may be a close relationship between an acute psychiatric condition and learned aggressive or self-injurious behaviors, such as when anxiety, depression, or mania lower the threshold at which a task demand triggers an aggressive act.
The new onset of paranoia, hallucinations, mania, depression and panic as well as worsening of rituals associated with obsessive compulsive disorder or avoidant behaviors around PTSD can each be expressed initially as irritability and aggression before the appropriate psychiatric diagnoses are made and specific treatments initiated (Sovner & Hurley, 1986). Once a person with mental retardation is treated with medications, the main effects and side effects of these various medications are often overlooked in their quite significant contribution to irritable and aggressive states. In reality, aggression is often multi-determined (Moyer, 1987). It is our position that people with developmental disabilities who display serious and persistent aggressive behavior deserve the benefit of a comprehensive, multimodal assessment and treatment planning approach. In tables 5 and 6, recommendations for comprehensive assessment and treatment of aggression are presented.
Case # 1: Billy was a 30 y/o male with Fragile X, Autistic Disorder and what appeared to be panic anxiety, who was admitted to a specialized inpatient psychiatric unit for people with developmental disabilities due to an increase in aggressive behavior. He became anxious and seemed easily overwhelmed or over stimulated in both positive and negative situations that were either exciting or chaotic. Prior treatment with antipsychotic medications, benzodiazepines, and anticonvulsants were not effective. The patient became increasingly violent, and was having multiple daily aggressive episodes, leading to frequent restraints just before his admission. His six month history of increased aggression appeared to be precipitated by loss of familiar staff in his residential program. He was started on Corgard (a medication usually used to treat hypertension that seems helpful in modulation of aggression related to over arousal states). A behavioral program was designed to provide him with a quiet space to follow along with the usual unit activities, and he followed a daily schedule with rotating activities, each 30 minutes in duration. He earned a choice of preferred items (paper products, pens) for each successful segment. It was learned the patient used to use a relaxation procedure some years before, and this was introduced to him again. Whenever he would show signs of anxiety (tense facial expression, decreased smiling, decreased response to questions, decreased focus on activities, angry statements, throwing objects), he was directed to lie down on a mat in his room. The combined therapies appeared to contribute to a successful outcome.
Case # 2: Linda was a 37 year old female with mild cognitive disabilities, seizure disorder (Lenox -Gastaut), long h/o severe aggressive outbursts, admitted to the specialized psychiatric inpatient service because of her aggressive behavior. Aggression without provoking events occurred more often when there were clusters of seizures. She had an extremely negative self-image. She lived with more independent peers in a group care situation, with minimal structure in her day. She presented with frequent somatic complaints and tended to have a very negative focus in most conversations. She told fantastic stories about past abuse that clearly never occurred (i.e. she reported her father murdered her mother), and often accused staff of harming her. On admission, she was sedated, her gait was somewhat unsteady, and she appeared depressed and irritable. She had multiple frequent somatic complaints. She had several seizures and had severe aggressive outbursts, seemingly related to a desire to engage staff. Medications at admission were: Dilantin 200 mgs and 300 qhs, Celexa 20 mgs bid, Synthroid 0.050 mgs qd just raised inpt , Risperdal 2 mgs bid, Klonopin 1 mg qam. 1.5 qhs, Lamictal 100 mgs qam 200 qhs, Colace 2 caps bid , Prevacid 30 mgs qd. Her Lamictal dose was increased while Klonopin dose was decreased. Seizure frequency was reduced, and she had a long stretch without any seizures (about 2 weeks) correlated with decreased aggression. She also responded to the high level of structure on the unit, having meaningful absorbing activity within a predictable routine. CBT (cognitive behavior therapy) techniques were successfully used. Linda seemed to be engaging staff with her somatic complaints, negative talk, threats, and aggression. She was given assignments to describe successes, positive events of the day, and positive attributes. (Previously, she would write in her journal about her problems.) She was given frequent praise and attention whenever she produced positive comments, and negative statements were ignored. She gradually became much less negative, smiled more, and greatly enjoyed attention she received for this.
Charlot, L.R. (1998). Developmental effects on mental health disorders in persons with developmental disabilities. Mental Health Aspects of Developmental Disabilities, 1, 29-38.
Charlot, L. R., Abend, S., Silka, V., Kuropatkin, B., Bolduc, M., Garcia, O., & Foley, M. A short-stay inpatient psychiatric unit for adults with developmental disabilities. manuscript in preparation.
Charlot, L. R. (1997). Irritability, aggression, and depression in adults with mental retardation: A developmental perspective. Psychiatric Annals, 98, 190-197.
Cooper, S. A. (1999). The relationship between psychiatric and physical health problems in elderly people with intellectual disability. Journal of Intellectual Disabilities Research, 43, 54-60.
Gardner, W. (2000). Understanding challenging behaviors. In D. M. Griffiths, W. I. Gardner, & J. A. Nugent (Eds.), Behavioral supports: Individual centered interventions, a multimodal functional approach (pp. 7-16). Kingston, NY: NADD Press.
Gunsett, R. P., Mulick, J. A., Fernald, W. B., & Martin, J. L. (1989). Brief report: Indications for medical screening prior to behavioral programming for severely and profoundly mentally retarded clients. Journal of Autism and Developmental Disabilities, 19, 167-172.
Horner, R. H. (1994). Functional analysis: Contributions and future directions. Journal of Applied Behavioral Analysis, 27, 401-404.
Moyer, K. E. (1987). Violence and aggression. New York: Paragon House.
Pettit, G. S. (1997). The developmental course of violence and aggression. Psychiatric Clinics of North America, 20, 283-296.
Rojhahan, J., Borthwick-Duffy, S. A., & Jacobson, J. W. (1993). The association between psychiatric diagnosis and severe behavior problems in mental retardation. Annals of Clinical Psychiatry, 5, 163-170.
Ryan R. & Sunada, K. (1997). Medical evaluation of persons with mental retardation referred for psychiatric assessment. General Hospital Psychiatry, 19, 274-280.
Sovner, R. & Hurley, A. D. (1986). Four factors affecting the diagnosis of psychiatric disorders in mentally retarded persons.The Habilitative Mental Healthcare Newsletter, 5, 45-49.
For further information:
Dr. Lauren Charlot
P.O. Box 784
Wrentham, MA 02093