Narrative overview of systematic reviews and meta-analyses: evidence on many treatments for psychopathology in people with developmental disabilities is limited
Question: What treatments are effective for psychopathology in people with developmental disabilities?
Outcomes: Effect of treatments for psychopathology.
Design: Narrative overview summarising systematic reviews and meta-analyses.
Data sources: Not stated.
Study selection and analysis: Systematic reviews and meta-analyses of pharmacological, psychosocial and other treatments for people with intellectual disabilities (ID), autism or developmental disabilities (DD) were included.
Applied behaviour analysis
The author reports that meta-analyses have found applied behaviour analysis (ABA) to be effective or promising for pica, fear, phobic avoidance and self-injurious behaviour, and to be an evidence-based practice for maladaptive behaviour and psychiatric disorders in people with mild disabilities (study types included in these analyses were not reported). One systematic review assessing treatments for phobic avoidance for people with ID was described, which did not find any randomised controlled trials (RCTs) meeting inclusion criteria. No formal systematic reviews or meta-analyses of behavioural treatment for psychotic behaviour or depression in people with DD were identified. Other non-drug interventions: sensory integration therapy was not found to be effective in one meta-analysis of ‘well-controlled studies’ (population not stated). One systematic review identified only a few, poor quality, studies of Cognitive Behavior Therapy for anger management. Two meta-analyses of music therapy in children and adolescents with autism were reported to have conflicting results. Pharmacotherapy: a recent systematic review (search date 2010, 33 RCTs) assessed RCTs of psychotropics in children and adolescents with Autism Spectrum Disorders. They rated studies as strong, adequate or weak, and the overall evidence as ‘established’ (at least two strong studies or at least four adequate studies), ‘promising’ (a least two adequate studies) or ‘preliminary’ (at least one adequate study). The review concluded that there was ‘established’ evidence for three atypical antipsychotics: aripiprazole, risperidone and haloperidol. Aripiprazole reduced irritability, hyperactivity and stereotypy; risperidone reduced irritability and hyperactivity, and haloperidol improved behavioural symptoms. ‘Promising’ evidence was found for methylphenidate for hyperactivity in this population, and ‘preliminary’ evidence for risperidone repetitive behaviour and stereotypy, atomoxetine and naltrexone for hyperactivity, and pentoxifylline. A second systematic review of second generation antipsychotics (SGAs) for non-psychotic disorders in children and adolescents suggested that there was maintenance of effects for up to 12 months’ open-label treatment after the RCTs, but the relapse occurred after medication was stopped. The author also describes a recent meta-analysis (31 RCTs, four in children and adolescents) assessing the negative effects of SGAs. It was found that side effects of SGAs included weight gain, increased risk of diabetes, changes in thyroid function and risk of changes in sexual functioning. A series of systematic reviews examining psychotropics in people with ID were found, but their results were not summarised in the review.
The author concludes that current research supports ABA for some forms of psychopathology, and there is some preliminary evidence for psychopharmacology in people with ID, DD or autism, but evidence is limited.
The methods used to perform the overview are not stated. The abstract above focuses on meta-analyses and systematic reviews described in the overview. The populations and study types included in the systematic reviews or meta-analyses were not always stated.
The context of this paper by Sturmey is the assessment of current treatment options for persons with intellectual disability (ID), who evince psychopathology. This critical review of evidence-based literature is both timely and important, since these emotional disorders occur at much higher rates (four to five times) among persons with ID compared to the general population. This work updates previous reviews performed on the topic. And, as the author points out, the biggest disappointment is the relative paucity of published studies compared to the work with other populations. Additionally, and equally disappointingly, little progress has been made in the last decade. It appears that much of the clinical practice in this area has been bootstrapped from the general literature. This approach is far from adequate, and more treatment research related directly with the ID population continues to be a major problem, and need.
The focus of the paper is to speak directly to the clinicians, but it is hard to say if Sturmey's words of wisdom will improve clinical practice. However, a positive and growing trend in the literature is a focus on underscoring how important it is for clinicians to adhere to evidence-based methods. This task can be daunting, given the constant drumbeat of often unsubstantiated talking points emanating from advertising and the internet. Having said that, the methods and procedures noted are ones that are very feasible and can be implemented in practice. The biggest limitations currently are the need for more and better treatment strategies, and more professionals who are trained to work directly with the mental health needs of persons with ID.
The information in this article is accurate and up to date. Professionals working in this area of mental health practice should find this article helpful both as a primary and secondary source regarding evidence-based treatments for the mental health needs of persons with ID.