Deprescribing in Patients with Intellectual Disability

June 1, 2025

Current Issue, Psychotherapy Rounds

by Larrilyn Grant, MD, MS; Kari Harper, MD; and Julie P. Gentile, MD, MBA

All authors are with the Department of Psychiatry at Wright State University in Dayton, Ohio.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.

Innov Clin Neurosci. 2025;22(4–6):29–37.

Department Editor

Julie P. Gentile, MD, is Professor and Chair of the Department of Psychiatry at Wright State University in Dayton, Ohio.

Editor’s Note

The patient scenarios presented in this article are composite cases written to illustrate certain diagnostic characteristics and to instruct on treatment techniques. The composite cases are not real patients in treatment. Any resemblance to real patients is purely coincidental.

Abstract

The prevalence of mental illness in individuals with intellectual disability (ID) is higher compared to the general population. Persons with ID typically have insufficient coping skills and fewer systems of natural support; they are often more vulnerable to stress. There is evidence that level of intelligence is not a sole indicator for appropriateness for psychotherapy, and that the full range of mental health services help improve quality of life for patients with ID. Polypharmacy is more common in patients with co-occurring ID and mental illness. It is common for patients with ID to be prescribed multiple medications for both physical and mental health conditions. In addition, when patients are discharged from state-operated institutions to the community, it is common for them to continue taking the same number of medications. This article will review the use of adapted psychotherapy in patients with ID, as well as deprescribing protocols to address polypharmacy.

Keywords: Intellectual disability, psychotherapy, deprescribing, off-label prescribing, polypharmacy, cardiometabolic side effects, extrapyramidal side effects, pharmacologic treatment

Intellectual disability (ID) is a condition marked by significant limitations in both intellectual functioning and adaptive behavior, encompassing many everyday social and practical skills.¹ This disability originates in childhood and is associated with a score two standard deviations below the population mean on intelligence testing (below 70). ID is a preferred term, but the condition is also referred to as Intellectual Developmental Disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).¹

A significant proportion of adults with ID—ranging from nearly 40 percent to over 90 percent—are prescribed psychotropic medications, with antipsychotics being the most commonly used, at rates between 13 and 80 percent.² However, despite their widespread use, the clinical rationale for prescribing psychotropic medications is often ambiguous, frequently lacking proper documentation of specific symptoms or diagnoses. It is important to note that many practice guidelines emphasize that psychotropics, specifically antipsychotics, should not be used unless other nonpharmacological approaches have been tried and found ineffective.³ A systematic review and meta-analysis has found no difference in efficacy of pharmacological and nonpharmacological interventions for challenging behaviors in people with ID.⁴

It is important to remember that self-report of side effects by persons with ID are commonly compromised by limited communication skill sets. It is estimated that 20 percent of individuals with ID experience adverse side effects. Scheifes et al⁵ found that 84.4 percent of individuals with ID taking psychotropic medications experienced at least one adverse event, and nearly 50 percent experienced multiple adverse events and evidence of increased risks associated with polypharmacy. Metabolic, pharmacodynamic, and pharmacokinetic alterations in the ID population might be secondary to variations in the central nervous system.

Polypharmacy is typically defined as the prescription of five or more medications. However, it also refers to the prescription of medications that do not have a specific current indication, that duplicate other medications, or that are known to be ineffective for the condition being treated. In other words, polypharmacy is the use of multiple medications that are unnecessary and have the potential to do more harm than good.⁶

In general, patients at risk for polypharmacy are older than 62 years of age, have comorbidities, have multiple prescribers and/or pharmacies, self-treat with over-the-counter medications, and have a history of hospitalizations.⁶ Polypharmacy often begins when a medication causes an adverse drug event, leading to additional treatment, which causes an additional reaction, and the process continues. The probability of harm increases exponentially with each medication. All medications have potential negative consequences.

Published manuscripts show that the percentage of participants among whom antipsychotics were discontinued totally has increased in recent years from 25 to 33 percent in 1996 and 2000 to 44 to 61 percent in 2014 and 2018;⁷ however, restarting of medication remains common.⁸

The purpose of this article is to review key principals when deprescribing medications in this population and important psychotherapeutic techniques that can make this process more successful.

General Principles of Deprescribing in ID

To avoid polypharmacy at the onset of treatment, medications should be based on the most specific and accurate psychiatric diagnosis possible. Currently, there are no best practices yet for ID, and expert consensus guidelines are needed. When pharmacological treatment is warranted, especially in children and older adults, starting doses of medication should be lower, and doses should be increased at slower rates. It is important to re-evaluate the use of medications at regular intervals; it is preferred that laboratory monitoring and screening for movement disorders not be abbreviated but rather should be conducted earlier and more frequently versus the general population. It is also important to remember that some antipsychotics and antidepressants lower the seizure threshold, which is a concern in the ID population given the increased prevalence of epilepsy.⁹

Deprescribing of psychotropic medications should be considered if 1) treatment is ineffective, 2) there are unacceptable adverse effects, 3) discontinuation is requested by the patient/family/other physician’s office, 4) target symptoms have resolved, and/or 5) the medication is no longer required.¹⁰

The process for deprescribing is as follows and is summarized in Table 1.¹¹ The first step in deprescribing is medication reconciliation, often centered around a thorough review. Instruct the patient to bring all of their medications (including prescription drugs, over-the-counter medications, and supplements, such as vitamins and minerals) to a visit and have your nurse or medical assistant take a medication history. The information collected, including which medications the patient is actively taking, what regimen is being followed, and whether the patient has experienced any side effects, should be documented in the patient’s medication list in the electronic health record. The physician should compare the current and future benefits and risks of each medication and then identify the medication with the lowest benefit-to-harm ratio and minimal risk of withdrawal or decompensation to taper first. A discontinuation plan should be carefully developed with close follow-up and monitoring. Deprescribing tools can be found in Boxes 1 and 2.^6,12

Recent studies have demonstrated that deprescribing neuroleptics in adults with ID is often successful, with up to 61 to 74 percent achieving complete discontinuation and approximately 50 to 83 percent experiencing a significant dose reduction.^13,14

In most cases, discontinuing antipsychotics or dose reduction will improve the person’s quality of life (QoL) by reducing medication-related adverse events.^7,15 Examples of increasing the QoL of individuals with ID include weight loss upon withdrawal from antipsychotics and less sedation, leading to the patient being more active, engaged, and interactive. Optimization of the medication regimen might also improve their chance of independent living, autonomy, and community inclusion, as well as increased access to programming, educational, and employment opportunities.

However, deprescribing of psychotropics, particularly antipsychotics, is not without risks. It is possible that it can precipitate challenging behavior. There is a possibility that the behavior change might not be directly related to the medication changes, but rather part of the usual pattern of cyclical changes in the mental health symptoms. In some cases, an additional underlying psychiatric disorder might be revealed. Also, withdrawal side effects, such as agitation, insomnia, and extrapyramidal symptoms, can lead to decompensation in mental status.⁷

These possibilities should be assessed thoroughly rather than reinstating psychotropic medication as a reactionary measure. It is common for caregivers and direct support professionals to be anxious about the possible recurrence of previous agitation and aggression, leading to over-reporting and exaggerated perception of the behaviors. This is called the nocebo effect.¹⁶ Psychiatrists must keep this important possibility in mind while considering deprescribing. Educating and involving caregivers and patients throughout the process will help with shared decision-making, improve the therapeutic alliance, and assistance in alleviation of the caregiver’s anxiety.¹⁷

Finally, a full range of mental health and other services can be utilized to help improve mental health symptoms and QoL for patients with ID. Although historically it was believed that individuals with ID could not benefit from psychotherapy, research produced in the past 20 years has demonstrated definitively that this is not the case. It is now understood that the efficacy of treatment improves dramatically when modifications are made to traditional treatment interventions so that the service delivery matches the developmental and cognitive needs of the patient.¹⁸ Psychotherapy, in addition to numerous other nonpharmacological interventions, is critically important during and after the deprescribing process.

Practice Point 1: The Value of Rapport and Communication

Experts in the field have emphasized the critical importance of a strong therapeutic alliance between the prescriber, the patient, and their support team.¹⁹ Specifically, patients and their support team should be provided clear information regarding indications for each medication, as well as any related risks, benefits, and potential side effects. For patients with ID, it is particularly important to discuss the possibility of withdrawal dyskinesias with caregivers, ensuring they are equipped to monitor, observe, and report any relevant signs and symptoms.

An interactive discussion is essential to the discontinuation process, addressing why the current medication and dosage is no longer indicated while providing detailed information about the deprescribing process. Physicians must demonstrate reliability, accessibility, and strong interpersonal skills to establish trust with both the patient and their support team. This trust is vital for successfully navigating medication withdrawal. The physician should remain available to address questions, concerns, withdrawal effects, or the recurrence of symptoms, ensuring ongoing support throughout the process.

de Kuijper et al¹⁹highlighted the importance of peers, family, and direct support professionals. Patients with ID have great variation in their personal coping skills, resilience, and internal resources, making individualized support a crucial factor for success. de Kuijper et al¹⁹ also reported that promotion of feelings of self-confidence and self-efficacy regarding management of their health and medical decisions should be encouraged and will promote successful deprescribing of inappropriate chronic medications. The engagement of support personnel is especially critical, as their role in fostering these positive outcomes cannot be overstated.

Clinical Vignette 1

Roger was a 45-year-old male patient with a past medical history of mild ID, attention deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), and aggression who presented to the clinic with his caregiver, Carrie, to see Dr. P. He had been seeing Dr. P for several years for medication management and had also engaged in behavioral therapy. He was in a day program and had a mentor who took him out several times per week to various social events. He had a history of aggression that had been stable for the past 6 to 12 months. His hemoglobin A1c had been increasing, and his cholesterol was slightly elevated. He was currently on methylphenidate, risperidone, sertraline, and guanfacine. Dr. P talked about potentially trying to decrease his medication at the last appointment.

Dr. P: Hello, Roger. It is great to see you. How are you doing?

Roger: Really good. I got promoted at my day program.

Dr. P: Congratulations! That is great to hear! I am glad you have been doing well.

Dr. P confirmed that Roger’s mood, aggression, sleep, and appetite had all been stable through talking with Roger and Carrie.

Dr. P: I know we talked at the last appointment about how if things continued to go well, we could try to decrease your risperidone. How does that sound to you?

Roger: Okay, but will I feel weird or get into trouble?

Dr. P: That is a great question, Roger. First, I want to talk about why we would like to try to decrease the risperidone. You were originally on this to help with some of your behaviors, like aggression. However, you have made great progress and worked so hard in therapy, so I do not think we need it anymore.

Roger: I would like to take less medication, and I have been doing good.

Carrie: You have been doing great, Roger!

Dr. P: I agree! I am worried if you are on the medication for a long time, it could lead to side effects such as movements in your body you cannot control, weight gain, or high blood sugar.

Roger: Those don’t sound good. I don’t want that to happen.

Carrie: What should we watch for as we reduce the medication?

Dr. P: That is a very important question. Sometimes when we reduce this type of medication, patients might notice abnormal movements in their bodies like face or arm twitching. They may have trouble sitting still or feeling uncomfortable. I would want you to call right away if you notice any of these things.

Carrie: We can definitely call if any of that happens. How long will it take to get him completely off?

Dr. P: We will go very slowly. It will take several months and will depend on how Roger feels.

Roger: What if I get mad or upset again?

Dr. P: That could happen, Roger, and it is OK to feel upset or mad. We will continue to work together to work through these feelings. It is important to keep using the skills you’ve developed the past few years, like taking breaks, talking about your feelings, and doing something relaxing if you start to feel angry or upset. Carrie, it might help Roger to have a list or pictures representing coping strategies he finds helpful, and staff can help him remember to use those techniques.

Carrie: Okay, we can work on that. How else can we support Roger, so we all feel more confident as the medication is reduced?

Dr. P: Excellent question. Roger, you have done great managing your life and health and shown how capable you are. We will talk about each step before making any changes and ensure that you are in agreement with the changes. I will also check in regularly to make sure everything is going smoothly.

Carrie: So, we should talk to Roger about each medication change?

Dr. P: Absolutely. Involving Roger in the decision-making process is key. It’s his body, and he knows himself best.

Carrie and Roger nod in agreement.

Roger: What if I start getting in trouble again?

Dr. P: We will figure out the next steps together. We can always stop the taper and even go back up if we need to. This is about finding what is best for you.

Roger: Do you promise you will help me if I don’t like how I feel?

Dr. P: Of course, Roger. We are a team, and you will never be alone in this. Carrie is also here to help and make sure we are always communicating. I would like to go over the plan one more time and signs to look out for. Remember Roger, we are in this together and I want you to feel your best.

Roger: Thanks, Dr. P. I feel less nervous now.

Dr. P: I am glad to hear that. We will take it one step at a time.

Practice Point 2: Overcoming Barriers to DePrescribing in ID

For patients with ID, their supported residential setting and direct support professionals play a pivotal role in their QoL and overall functioning. Optimizing medication regimens in this population can be a complex but worthwhile endeavor, significantly enhancing overall health and wellbeing. However, some prescribers can feel insufficiently equipped to lead such efforts and might benefit from consulting psychiatrists with expertise in this area. Additional challenges can include high staff turnover, incomplete or missing medical documentation, and resistance from caregivers to tapering or discontinuing medications.

Recent studies, such as one by Kleijwegt et al,²⁰ have explored the perspectives of support staff regarding antipsychotic use in this population. Many staff members view these medications as effective for managing challenging behaviors, and they tend to be more optimistic about dose reductions rather than complete discontinuation. Addressing these barriers requires careful planning and collaboration to ensure a successful outcome.

A systematic review of the literature on deprescribing antipsychotic medication for challenging behavior found mixed outcomes.¹⁴ While a significant proportion of patients successfully reduced or discontinued their medication, an equal number experienced adverse effects or decompensation necessitating represcription. In some cases, antipsychotics were reintroduced at even higher doses. The authors emphasized that decisions to taper or discontinue psychotropic medications must be carefully tailored to each individual, considering their unique needs and circumstances.

The process of deprescribing antipsychotic medications is not always successful.²¹ Beumer et al²¹ identified several potential reasons for this:

Behavioral symptoms can be subjectively interpreted by caregivers, family members, and other professionals, influencing treatment decisions;

Some people with ID have valid clinical indications for antipsychotic treatment; and

Withdrawal symptoms following long-term antipsychotic use can complicate the clinical presentation, making it challenging to assess the underlying condition.

These complexities highlight the need for a multidisciplinary approach, clear communication, and robust support systems to optimize the process of deprescribing antipsychotic medications in individuals with ID.

Clinical Vignette 2

Rosie, a 45-year-old female individual with moderate ID and MDD, presented to the clinic with her caretaker, Bella. She had been decreasing her aripiprazole for the last two weeks, and her caretakers were concerned her mood might be worsening.

Dr. E: Hello, Rosie and Bella. How are you doing today?

Rosie: Great!

Bella: Well, we are OK, but we are concerned that Rosie is starting to become more depressed again.

Dr. E: I am glad you came in, as I know we have been decreasing your aripiprazole. Rosie, you said you are great. Have you noticed any changes?

Rosie: I’m not sure.

Dr. E: Bella, what have you and other staff noticed?

Bella: I have been out of town recently for family matters, and she has a new caretaker in the home, Jen. Jen tells me Rosie doesn’t talk very much and stays in her room. I just got back a few days ago and haven’t noticed too much of a difference. (Smiling) Rosie was happy to see me!

Dr. E: I am glad Bella and Jen are both looking out for you, Rosie. Have you noticed yourself not talking as much?

Rosie: No.

Bella: Even when I am there, she doesn’t always talk a lot unless spoken to or if we are out doing something. Sometimes she gets excited about things.

Dr. E: I am glad you brought that up, Bella. I think it is going to be important to make sure we know how Rosie interacts when she feels her best and what differences we should look out for. Does that make sense?

Rosie: Yes.

Bella: Yes, I think that is a good idea, especially since different staff work with her at different times of year. How do we do that?

Dr. E: That is a great question. There are several ways. One way is through a daily monitoring tool. You could utilize an app in which caregivers can log Rosie’s mood, sleep, problematic behaviors, and context. You also could create a spreadsheet that you can share among all Rosie’s caretakers. Would it be alright if I share an example sheet?

Bella: Yes, please.

Dr. E shares a chart with the following information:

Mood (eg, happy, neutral, sad)
Aggression (frequency and severity using a 0–3 scale)
Triggers/contexts (what happened before the mood or aggression episodes?)
Recommendations for implementation:
- Use clear descriptors for each rating point to ensure consistency among caregivers.
- Combine mood tracking with event tracking (eg, noting sleep, environment, or triggers).
- Choose tools with visual representation (eg, graphs) to help caregivers and clinicians identify patterns easily.

We should track her mood, problematic behaviors, and context of the situation; who is around, what is happening, and changes to routine are important. The chart should be explained to all caregivers so that there is consistency in how they are tracking.

Bella: That looks simple enough. We will try this. I can also type some information about Rosie and her baseline for all staff to get to know her better. I think some of the staff are concerned about her behaviors knowing she is reducing the medication.

Dr. E: That is a great idea. I definitely hear their concerns about wanting to make sure Rosie feels her best as we decrease the medication, and I want them to know that we value their input. As they record what they are seeing every day on this spreadsheet, we can use it to make sure we are doing what is best for Rosie. I want to follow-up in a month and see how things are going.

The care team determined that Rosie was a little quieter and had a few more aggressive outbursts when new caregivers were present; however, as the care team became familiar with Rosie, they realized these behaviors were much less frequent than originally thought. They paused the taper of aripiprazole until Rosie became accustomed to her new caretakers, then resumed the taper. With the spreadsheet and baseline description, the team felt more comfortable documenting Rosie’s behaviors, and she was successfully able to reduce her dose of aripiprazole.

Practice Point 3: NonPharmacological Treatment Interventions

Addressing the underlying condition—whether it is a medical illness, social situation, grief or loss, psychiatric disorder, or another issue identified through a biopsychosocial assessment—is critical to achieving targeted and effective treatment outcomes.⁹ Nonpharmacological interventions, often recommended as the first line of treatment for challenging behaviors in adults with ID, offer significant advantages and long-term benefits when appropriately applied.^3,22,23 Although the literature on the role of nonpharmacological interventions in deprescribing is limited, it is reasonable to conclude that combining these approaches with the aforementioned strategies could enhance the success of deprescribing efforts.

Psychotherapy. Psychotherapy is effective for individuals with ID, provided that treatment protocols are adapted to meet their specific needs (Box 3).^18,24 This flexibility allows for better engagement and outcomes. Concerns regarding difficulties with abstract thinking in cognitive behavioral therapy (CBT) can be mitigated by simplifying language, breaking material into manageable portions, using visual aids and other therapeutic activities, engaging caregivers, employing roleplay, and allowing extended processing time.^25,26 Similar adaptations can be used in a variety of therapies, including psychodynamic psychotherapy.²⁷

Therapies emphasizing mindfulness, emotional regulation, and values have shown promise in this population. Mindfulness-based approaches are particularly well-studied and have demonstrated effectiveness in reducing challenging behaviors.^28,29 Other approaches, including dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT),³⁰ and compassion-focused therapy (CFT),³¹ have also shown potential despite limitations in sample sizes and methodological rigor in existing studies.

Eye movement desensitization and reprocessing therapy (EMDR) is showing promise in treatment of PTSD in people with ID.^32,33 Other methods of therapy, such as music therapy,³⁴ equine-assisted therapy,³⁵ and art therapy,³⁶ could be useful tools when accessible. More research is needed into these forms of therapy.

Parent and caregiver support. Parent training programs have demonstrated efficacy in improving behavioral outcomes in children with ID. These programs increase appropriate behaviors, improve obedience, and reduce disruptive behaviors, such as hyperactivity, oppositionality, and conduct issues.²⁴

Similarly, a recently tested short-term training program for support staff has demonstrated promising results in field studies. This approach shows potential for broader implementation, offering a scalable solution to enhance caregiver support and improve outcomes for individuals with ID.³⁷

Training modules for caregivers and direct support professionals can teach strategies to manage aggression, handle withdrawal effects, and provide consistent support during deprescribing. Digital forums and apps connect caregivers with peers who have experience in similar situations, offering emotional support and practical advice.

Skills training. While social competence training has shown limited statistical significance in systematic reviews, there is a trend toward improvement in specific skills, such as remaining calm under criticism.²⁴ Recent field tests of short-term training programs for support staff suggest potential for broader application.³⁷

Physical, speech, and occupational therapies. While there is limited research directly linking physical and speech therapies to medication dose reduction in individuals with ID, these therapies play a crucial role in enhancing overall functioning and QoL. By improving communication, mobility, and daily living skills, they might indirectly reduce the need for certain medications, particularly those prescribed for challenging behavior.

Physical therapy focuses on improving motor skills, balance, and coordination, which can lead to increased independence and participation in daily activities. Enhanced physical functioning can reduce frustration and behavioral issues, potentially decreasing reliance on medications. For example, physical therapy can enhance mobility and self-locomotion, providing adaptive solutions to mobility problems and increasing sensory integration. Bellemans et al³⁸ found that utilizing psychomotor therapy to identify and downregulate increasing tension in individuals with ID or borderline intellectual functioning was successful in reducing aggressive outbursts and improving self-esteem.

Speech and language therapy aims to improve communication skills, enabling individuals to express their needs and emotions more effectively. Better communication can lead to a reduction in behavioral challenges. For instance, speech therapy can improve receptive and expressive language skills, speech articulation, and vocabulary, thereby enhancing overall communication abilities. Additionally, speech therapy can find alternative ways of communication, such as the use of assistive devices, cards, or story charts, that can improve challenging behaviors,³⁹ though more robust studies are needed.

Occupational therapy (OT) has been shown to reduce aggressive behavior and improve self-esteem. For example, a 20-week OT program incorporating movement stories, roleplaying, and musical activities was effective in achieving these outcomes.⁴⁰

Combined behavioral approaches. Interventions that combine mindfulness, CBT, and positive behavioral support are also effective in reducing aggressive behavior and improving overall functioning in individuals with ID.^28,29

Technology. Wearable devices, including watches, rings, and smart clothing, have experienced rapid advancements over the past decade. These technologies are increasingly being utilized to support caregivers by addressing issues such as wandering or elopement and providing physiological feedback, including heart rate, electrodermal activity, skin temperature, and sleep patterns. Such data can help identify precursors to aggressive behaviors, such as anxiety and stress, enabling earlier and more effective interventions.⁴¹ In a recent study involving patients with autism spectrum disorder and ID, wearable devices demonstrated the ability to predict aggressive behavior up to three minutes before onset, showcasing their potential for proactive management of challenging behaviors.⁴² This emerging field presents significant opportunities for application in individuals with ID, offering promising tools to manage challenging behaviors more effectively. By leveraging wearable technology, there is potential not only to improve behavioral outcomes but also to support medication reduction strategies, enhancing overall quality of care.⁴³

Augmentative and alternative communication. Speech-generating devices and apps improve communication for individuals with limited verbal abilities. By enabling them to express needs and emotions, augmentative and alternative communication methods can reduce frustration and aggression, indirectly supporting deprescribing efforts.⁴⁴

Telehealth support. Virtual consultations allow for improved access to care with clinical experts who otherwise might not be available to assist with medication review and deprescribing. Telehealth also provides the opportunity for consistent communication with healthcare providers, offering timely guidance during medication tapering and addressing concerns about aggressive behaviors.^45,46

Nonpharmacological interventions, when tailored to the unique needs of individuals with ID, can provide effective alternatives for managing challenging behaviors and improving QoL. Leveraging these interventions alongside targeted treatments of underlying conditions ensures a comprehensive approach to care.

Clinical Vignette 3

Jay, a 35-year-old male individual with profound ID and history of aggression, was in the process of reducing his valproic acid that was utilized for aggression. He had successfully been decreasing his medication over the last four months; however, his family noted an increase in aggression the last two weeks. Jerry, his brother and guardian, was present with him at the appointment with Dr. B. Jay was nonverbal but did communicate through a communication device.

Dr. B: Hello, Jay and Jerry, it is good to see you today. I hear things have been a little difficult for you during the last few weeks, Jay.

Jay: (Looks around.)

Jerry: Yes, we have noticed he seems a little more agitated lately, especially during the day. He has been pacing around and yelling more.

Dr. B: It sounds like that would be difficult for both you and Jay. Jay, have you been sick recently?

Jerry: No, he hasn’t been sick and can usually tell us through his device when something is hurting.

Dr. B: I am glad you haven’t been sick, Jay. Have there been any other changes in the home?

Jerry: Now that you mention it, we did start having a room redone in our house and the construction team has been there. It has been a little loud.

Dr. B: That would definitely be a big change. Jay, does loud noise usually bother you?

Jay (through device): Yes.

Jerry: Yes, when we were children, we couldn’t do fireworks without him having special ear plugs, or he would become very upset and start hurting himself and trying to run away.

Dr. B: I am wondering if the loud noises might be bothering him now. Would it be possible to have him out of the home when the construction crew is working, or would you be interested in talking to OT to see if they can help with his sensory needs?

Jerry: I’ll have to think about where he could go during the day. That might be a challenge. This is going to go on for a while though. You know how these projects can be! I think Jay had OT when he was in school. They work with sensory stuff, like loud noises.

Dr. B: Yes, occupational therapists have a wide range of skills, and they can offer a variety of techniques and tools to help someone who has sensory sensitivities.

Jerry: I would love to try that. I hate that Jay doesn’t get to participate in some things due to his intolerance of the noise.

Dr. B. placed a referral to OT. They worked with Jerry on his sensory needs and fit him with noise cancelling headphones and other devices, such as a weighted blanket, that he could use when he became upset. They provided Jay and Jerry with a list of activities Jay could use to feel calmer and showed Jerry how to help Jay engage in these. His service and support administrator through his insurance was able to acquire these items at little-to-no cost to Jay and his family. Jay was able to tolerate the noise in the home, and the challenging behaviors decreased. He was able to successfully taper off valproic acid and attend other events with his family that he previously could not due to noise.

Clinical Pearls

Though psychotropic medications are commonly prescribed to individuals with ID, nonpharmacological interventions should be tried first and can be at least as effective as medications without the side effects and adverse events commonly associated with medication use in this population.

If symptoms have resolved, medication is ineffective, or there are concerns about adverse effects, deprescribing should be considered. Involving the patient and caregiver in discussions and decision-making is an essential part of the deprescribing process. Tools can be utilized to obtain consistent input and monitor progress.

If symptoms or challenging behaviors emerge during the process of deprescribing medication, a thorough evaluation should be completed to assess for the underlying concern before reinstating medication. These causes could include social stressors, illness, or an underlying psychiatric condition better treated with other medications.

While deprescribing can be successful and helpful, the process might also reveal the continued need for the medication, and this should be discussed and planned for. Psychotherapy can be adapted for patients with ID and should be utilized in a comprehensive treatment plan.

Other supports, including physical, speech, and occupational therapies, technology, caregiver support, and smart apps and monitoring devices can be utilized to support independence, self-efficacy, and involvement in the community. An improved QoL could be important in deprescribing efforts.

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