Practice parameters for the assessment and treatment of children, adolescents, and adults with mental retardation and comorbid mental disorders. American Academy of Child and Adolescent Psychiatry Working Group on Quality Issues

Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

Music Therapy for Children With Autistic Spectrum Disorder and/or Other Neurodevelopmental Disorders: A Systematic Review

Background: Several studies have reported contradictory results regarding the benefits of music interventions in children and adolescents with neurodevelopmental disorders (NDDs), including autism spectrum disorder (ASD). Methods: We performed a systematic review according to the PRISMA guidelines. We searched the Cochrane, PubMed and Medline databases from January 1970 to September 2020 to review all empirical findings, except case reports, measuring the effect of music therapy on youths with ASD, intellectual disability (ID), communication disorder (CD), developmental coordination disorder (DCD), specific learning disorder, and attention/deficit hyperactivity disorder (ADHD). Results: Thirty-nine studies (N = 1,774 participants) were included in this review (ASD: n = 22; ID: n = 7; CD and dyslexia: n = 5; DCD: n = 0; ADHD: n = 5 studies). Two main music therapies were used: educational music therapy and improvisational music therapy. A positive effect of educational music therapy on patients with ASD was reported in most controlled studies (6/7), particularly in terms of speech production. A positive effect of improvisational music therapy was reported in most controlled studies (6/8), particularly in terms of social functioning. The subgroup of patients with both ASD and ID had a higher response rate. Data are lacking for children with other NDDs, although preliminary evidence appears encouraging for educational music therapy in children with dyslexia. Discussion: Improvisational music therapy in children with NDDs appears relevant for individuals with both ASD and ID. More research should be encouraged to explore whether oral and written language skills may improve after educational music therapy, as preliminary data are encouraging.

Practice Parameter for the Assessment and Treatment of Psychiatric Disorders in Children and Adolescents With Intellectual Disability (Intellectual Developmental Disorder)

Intellectual disability (intellectual developmental disorder) (ID/IDD) is both a psychiatric disorder and a risk factor for co-occurring psychiatric disorders in children and adolescents. DSM-5 introduced important changes in the conceptualization and diagnosis of ID/IDD, and current research studies clarify assessment and treatment of co-occurring psychiatric disorders in this population. Optimal assessment and treatment of psychiatric illness in children and adolescents with ID/IDD includes modifications in diagnostic and treatment techniques, appreciation of variations in the clinical presentation of psychiatric disorders, an understanding of the spectrum of etiologies of behavioral disturbance, and knowledge of psychosocial and medical interventions.

High Rates of Psychiatric Disorders and Below Normal Mental Capacity Associated With Spastic Peroneal Flatfoot: A New Relationship

Spastic peroneal flatfoot (SPFF) is a rare hindfoot pathology usually seen in the adolescent age group that is characterized by painful spasms in the peroneal muscles. We have clinically observed that patients with SPFF also have some behavioral and emotional difficulties and problems in their academic achievements. Because of these observations, we investigated the prevalence and patterns of psychiatric disorders and intellectual disability among young subjects with SPFF. Our cohort consisted of 16 patients with SPFF. Their mean age at presentation was 21 (range 13 to 31) years. Only 6 patients had a tarsal coalition as an underlying condition. The psychometric evaluation was conducted using validated instruments (Wechsler Intelligence Scale for Children-revised form, Stanford Binet intelligence quotient [IQ] test, and Cattell IQ test). Psychiatric disorders were assessed using a semistructured diagnostic instrument (Schedule for Affective Disorders and Schizophrenia for School Age Children Present and Lifetime Version). The testers and psychiatrists were unaware of the orthopedic condition and the preliminary psychiatric diagnoses. The ethical committee approved the study protocol. The mean follow-up period was 41 (range 12 to 97) months. The mean IQ score of the patients was 75.1 ± 17.9 (range 52 to 107). Compared with the general population, the rate of intellectual disability was significantly greater (p = .0001) and the rate of normal intelligence significantly lower (p = .0015) in our patient group. Furthermore, according to the community schooling ratio, our cohort also had lower junior high and secondary education rates compared with the general population. The rate of most psychiatric disorders diagnosed in the SPFF patients was greater than that in the normal population. The most commonly identified psychiatric disorders were social phobia and attention deficit and hyperactivity disorder (75%). Timely interventions of the psychosocial and academic problems of patients with SPFF might increase their compliance with orthopedic treatment and help with their psychological well-being and academic achievement. In addition, this relationship might be a clue for uncovering the etiology of this disease, which has not yet been clarified.

Diagnostic Masking and Overshadowing in Intellectual Disability-How Structured Evaluation Helps

PROBLEM

Comorbid psychiatric diagnoses tend to be underdiagnosed in patients with intellectual disability. Diagnosing anxiety disorders in such patients can pose challenges, in particular with regard to obsessive and compulsive disorder (OCD).

METHODS

We present the case of an adolescent diagnosed with intellectual disability with poor expressive language skills who presented with nonspecific mood and behavioral symptoms, not improving with routine clinical evaluations and treatment. A structured assessment was done to decipher the psychopathology.

FINDINGS

The structured evaluation was able to diagnose OCD, and the treatment response was accentuated, bringing about a significant reduction in patient and caregiver distress. Psychosocial interventions through nurses played a significant role.

CONCLUSIONS

The case highlights the need for a systematic assessment of patients with intellectual disability to arrive at reliable diagnoses and to plan appropriate treatment strategies.

Genetic Approach to Diagnosis of Intellectual Disability

Intellectual disability is a non-specific phenotype present in a genetically heterogeneous group of disorders. It is characterized by deficits in intellectual and adaptive functioning, presenting before 18 y of age. Identifying the cause of ID is important to provide treatment where available, genetic counseling, recurrence risks and reproductive options for subsequent pregnancies. Advances in technology, especially next generation sequencing and microarrays, have greatly increased the diagnostic yield of evaluation in cases of ID. This paper describes the points in history taking and examination in the evaluation of a proband, and discusses the proper use of newer diagnostic technologies.

State Variation in School-Based Disability Services Financed by Medicaid

To understand the role of Medicaid in financing health services delivered through special education, program characteristics and covered services were compared from all 50 states and Washington, D.C. Data were collected from school-based fee schedules and policy manuals available through state Medicaid or education agencies. Except Wyoming, all states bill Medicaid for school-based health services, but there is substantive variation across states in services covered. The service categories most often covered by states’ Medicaid special education programs are speech–language/audiology, occupational/physical therapy, and behavioral health. Almost all states use a fee-for-service payment methodology to reimburse for services. Implications for the delivery of care to and health outcomes of students with disabilities are discussed.

Adaptive Interventions in Child and Adolescent Mental Health

The treatment or prevention of child and adolescent mental health (CAMH) disorders often requires an individualized, sequential approach to intervention, whereby treatments (or prevention efforts) are adapted over time based on the youth's evolving status (e.g., early response, adherence). Adaptive interventions are intended to provide a replicable guide for the provision of individualized sequences of interventions in actual clinical practice. Recently, there has been great interest in the development of adaptive intervenions by investigators working in CAMH. The development of such replicable, real-world, individualized sequences of decision rules to guide the treatment or prevention of CAMH disorders represents an important "next step" in interventions research. The primary purpose of this special issue is to showcase some recent work on the science of adaptive interventions in CAMH. In this overview article, we review why individualized sequences of interventions are needed in CAMH, provide an introduction to adaptive interventions, briefly describe each of the articles included in this special issue, and describe some exciting areas of ongoing and future research. A hopeful outcome of this special issue is that it encourages other researchers in CAMH to pursue creative and significant research on adaptive interventions.

The effectiveness of psychosocial interventions for children with a psychiatric disorder and mild intellectual disability to borderline intellectual functioning: A systematic literature review and meta-analysis

Children with intellectual disability frequently have difficulties in adapting to their environment. The extent of the experienced problems does not only depend on cognitive functioning but is influenced by other factors, such as the presence of a psychiatric disorder or other brain disorders, or adverse environmental factors. Several epidemiological studies show that children with intellectual disabilities are at an increased risk to develop psychiatric disorders. This is also true for youth with a mild intellectual disability and even those with borderline intellectual functioning (mild to borderline intellectual disability (MBID)). Psychiatric disorders are often overlooked because behavioral problems are rather attributed to the intellectual disability. Consequently, effective psychiatric interventions, which are needed to improve the level of functioning, are not applied. This review aimed to systematically evaluate the currently available, qualitatively sound research concerning the effectiveness of psychosocial interventions, specifically directed at psychiatric disorders in children with MBID. Assessed for eligibility were 1409 unique reports, and the review ultimately included only 12 reports. Review of the results and meta-analyses showed that the majority of studies suffer from multiple limitations and that methodological variations between studies are extensive. This possibly reflects the high variance of factors that may be involved in MBID. It will be important in future research to address multi-causality.

Lessons learned from our elders: how to study polypharmacy in populations with intellectual and developmental disabilities

Polypharmacy is the concurrent use of multiple medications, including both psychotropic and non-psychotropic drugs. Although it may sometimes be clinically indicated, polypharmacy can have a number of negative consequences, including medication nonadherence, adverse drug reactions, and undesirable drug-drug interactions. The objective of this paper was to gain a better understanding of how to study polypharmacy among people with intellectual and developmental disabilities (IDD). To do this, we reviewed literature on polypharmacy among the elderly and people with IDD to inform future research approaches and methods on polypharmacy in people with IDD. Results identified significant variability in methods used to study polypharmacy, including definitions of polypharmacy, samples studied, analytic strategies, and variables included in the analyses. Four valuable methodological lessons to strengthen future polypharmacy research in individuals with IDD emerged. These included the use of consistent definitions of polypharmacy, the implementation of population-based sampling strategies, the development of clinical guidelines, and the importance of studying associated variables.

Neurodevelopmental and psychiatric issues in Down's syndrome: assessment and intervention

Down's syndrome (DS) is the most frequent genetic cause of intellectual disability and patients with DS show significant psychopathology (18-23%). Moreover, individuals with DS often show a cognitive decline associated with ageing characterized by a deterioration in memory, language and cognitive functioning. According to these relevant findings, an overview is presented of state-of-the-art knowledge of the neurocognitive, neurobiological and psychopathological profile, assessment and treatment of patients with DS. The linguistic characteristics of DS develop differently along distinct developmental trajectories. Thus, for example, morphosyntax deficit, especially in production, is more evident in adolescence than in early childhood and lexicon is usually better preserved in all ages (at least in comprehension). So far, rehabilitation is the only effective approach for improving cognitive and linguistic abilities. However, ongoing preliminary reports on other approaches such as transmagnetic stimulation or drugs suggest alternative or integrative treatment for the future. Individuals with DS show typical organization of brain structures related to some cognitive abilities, such as reduced volume in frontal and prefrontal areas, which is related to poor executive and linguistic abilities. They also frequently show psychiatric disorders such as externalizing disorders as well as depression, anxiety and obsessive-compulsive disorder. Nevertheless, as for other genetic syndrome with intellectual disability, there is a significant lack of research specifically focused on treatments of psychiatric and behavioural problems in DS. This is true both for psychosocial and for pharmacological interventions.

Towards the prevention of behavioural and psychiatric disorders in people with intellectual disabilities

Intervention for behavioural and psychiatric disorders in people with intellectual disabilities often only takes place once these conditions are well established and more resistant to change. As an alternative, this paper promotes a public health prevention model and maps out opportunities for intervention at primary, secondary and tertiary levels. The resulting model is partly derived from generic research into these issues and partly on specific evidence on interventions for people with intellectual disabilities; it also contains more theoretical considerations. The additional research that is necessary to demonstrate the efficacy of the interventions identified is also considered. Central to this proposal is a greater integration of issues for people with intellectual disabilities within much broader policy and research agendas.

Gender and geographic differences in the prevalence of intellectual disability in children: analysis of data from the national disability registry of Taiwan

Intellectual disability (ID) is not uncommon in children, but data at the national level are limited, especially those on geographic differences. On the basis of the Disabled Welfare Law, Taiwan began to certify disabled residents and provide various services in 1980. All the cases are registered, and the registry provides a rare opportunity for studying ID at the national level. Using the data from 2004 to 2010, we calculated the prevalence of ID in children by age, gender, and geographic area and assessed the changes over time. We limited analyses to children at least 3 years of age, because certification before 3 years old is discouraged by the government. We found that from 2004 to 2010, the registered cases between 3 and 17 years old ranged from 20,531 to 23,547, and the prevalence of ID increased constantly from 4.40/1000 to 5.79/1000 (p<0.01), which generally increased every year in all age groups (p<0.01). In each year there were more boy cases than girl cases, and the boy-to-girl ratio generally decreased with age (p<0.01 for chi-square test for trend in all years). The prevalence rate ratio ranged from 1.33 to 1.37 (p<0.01 in all years), and the changes in the rate ratio were small over the years. We observed a higher prevalence in the rural areas over the years, and the prevalence rate ratio ranged from 1.34 to 1.43 (p<0.01 in all years), with an increasing trend over time (p<0.01).

Antipsychotic medication prescription patterns in adults with developmental disabilities who have experienced psychiatric crisis

Antipsychotic medication rates are high in adults with developmental disability. This study considered rates of antipsychotic use in 743 adults with developmental disability who had experienced a psychiatric crisis. Nearly half (49%) of these adults were prescribed antipsychotics. Polypharmacy was common with 22% of those prescribed antipsychotics taking 2 or more antipsychotics at once. Predictors of multiple antipsychotic use included gender, residence, psychiatric diagnosis and previous hospitalizations. Implications of medication prescriptions to this vulnerable population are discussed.

Developmental and behavioral disorders through the life span

Developmental and behavioral disorders including intellectual disability, learning disabilities, and attention-deficit/hyperactivity disorder are highly prevalent, chronic health conditions. Despite being versed in caring for children with these conditions, pediatricians might be less prepared for challenging questions from families about the long-term course of these conditions and what can be done to improve outcomes. Through this state-of-the-art review, we provide clinicians with an understanding of the course of these conditions and adult outcomes in several areas including vocational, social, and health domains. We also provide a review of the most current research examining factors that predict or mediate adult outcomes for people with intellectual disability, learning disabilities, and attention-deficit/hyperactivity disorder. On the basis of the current literature, we offer practice recommendations aimed at optimizing adult outcomes for those with these disorders.

Psychiatry of Intellectual and Developmental Disability in the US: Time for a New Beginning

Although psychiatry in the United States owes its origins to the treatment of persons with intellectual disabilities (ID), over the past 50 years, clinical services, education of professionals and research in psychiatry of ID have consistently lagged behind other fields in psychiatry. The historical and contemporary reasons for this development are discussed with recommendations for establishment of a fully credentialed subspecialty of Psychiatry of Intellectual and Developmental Disabilities in the United States.

Understanding basic behavioral support techniques as an alternative to sedation and anesthesia

Patients with special needs often present a challenge for the dental care team. The exacting and surgical nature of dental procedures requires significant patient cooperation to ensure the safe delivery of care. Some individuals who have special care needs have difficulty cooperating during treatment, thus creating a potentially harmful situation. Modern dentistry, particularly pediatric dentistry, provides the dental team with a variety of strategies designed to enable the team to safely provide comprehensive care in the least restrictive manner. These techniques range from tell-show-do, to medical stabilization, to general anesthesia. The effective use of noninvasive, nonpharmacologic behavioral guidance/support techniques cannot only avoid the need for sedation or general anesthesia, they can teach the patient to develop coping skills that may enable them to receive comprehensive care in a traditional dental setting over a lifetime. Unfortunately, many providers are inadequately trained in behavioral support strategies. This paper presents a review of noninvasive, nonpharmacologic behavioral support techniques with discussion regarding their application to persons with special care needs.

Adolescer com deficiência mental: a ótica dos pais

Este trabalho tem como objetivo conhecer a representação da adolescência para os responsáveis por adolescentes com deficiência mental. Como metodologia, utilizamos a análise de narrativas de pais de adolescentes com deficiência mental. Baseamo-nos, principalmente, nas orientações de Thompson (1998) e Byron-Good (1996). Embora os pais reconhecessem nos filhos algumas características próprias da adolescência, nem sempre os consideravam como adolescentes, devido à pouca autonomia que possuíam. Muito freqüentemente, não propiciavam uma educação que contribuísse para uma maior autonomia dos filhos, ressentindo-se da falta de referências de como se comportar diante das mudanças de comportamento deles. Tendo em vista a constatação da importância da aquisição de uma maior autonomia para que os adolescentes tenham o reconhecimento deste período do desenvolvimento humano e possam vivenciá-lo da melhor forma possível, é neste sentido que algumas ações devem se desenvolver. Se forem apresentadas novas oportunidades de aprimoramento das competências e habilidades dos adolescentes com deficiência mental que ampliem seus " horizontes" , muitos poderão alcançar uma melhor autonomia que possibilite sua participação nas tomadas de decisão sobre seu destino e a vivência satisfatória de todas as etapas do seu ciclo de vida.

Psychiatric and behavioral disorders in persons with Down syndrome

Similar to the state of the broader intellectual disabilities field, many gaps exist in the research and treatment of mental health concerns in people with Down syndrome. This review summarizes key findings on the type and prevalence of behavior and emotional problems in children, adolescents, and adults with Down syndrome. Such findings include relatively low rates of severe problems in children, and well-documented risks of depression and Alzheimer's disease in older adults. The review also considers emerging data on autism, and the paucity of studies on adolescents. Three next steps for research are highlighted, including a need to: (1) connect research on psychiatric status and diagnoses across developmental periods, including adolescence, and to examine such associated processes as sociability, anxiety and attention; (2) unravel complicated biopsycho-social risk and protective factors that serve to increase or diminish psychopathology; and (3) identify evidence-based treatments that both reduce distressful symptoms and enhance well-being in individuals with Down syndrome.

Environmental evaluation of a child with developmental disability

Children's health can be affected adversely by the environment in which they live. It is well recognized that some environmental chemicals are harmful to the brain, but the role these chemicals play in the development of specific disabilities such as attention deficit hyperactivity disorder and autism is not certain. Parents of children who have developmental disabilities often ask the primary care physician whether certain environmental toxicants might be the cause of the illness. A detailed environmental history and physical examination may help clarify whether there is a plausible relationship between an environmental toxicant and a child's disability.

Integrative treatment in persons with intellectual disability and mental health problems

BACKGROUND

Clinical experience has proven thus far that a monodisciplinary treatment approach to behavioural and psychiatric problems in persons with intellectual disability (ID), such as psychotropic medication or behaviour modification programmes, has yielded limited success. It is clear that the complexity of behavioural and psychiatric problems in this population calls for a treatment approach from different perspectives.

METHODS

A multidimensional treatment approach to the persons with ID who suffer from behaviour problems and psychiatric disorders is described.

RESULTS

Four dimensions - biological, psychological, social and developmental - are represented as well in an integrative diagnosis as in an integrative treatment, embodied by cooperation of different professionals, such as a psychiatrist, psychologist, pedagogues, social worker, nurse and, where possible, the person's caretakers. The developmental dimension receives a salient attention of assessors. By introducing the developmental dimension in diagnostics and treatment, the bio-psycho-social dimensions are set in a new context, more appropriate for persons with ID.

CONCLUSION

The integrative treatment should not be primarily directed towards the symptoms of the disorder but towards restoring a person's mental well-being. The disorder is combated through treatment of the underlying processes that have led to its onset. Different treatment methods from different perspectives may be applied. Strategy and methodological procedures of an integrative treatment are discussed by way of case presentations.

Mental retardation in children ages 6 to 16

Mental retardation (MR) is a life long condition that affects 6 million American and 560,000 Canadian children under the age of 14. This review discusses the definition of MR, an approach to investigation, common comorbidities, and a general approach to management.

Intellectual disability and mental illness in the NSW criminal justice system

There has been increasing international, national and local recognition of the need for more appropriate responses and services for individuals who come in contact with the criminal justice system and who have an intellectual disability and mental health issues. This article provides an overview of prevalence data that indicates a significant over representation of people with intellectual disabilities in correctional facilities and reviews the problems facing this population. Findings from two specific evaluation studies undertaken by the Centre for Developmental Disability Studies are presented, along with recommendations for future provision based on these results. One of these projects trialled a case management approach to supporting offenders with an intellectual disability upon their release from prison. The 20-month follow-up found that a number of serious barriers were encountered within the overall system of provision for this population; the most serious of which related to lack of adequate accommodation upon release. The second project involved a two-stage evaluation of one model of provision for individuals with intellectual disabilities who are sex offenders, only some of whom were on parole. This service provided both residential and therapy services in a small group home located in the community. Residents were found to have high levels of emotional and behavioural difficulties, in addition to offending behaviour, that continue to require support and supervision. Critical issues, including guardianship involvement, restrictive practices and retrieval, therapy provision, and risk management issues are discussed in relation to overall clinical and lifestyle outcomes.

Mental health disorders among individuals with mental retardation: challenges to accurate prevalence estimates

OBJECTIVES

The objectives of this literature review were to assess current challenges to estimating the prevalence of mental health disorders among individuals with mental retardation (MR) and to develop recommendations to improve such estimates for this population.

METHODS

The authors identified 200 peer-reviewed articles, book chapters, government documents, or reports from national and international organizations on the mental health status of people with MR. Based on the study's inclusion criteria, 52 articles were included in the review.

RESULTS

Available data reveal inconsistent estimates of the prevalence of mental health disorders among those with MR, but suggest that some mental health conditions are more common among these individuals than in the general population. Two main challenges to identifying accurate prevalence estimates were found: (1) health care providers have difficulty diagnosing mental health conditions among individuals with MR; and (2) methodological limitations of previous research inhibit confidence in study results.

CONCLUSIONS

Accurate prevalence estimates are necessary to ensure the availability of appropriate treatment services. To this end, health care providers should receive more training regarding the mental health treatment of individuals with MR. Further, government officials should discuss mechanisms of collecting nationally representative data, and the research community should utilize consistent methods with representative samples when studying mental health conditions in this population.

Psychosocial Theories of Depression for Individuals With Intellectual and Developmental Disabilities: A Historicist Perspective

The mental health care system has historically marginalized individuals with intellectual and developmental disabilities (I/DD). Until the mid-1980s, many clinicians doubted that individuals with I/DD were capable of depression (Sovner & Pary, 1993). Although it is now generally accepted that individuals with I/DD do have depression, they may not be treated or may be inappropriately treated (Matson et al., 2000). A historicist perspective takes into account the effect of marginalization on science and practice. Depression has both biological and psychosocial aspects. Key groups of theories regarding the psychosocial aspects of depression include psychodynamic/psychoanalytic, behavioral, cognitive, and ecological/interpersonal theories (Clark, Beck, & Alford, 1999; Joiner, Coyne, & Blalock, 1999). The application of psychosocial theories of depression to individuals with I/DD continues to reflect their marginalization and oppression. Behavioral theories of depression are limited in their conceptions for research, identification, and treatment of depression but continue to be used widely with individuals with I/DD. Cognitive theories of depression are widely used in research and treatment of depression in the general population, but have limited usage among individuals with I/DD. Interpersonal theories of depression are used in the general population and have many benefits, but are only now being investigated for use with individuals with I/DD. In this article, theories of depression as applied to individuals with I/DD are discussed from a historicist perspective.

The quality of health care for adults with developmental disabilities

OBJECTIVE

The purpose of this study was to determine the health status of adults with developmental disabilities residing in community settings and the quality of the preventive, medical, dental, and psychiatric services they receive.

METHODS

Data were collected on a sample of 353 adults residing in Los Angeles, California, in 1997. Historical data were obtained from study subjects or caregivers, physical and dental examinations were performed, blood was drawn for analysis, and a psychiatrist reviewed medical records for reports of psychiatric diagnoses and consultations.

RESULTS

Health markers, such as rates of obesity, and laboratory test results of routine screening panels including blood cell counts, hemoglobin, and hematocrits; blood concentrations of liver enzymes and other enzymes, cholesterol, and tryglycerides; and urinalyses were within normal limits for an adult population. However, preventive services were notably lacking, especially for individuals living at home. Fewer than half of the study subjects had received influenza vaccine; only a third of those living alone or with family or friends had received this vaccination. Chart audits revealed that about a third received psychotropic medications, but only 24% of these individuals had psychiatric consultations noted in their record. Further, 36% of this medicated group received psychotropic drugs without any identifiable diagnosis, and simultaneous receipt of two or more antipsychotics was not uncommon.

CONCLUSIONS

Given that the U.S. health care system fails to ensure the provision of preventive services for all people, including the developmentally disabled, a systematic overhaul is necessary to establish an effective quality assurance program that will provide preventive medical, dental, and psychiatric services for people with developmental disabilities.