Neurodevelopmental disorders including intellectual disability: a clinical toolkit for mental health professionals (part 2)

Summary

This editorial introduces the second of two special issues of BJPsych Advances on neurodevelopmental disorders, including intellectual disability, autism spectrum disorder, attention-deficit hyperactivity disorder and epilepsy. Topics discussed in the issue include using technological advances such as apps to manage epilepsy in intellectual disability, person-centred support and integrated care, training, and non-restrictive approaches and appropriate medication for managing self-injurious and challenging behaviour.

In this second of two themed issues on neurodevelopmental disorders including intellectual disability, the spotlight is on training, the lived experience of autistic people and people with intellectual disability, reducing restrictive interventions and using assistive technology in the management of neurodevelopmental disorders and associated conditions, such as epilepsy and challenging behaviour.

Assistive technology to improve outcomes in epilepsy

Kerr et al (2023), in their article on improving outcomes, explore the importance of technological advances, including apps, that can empower those with epilepsy and intellectual disability in making decisions together with their carers, thereby supporting a fulfilled life. This includes minimising risks from sudden unexpected death in epilepsy (SUDEP). The commentary by Shankar (2023) discusses apps and ways of creating capable communities for managing epilepsy in this vulnerable group of patients.

Person-centred, social and integrated care models

Quinn et al (2023) discuss person-centred approaches to supporting autistic people and persons with intellectual disability. They provide invaluable insights, for mental health professionals, carers and service commissioners, into reducing restrictive practices and interventions, thus reducing distress and trauma and helping individuals to lead their best lives in community settings of their choosing, with the right support.

Tromans et al (2023), in their reflection on a social model of care in autism, outline upskilling, dealing with inequalities, promotion of social inclusion, making reasonable adjustments in both employment and healthcare settings and promoting well-being.

Barriers to accessing healthcare systems faced by people with neurodevelopmental disorders worldwide are discussed by Roy et al (2023). Their article explores service models globally and proposes a model of integrated care. It draws on the recommendations of the World Psychiatric Association Action Plan 2020–2023 (Roy 2021; Biswas 2023a) for people with intellectual disability, which include: (a) promotion of public mental health as a guiding principle; (b) promotion of early preventive and secondary treatment strategies in the mental healthcare of children and young persons to reduce future care burden; (c) addressing physical and mental health-related comorbidities promptly, thereby lessening health inequalities and decreasing early morbidity and mortality rates; (d) building teaching, training and research capacity; (e) promoting partnership with non-governmental organisations (NGOs) and other national and regional social care systems.

Pharmacological management of psychopathology

Deb et al (2023) and Bertelli (2023) provide a timely update on the pharmacological management of psychopathology in intellectual disability and autism spectrum disorder. The authors express caution in the use of psychotropic medication for challenging behaviour.

Self-harm among people with intellectual disability can be chronic, and Biswas et al (2023b) reflect on its assessment and treatment, outlining current systemic thinking on functional differentiation and case stratification of self-injurious behaviour, promoting non-restrictive approaches in the care pathways for management.

Estimates of the proportion of autistic children who meet diagnostic criteria for attention-deficit hyperactivity disorder (ADHD) range from 22% to 83%, and an estimated 30–65% of children with ADHD have autistic traits (Sokolova 2017). Children in both groups can present with overlapping symptoms and diagnostic overshadowing, leading to misdiagnosis, missed diagnoses or overdiagnosis. Swanepoel & Lovell (2023), in their article on the STOMP-STAMP initiative and appropriate medication for children with neurodevelopmental disorders, highlight inappropriate antipsychotic prescribing for behaviour that challenges, as well as appropriate use of psychotropic medication in, for example, improving concentration in children with ADHD. Judicious and appropriate use of pharmacotherapy will enhance the engagement of the child with behavioural and communication strategies.

Hirsch & Pringsheim (2023), in their Cochrane review, explore the safety and efficacy of aripiprazole for autism spectrum disorders, and this is followed by a critique of the meta-analysis by Bunting & Feldman (2023), which, among other issues, explores the pitfalls of a protocolised approach to synthesis of evidence.

Training

There is a recognised shortage of doctors training in this area of psychiatry and Barrett et al (2023) describe key capabilities frameworks, policies and resources relevant to training in neurodevelopmental disorders. They point to successful initiatives internationally and future directions that could help provide a model for this training.

Conclusion

In these two special issues on neurodevelopmental disorders our objective was to provide mental health professionals a well-rounded, holistic and updated overview, including dilemmas, of the clinical assessment and management of neurodevelopmental disorders including intellectual disability and associated conditions (Biswas 2022). We hope that this has been achieved.