Are opioid antagonists effective in reducing self-injury in adults with intellectual disability? A systematic review

Mental health in autistic adults: A rapid review of prevalence of psychiatric disorders and umbrella review of the effectiveness of interventions within a neurodiversity informed perspective

BACKGROUND

Autistic adults have high risk of mental ill-health and some available interventions have been associated with increased psychiatric diagnoses. Understanding prevalence of psychiatric diagnoses is important to inform the development of individualised treatment and support for autistic adults which have been identified as a research priority by the autistic community. Interventions require to be evaluated both in terms of effectiveness and regarding their acceptability to the autistic community.

OBJECTIVE

This rapid review identified the prevalence of psychiatric disorders in autistic adults, then systematic reviews of interventions aimed at supporting autistic adults were examined. A rapid review of prevalence studies was completed concurrently with an umbrella review of interventions. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were followed, including protocol registration (PROSPERO#CRD42021283570).

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, and Cochrane Database of Systematic Reviews.

STUDY ELIGIBILITY CRITERIA

English language; published 2011-2022; primary studies describing prevalence of psychiatric conditions in autistic adults; or systematic reviews evaluating interventions for autistic adults.

APPRAISAL AND SYNTHESIS

Bias was assessed using the Prevalence Critical Appraisal Instrument and AMSTAR2. Prevalence was grouped according to psychiatric diagnosis. Interventions were grouped into pharmacological, employment, psychological or mixed therapies. Strength of evidence for interventions was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Autistic researchers within the team supported interpretation.

RESULTS

Twenty prevalence studies were identified. Many included small sample sizes or failed to compare their sample group with the general population reducing validity. Prevalence of psychiatric diagnoses was variable with prevalence of any psychiatric diagnosis ranging from 15.4% to 79%. Heterogeneity was associated with age, diagnosis method, sampling methods, and country. Thirty-two systematic reviews of interventions were identified. Four reviews were high quality, four were moderate, five were low and nineteen critically low, indicating bias. Following synthesis, no intervention was rated as 'evidence based.' Acceptability of interventions to autistic adults and priorities of autistic adults were often not considered.

CONCLUSIONS

There is some understanding of the scope of mental ill-health in autism, but interventions are not tailored to the needs of autistic adults, not evidence based, and may focus on promoting neurotypical behaviours rather than the priorities of autistic people.

Pharmacological management of psychopathology in people with intellectual disabilities and/or autism spectrum disorder

On average, 49–63% of people with intellectual disabilities and/or autism spectrum disorder (ASD) are prescribed psychotropic medications to treat psychopathology, including psychiatric illness, behaviours that challenge and the core symptoms and associated behaviours of these developmental disorders. In many cases, psychotropics, particularly antipsychotics, are used off-label without a proper indication, particularly to manage behaviours that challenge. The RCTs show moderate evidence supporting the efficacy of low-dose risperidone and some preliminary evidence for aripiprazole in treating behaviours that challenge among children with ASD and/or intellectual disabilities. The RCT-based evidence for the other psychotropics is equivocal, so no definitive conclusions can be made on their efficacy. Polypharmacy and the use of high doses of antipsychotics are prevalent in this population, leading to the risk of adverse events and drug–drug interactions. Despite various national and international guidelines, and government initiatives encouraging reduced psychotropic use, there is little evidence of this happening; on the contrary, the use of antidepressants, mood stabilisers and benzodiazepines may be increasing. A concerted multi-agency effort is urgently needed to address this significant public health concern of the overmedication of people with intellectual disabilities and/or ASD.

Efficacy of caries and gingivitis prevention strategies among children and adolescents with intellectual disabilities: a systematic review and meta-analysis

BACKGROUND

Dental caries and periodontal diseases are the most common oral diseases among human beings. Individuals with intellectual disabilities (IDs) have poor oral health and limited access to dental care. The aim of this study was to investigate the efficacy of strategies in caries and gingivitis prevention among children and adolescents with ID.

METHODS

Four electronic databases (PubMed, Cochrane Library, Web of Science and Scopus) were searched from their commencement date to 17 April 2017. Randomised or non-randomised controlled trials evaluating the efficacy of interventions in caries and gingivitis prevention were included if the participants were children and adolescents with ID. Gingival index and caries experiences were reported in the format of mean difference and standard error. Meta-analysis was conducted if data could be pooled from two or more studies using similar outcome measurements and intervention.

RESULTS

A total of 1455 articles published in English were identified. Fourteen studies formed the basis of qualitative analysis; six studies were feasible to perform quantitative analysis. Meta-analysis favoured fluoride to placebo in caries prevention [Z = 2.02, P < 0.05, 95% CI: -0.71 (-1.40, -0.02)], while the effectiveness of chlorhexidine remained elusive.

CONCLUSIONS

Both mechanical and chemical approaches had been applied to caries and gingivitis prevention among children and adolescents with ID. Insufficient evidence supported the efficacy of chlorhexidine nor powered toothbrush, while fluoride was suggested to be an effective caries preventive strategy in fluoride-deficient areas. More well-designed randomised controlled trials using integration strategies are encouraged in further studies.

A systematic review and meta-analysis of dental plaque control among children and adolescents with intellectual disabilities

BACKGROUND

People with intellectual disabilities (ID) typically have poorer oral health. Oral diseases have a microbiological origin, and thus, dental plaque control (DPC) is key to safeguard their oral health.

METHODS

A structured search strategy was applied to screen oral health promotion initiatives for DPC among children and adolescents with ID following PRISMA statements. Qualitative and quantitative analyses were performed.

RESULTS

From 1,455 citations, 22 studies informed this review. Seven studies related to mechanical interventions and 13 to chemical interventions. Qualitative analyses found conventional toothbrushes were less effective than modified toothbrushes but quantitative analyses were conflicting. Of the nine studies that compared chlorhexidine to placebos, seven reported chlorhexidine was more effective than placebos. Meta-analysis favoured chlorhexidine to placebos (p < 0.0001, 95% CI 0.34-0.63).

CONCLUSIONS

Both mechanical and chemical interventions are effective for DPC. It is unclear whether they are alternative means for DPC or whether they are best employed together.

Classification of self-injurious behaviour across the continuum of relative environmental-biological influence

Self-injurious behaviour (SIB) is generally considered to be the product of interactions between dysfunction stemming from the primary developmental disability and experiences that occasion and reinforce SIB. As a result of these complex interactions, SIB presents as a heterogeneous problem. Recent research delineating subtypes of SIB that are nonsocially mediated, including one that is amenable to change and one that is highly invariant, enables classification of SIB across a broader continuum of relative environmental-biological influence. Directly examining how the functional classes of SIB differ has the potential to structure research, will improve our understanding this problem, and lead to more targeted behavioural and pharmacological interventions. Recognising that SIB is not a single entity but is composed of distinct functional classes would better align research with conceptual models that view SIB as the product of interactions between environmental and biological variables.

Self-Injury in Autism Spectrum Disorder and Intellectual Disability: Exploring the Role of Reactivity to Pain and Sensory Input

This paper provides information about the prevalence and topography of self-injurious behavior in children and adults with autism spectrum disorder and intellectual disability. Dominant models regarding the etiology of self-injury in this population are reviewed, with a focus on the role of reactivity to pain and sensory input. Neuroimaging studies are presented and suggestions are offered for future research.

Oral health status of children and adolescents with intellectual disabilities: a systematic review and meta-analysis

AIM

To compare the oral health status of children and adolescents affected by intellectual disabilities with their unaffected counterparts.

METHOD

Citations published in English were searched from electronic databases (PubMed, Embase, Web of Science, and Scopus) from their start dates to March 2017. The whole process was conducted following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. The PICO (population, intervention/interest, comparator, outcome) principle was used to formulate the topic. Studies were synthesized through qualitative summary or, whenever possible, meta-analysis.

RESULTS

The initial search yielded 2393 records. Thirty-nine studies from 22 countries were identified for qualitative analysis; 26 studies were eligible for meta-analysis. Participants with intellectual disabilities had higher levels of dental plaque, worse gingival status, fewer decayed and filled permanent teeth, and similar caries experience between males and females. These findings were supported by both qualitative and quantitative analysis. Various patterns of caries experiences were indicated by qualitative analysis, but it was not substantiated by meta-analysis.

INTERPRETATION

There is increasing worldwide interest in oral health status of children with intellectual disabilities. Differences in dental plaque deposition, gingival inflammation, and the number of decayed and filled permanent teeth were investigated between children and adolescents with and without intellectual disabilities. Evidence remains elusive about the pattern of caries experience among those children.

Comparative analysis of self-injury in people with psychopathology or neurodevelopmental disorders

Self-injury is a complex and poorly understood behavior observed in people with psychopathology or neurodevelopmental disorders (NDD). Despite the differences in etiology and progression of these distinct disease domains, it is possible that overlapping molecular pathways underlie the expression of self-injurious behaviors (SIBs). This review outlines the similarities and differences at the behavioural and molecular level, where SIBs in both conditions may involve opioid, nucleoside, and dopamine signalling. These points of convergence have important implications for treatment and research of SIB in both populations.