2023 14th Annual NUBE Conference

Patients with neurodevelopmental disorders can exhibit agitation/challenging behaviors (A/CBs) that frequently present in the emergency room and are distressing both for the caregivers and the patients themselves. These behavioral crises are more frequent in nonverbal individuals with intellectual disability and autism spectrum disorders and usually during the transition period from late childhood to young adulthood.

This presentation will take a deep look into multiple factors in managing behavioral health crises in special populations, including:
• High incidence of co-occurrent trauma, therefore behavioral interventions are Gold Standard
• Consideration of medical/proximate and reversible causes
• Recognizing true psychosis using criteria that are part of standard diagnostic procedure‚
• Consideration of antipsychotics/mood stabilizers; avoiding drugs that can cause paradoxical agitation
• Consideration of rare causes

Causes are extremely diverse, but include comorbid medical conditions, either organic or psychiatric. Look at developmental, environmental, medical, and psychiatric causes precipitating a behavioral crisis.

Discuss Psychosis: Persons with intellectual disabilities and/or developmental disabilities such as autism are vulnerable to the same psychiatric conditions as anyone else. However, recognition of psychosis (hallucinations, delusions, or paranoia) requires the examiner to try to ascertain the internal perceptual experiences of persons who do not use the same primary spoken language as the examiner.

Discuss non-pharmacologic therapeutic approaches, including:
• Maintaining a low-stimulus environment
• Avoiding retraumatization
• Allowing self-soothing
• Minimizing distress by performing all relevant investigations together
• Note that the patient may have an existing Behavioral Management Plan with advice on how to manage acute distress

Discuss pharmacologic approaches, including:
• Observing if there has been an acute change in sleep habits or patterns
• Were new meds started? Specifically AED: levetiracetam ; Antihistamine; selective serotonin reuptake inhibitors (SSRIs), or neuroleptic malignant syndrome (NMS)
• Were medications suddenly discontinued or doses missed?
• Is there further regression of neurologic baseline?
• Is there akathisia?
• FDA-approved medications, with associated limitation considerations and monitoring needs

Discuss rare situations, including:
• Is there marked vital sign change with paroxysmal sympathetic hyperactivity (PSH), otherwise known as autonomic storming?
• Is there Status dystonicus, or "dystonic storm," as has been described in patients with dystonic cerebral palsy and other underlying dystonic conditions
• Postictal/interictal psychosis and forced normalization
• Autoimmune encephalitis