Evaluation of Antiepileptic for Behavioral Symptoms in Severe Intellectual Disabilities

Research Article

Austin J Psychiatry Behav Sci. 2014;1(4): 1019.

Evaluation of Antiepileptic for Behavioral Symptoms in Severe Intellectual Disabilities

Ken Taniguchi1, 2, Kouzin Kamino1, 2,*, Takashi Kudo2 and Masatoshi Takeda2

1National Hospital Organization, Yamato Mental-Medical Center, Japan

2Department of Psychiatry, Osaka University Graduate School of Medicine, Japan

*Corresponding author: Kouzin Kamino, National Hospital Organization, Yamato Mental-Medical Center, 2815 Koizumi, Yamatokoriyama, Nara 639-1042, Japan

Received: May 08, 2014; Accepted: May 20, 2014; Published: May 21, 2014


Antiepileptic, known to manage mood disorders, has been prescribed for behavioral symptoms in severe intellectual disabilities, but often results in multiple prescriptions.

Objective: To classify the behavioral symptoms and evaluate the prescription of antiepileptic for the extent of the behavioral symptoms.

Method: The extent of the behavioral symptoms was scored using Severe Behavior Disorder Assessment Scale, composed of the 11–items and 4–frequency scale, in 80 hospitalized subjects with severe intellectual disabilities, and analyzed in relation to the number and dose of prescribed antiepileptic. Phenytoin was prescribed for 4 subjects, and their scores were evaluated at baseline and after the prescription.

Results: The subjects with organic brain disease or epilepsy showed lower frequency of the behavioral symptoms compared to those without. Factor analysis indicated that the behavioral symptoms were classified into 3 factors; representatively, obsessive⁄hyperactive, aggressive and self–injurious behavior. The extent of the symptoms was inversely correlated to the number of antiepileptic, including valproic acid, carbamazepine and phenytoin. While valproic acid was significantly inversely correlated with the symptoms of obsessive⁄hyperactive and self–injurious behavior, phenytoin was possibly effective for the aggressive behavior. When phenytoin was prescribed in 4 subjects, the score of aggressive behavior was significantly decreased after the prescription of phenytoin, but paroxysmal tonic upgaze was often observed.

Conclusion: Valproic acid was effective for the behavioral symptoms, similarly to mood disorders, and phenytoin could stabilize the aggressive behavior. Therefore, among antiepileptic, valproic acid could be the first choice to the symptoms, and prescriptions of antiepileptic could be symptomatically selected.

Keywords: Intellectual disabilities, Behavioral symptom, Antiepileptic, Valproic acid, Carbamazepine, Phenytoin


Aggressive, self–injurious, and the other aberrant behaviors are troublesome in nursing and care for subjects with severe intellectual disabilities [1]. Because of resulting in self–injury and injury to their caregivers, the subjects are extremely difficult to stay at home, and necessary to intensive care in nursing home or hospital. The behavioral symptoms of the subjects, frequently and intensively acting these behaviors in the unusual manner, are symptomatically categorized as an entity called severe behavior disorder, and also synonymously “disruptive behavior disorder”, “destructive behavior”, “challenging behavior”, “aggression”, etc. Severe Behavior Disorder Assessment Scale; SBDAS has been utilized to evaluate the behavioral symptoms in Japan [2]. The total scores of the scale more than 10 were observed in 50% of inpatients admitted in national facilities for those with severe intellectual disabilities, and behavioral symptoms were more evident in those without disabled motor activity [3].

The symptoms are thought to be complicatedly caused by genetic, brain organic, physical and circumstantial factors. Winter showed that there were significant and independent associations of challenging behavior with urinary incontinence, pain related to cerebral palsy, chronic sleep problems, and visual impairment, but not with hearing impairment, bowel incontinence, mobility impairment or epilepsy [4]. Cooper reported a cohort study to examine factors affecting aggressive behavior and self–injury in those with intellectual disabilities; aggressive behavior is correlated to lower intelligence, female, not living with family care–giver, no Down syndrome, attention–deficit hyperactivity disorders (AD⁄HD), and urinary incontinence, and that self–injury is the most strongly correlated to lower intelligence and AD⁄HD, and also correlated to no Down syndrome, not living with family care–giver and urinary incontinence [1,5]. Psychological management of the behavioral symptoms is principally the most important, but often results in care–givers exhausted. A number of studies have been undertaken with psychotropic such as antipsychotics, antiepileptic, lithium and anti depressant, and reviewed that risperidone is well demonstrated to be effective for the behavioral symptoms [6]. Because of unwilling adverse effects, such as dizziness, fall, apathy, weight gain, the dose of antipsychotics is limited, resulting in insufficient management of the behavioral symptoms, especially aggressive behavior. The selection of prescription remains in practical experiences, and often results in multiple prescriptions.

To examine psychiatric characters of the severe behavior disorder, we evaluated and analyzed the behavioral symptoms of institutionalized subjects. To evaluate the effectiveness of antiepileptic, we also analyzed the relation between the extent of the behavioral symptoms and the number and dose of prescribed antiepileptic.

Subjects and Methods


Subjects with severe intellectual disabilities were 80 inpatients in National Hospital Organization, Yamato Mental–Medical Center, composed of 59 males and 21 females, with their mean ± SD age of 37.6 ± 8.8 years. The causes underlying in intellectual disability were identified in 12 cases; tuberous sclerosis (2 cases), carbohydratedeficient syndrome (2 cases), head trauma (2 cases), encephalitis (3 cases), microcephaly (1 case), fragile X syndrome (1 case) and Down syndrome (1 case), but unknown in the other 68 cases. Information of this study was given to the subjects, when possible, and their guardians, and the informed consent to participate in this study was obtained from each guardian. The study was approved by the Ethics Committee of Yamato Mental–Medical Center.

Definition of severe behavior disorder

Clinical information of the subjects was obtained from their case records, and intelligence quotient (IQ) had been evaluated by clinical psychologists using Tanaka–Binet Intelligence Scale [7] or the Enjoji developmental test that evaluates physical abilities of the whole body, skilled hand motor activities, behavior, interpersonal skills, speech ability, and language comprehension [8]. Motor and intellectual disability of each subject was evaluated for their IQ and motor activity, and classified in Oshima's classification (Figure 1) [9]. Severe behavior disorder with intellectual disabilities corresponds to type 5, 6, 10, 11, 17 and 18 in the classification, where IQ level is ranged from 0 to 35, and motor activity is normal or mildly disabled (Table 1). The total score of Severe Behavior Disorder Assessment Scale; SBDAS, abbreviated hereafter, has been shown to be correlated with all five sub–scores on the Japanese version of the Aberrant Behavior Checklist–Community (ABC–J), namely, (I) Irritability, Agitation, Crying; (II) Lethargy, Social Withdrawal; (III) Stereotypic Behavior; (IV) Hyperactivity, Noncompliance; and (V) Inappropriate Speech[10,11].