Mental Health Issues

What are the Major Mental Health Concerns in People With Down Syndrome?

At least half of all children and adults with Down syndrome face a major mental health concern during their lives. Those with multiple medical problems experience an even higher rate of mental health problems.

The most common mental health concerns include:

  • General anxiety
  • Obsessive-compulsive behaviors
  • Oppositional, impulsive and inattentive behaviors
  • Sleep related difficulties
  • Depression
  • Autism spectrum conditions
  • Neuropsychological problems characterized by progressive loss of cognitive skills.

Many of these seem to occur as a reaction to a psychosocial or environmental stressor such as illness, separation or loss of a key attachment figure.

What are the Symptoms of Generalized Anxiety, Obsessive- Compulsive Disorder and Depression in Down Syndrome? How are They Diagnosed and Treated?

Generalized Anxiety

This manifests an increased level of both baseline and situational anxiety with clear cut stressors for each. Situational anxiety often manifests during transitions and anticipation of new situations.

Obsessive Compulsive Symptoms

Increased levels of restlessness and worry may lead the child or adult to behave in a very rigid manner, even resulting in a state of being “stuck”. The child or adult needs to follow familiar routines in these situations. They also engage in repetitive, compulsive, as well as ritualistic behaviors that raise the question of obsessive-compulsive disorder. The child or adult tends to be unhappy and fearful.

Depressive Symptoms

People with Down syndrome present with extreme social withdrawal, sad (but not labile) affect, and inability to enjoy many activities they used to love. Parents or caregivers often report that the person’s demeanor had not previously been like that. A most remarkable aspect of depression in children and adults with Down syndrome is its association with environmental noxious triggers. These may include previously unrecognized medical illness or pain or psychosocial stressors such as an older sibling moving to college, sudden or chronic illness in a family member, or absence of a teacher. All these ordinary events seem extraordinary for children and adults with Down syndrome with a disproportionate psychological impact. People with Down syndrome are exquisitely sensitive to changes in their environment which they often perceive unfavorably.

What are the Inattentive, Impulsive, Hyperactive and Disruptive Symptoms in People With Down Syndrome? How are They Diagnosed and Treated?

People with Down syndrome often have significant processing difficulties and have trouble staying focused on tasks. This is often accompanied by impulsive and hyperactive consistent with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). For this reason, many of them are treated with stimulant medications.

In a subpopulation of people with Down syndrome, there is a definite adverse behavioral activation in response to these medications. The most commonly observed adverse effects include: irritability, agitation, aggression, transitional anxiety, and sleep related problems. Parents and caregivers must be forewarned about these adverse effects since they can occur soon after initiation of treatment. A small group of children with ADHD symptoms may nevertheless benefit from stimulant medication, but even these children may experience an increase in anxiety along with obsessive-compulsive symptoms. For this reason, the main emphasis in treatment of ADHD-like symptoms needs to focus on behavioral and therapeutic strategies to enhance adaptive functioning and performance in the home and classroom settings.

For children with high-degree impulsivity and disruptive behaviors, the use of low dose clonidine has been helpful, but this medication may also have limited efficacy as it may lead to daytime drowsiness in some children. It should be emphasized that the use of clonidine can be effective only in addressing impulsive, hyperactive and disruptive behavior and does not necessarily improve primary attention. Clonidine administered at bedtime may also help the child sleep.

What are the Major Environmental Triggers of Behavioral and Emotional Difficulties?

People with Down syndrome are often very sensitive to psychosocial and environmental stressors. Illness or lose of loved ones and family is particularly devastating and almost invariably leads to a complicated grief reaction during which time the person with Down syndrome may experience regressive changes in his or her ability to think, reason, remember, process information, and learn. The psychosocial and environmental triggers also lead to a state of generalized anxiety, obsessive compulsive symptoms, depression and sleep difficulties. They may be associated with weight loss, poor self care, and an inability to attend school or go to work. If the situation persists and there is no attempt to intervene with psychosocial counseling, medications or behavioral interventions, the mental state may persist and lead to a longer-term decline in psychosocial and cognitive functioning.

Is Oppositional Defiant Disorder Common in People With Down Syndrome?

Many people with Down syndrome have a wonderful disposition. They are fun loving and their interactions generally involve teasing, making jokes, and giggly outbursts. But these may lead to intrusive, uninhibited social behaviors. Sometimes these behaviors take over and the person may become increasingly oppositional, unable to listen, and self-immersed. For example, sitting down and refusing to get up or continuing in a self-directed activity with total disregard for meal, bath and bed times. The oppositional behaviors occur among individuals with all levels of cognitive and language skills, but are more difficult to manage in those with greater receptive-expressive communication difficulties. In the classroom setting, behavioral management and a one-on-one aide may help to keep the situation under control. Oppositional behavioral problems in children with receptive-expressive and cognitive limitations also tend to be associated with an increased level of impulsive and hyperactive behaviors and can often co-occur with ADHD symptoms.

Are Mood and Bipolar Disorders Common in People With Down Syndrome?

A comprehensive approach is needed to assess a person with Down syndrome presenting with mood instability. It is essential to rule out any underlying medical and neurological conditions and to consider the possibility of adverse medication effects that may lead to secondary mood instability.

A young child with Down syndrome that presents with persistent oppositional, impulsive, disruptive, irritable and aggressive behaviors could have a mood disorder. The coexistence of true bipolar disorder and Down syndrome is unknown. The use of anticonvulsant medications (as mood stabilizers) need only be considered under careful supervision. Likewise, the use of atypical neuroleptic medications ought to be considered only as a last resort with careful monitoring of side effects. Since people with Down syndrome are already at increased risk of weight gain, the increased appetite that comes with atypical neuroleptic medications can be destabilizing. Concurrent behavioral and nutritional interventions are therefore always essential.