Mental Health Influences on Aggression

See a chart to help identify behavior changes that may be indicative of mental illness.

“Cate” is a 25-year-old individual with Angelman syndrome (deletion positive).  Cate lives at home with her mother and father. She suffers from a seizure disorder, requires use of wheelchair to walk long distances, and has a history of bowel and bladder incontinence. Cate does not use a formal communication system, but is able to communicate with some idiosyncratic signs. She also points and leads others to what she wants. She is able to use several word approximations consistently. Cate attends a day program on weekdays, riding the bus to and from her program. In the evenings and on weekends she is home with her parents with no support staff.

Cate has always struggled with impulsivity, especially in social settings. She often will grab at others, pulling at their hair and clothes. Cate also often bangs on the walls of her home to get her parents attention and to get some of her needs met (such as turning on the television or obtaining a favorite food).  These behaviors were manageable by redirection when she was younger, however now as an adult they have become more disruptive. Cate often grabs at people in public, limiting her mother’s comfort with taking her out of the home. She also has become disruptive on the bus to day program, grabbing at her aide and at times becoming aggressive while she is strapped in her seat on the bus. Cate’s banging behaviors have also become more troublesome to her parents, as she will bang on the wall between their bedrooms at night when she is awake in an attempt to get their attention.

Cate and her mother worked with a behavioral therapist for several months targeting her “banging” and “grabbing” behaviors. Some improvement in the banging was made through practical interventions such as padding the wall. However the impulsive grabbing continued, and Cate was at risk of not being allowed on the bus to her day program.

At this time, Cate was seen for a psychotropic medication evaluation. Following a great deal of discussion, the decision was made to start Cate on a low dose of Seroquel (quetiapine) targeting her impulsive and irritable behaviors. At the initial dose of Seroquel, little changed with Cate’s behavior. However, as the medication was slowly increased to three times per day dosing, Cate’s behavior began to improve. There was a notable reduction in her behavior on the bus, much to the relief of her aide and the bus driver. Cate was more easily redirectable away from her banging behaviors. She also began to sleep a bit better at night. Unfortunately Cate did experience some sedation with this medication, which limited increasing the dose further. However, over time she was able to tolerate a dose that was helpful with her behavior without being overly sedating.

Individuals with Angelman syndrome are at risk of the development of mental illness, just like those of us without developmental disabilities. When severe changes in behavior, mood or functioning occur, mental illness should be considered as a potential cause. In those cases, individuals should be evaluated by a certified mental health practitioner such as a psychologist or a psychiatrist. When mental illness is identified, often there are medications that can be used to help treat these symptoms. Medications for anxiety and depression are often quite effective, and in the rare cases of severe disruptive or aggressive behavior, atypical antipsychotics can often help with these behaviors.