Managing Mentally Challenged Patients in the Intensive Care Unit: A Comprehensive Review

Dr Neeraj Manikath. , Claude.ai

Abstract

Patients with intellectual and developmental disabilities (IDD) represent a vulnerable population in intensive care settings, presenting unique clinical, ethical, and communication challenges. Despite comprising approximately 1-3% of the general population, these patients remain underrepresented in critical care literature. This review synthesizes current evidence and expert recommendations for optimizing care delivery to mentally challenged patients in the ICU, addressing physiological considerations, communication strategies, behavioral management, family engagement, and ethical frameworks. Through integration of clinical pearls and practical approaches, this article aims to enhance competency among critical care practitioners in delivering equitable, person-centered intensive care to this population.

Keywords: Intellectual disability, developmental disability, intensive care, critical care, patient-centered care, behavioral management

Introduction

The term "mentally challenged" encompasses a heterogeneous group of conditions characterized by significant limitations in intellectual functioning and adaptive behavior, manifesting before age 18.¹ Contemporary medical practice favors the terms intellectual disability (ID) or intellectual and developmental disabilities (IDD), which include conditions such as Down syndrome, autism spectrum disorder, cerebral palsy, and genetic syndromes.

Critical illness in patients with IDD presents a confluence of challenges: baseline cognitive impairments, communication barriers, altered pain perception, behavioral dysregulation under stress, polypharmacy, and complex comorbidities.²,³ Traditional ICU protocols, designed for neurotypical adults, often prove inadequate for this population, potentially compromising both quality of care and outcomes.

Clinical Pearl #1: Always obtain a comprehensive baseline functional assessment early. What appears as acute delirium may be the patient's baseline cognitive state, and conversely, subtle changes in a nonverbal patient may represent significant deterioration.

Epidemiology and ICU Utilization

Approximately 1-3% of the population has IDD, with prevalence increasing due to improved pediatric survival rates and aging of this population.⁴ Studies demonstrate that adults with IDD have:

Higher rates of ICU admission compared to the general population⁵
Increased susceptibility to respiratory infections, aspiration, and seizures⁶
Greater mortality risk, often related to delayed recognition of illness⁷
Longer ICU length of stay due to communication barriers and complex care needs⁸

Oyster #1: Patients with IDD often have atypical presentations of common illnesses. A patient with Down syndrome may not mount a fever with sepsis; an autistic patient may not localize pain conventionally. Maintain a high index of suspicion and low threshold for investigation.

Pre-ICU Assessment: The Foundation of Care

1. Comprehensive History Gathering

The admission history must extend beyond the acute illness:

Essential Elements:

Baseline functional status: Communication methods (verbal, sign language, picture boards, assistive devices), mobility, activities of daily living, behavioral patterns
Medical complexity: Existing organ dysfunction, seizure history, aspiration risk, swallowing function, surgical history
Medication reconciliation: Including scheduled and PRN psychotropic medications, antiepileptics, and the timing of last doses
Behavioral triggers and calming strategies: Specific fears (needles, loud noises), comfort objects, preferred routines
Pain assessment baseline: How the patient typically expresses pain or discomfort
Decision-making capacity and legal guardianship status⁹

Hack #1: Create a "Patient Passport" or "Hospital Communication Book" with family input during the first 24 hours. Include photos, communication tips, behavioral triggers, calming strategies, and daily routine preferences. Laminate it and keep it at the bedside. This becomes an invaluable reference for all staff members across shifts.

2. Family as Expert Consultants

Families and caregivers possess irreplaceable expertise about their loved one. They can interpret subtle behavioral changes, recognize distress signals, and implement individualized comfort measures.¹⁰

Clinical Pearl #2: Frame family presence as a clinical intervention, not a privilege. Studies show that familiar caregiver presence reduces behavioral escalation, improves cooperation with care, and may reduce need for chemical restraint.¹¹

Communication Strategies

Understanding Communication Diversity

Communication impairment exists on a spectrum:

Verbal but concrete: May not understand abstract concepts, medical jargon, or future-oriented thinking
Limited verbal: May use single words, echolalia, or scripted phrases
Nonverbal: May use sign language, picture boards, assistive technology, or behavioral communication
Inconsistent communication: May regress under stress to earlier developmental levels

Practical Communication Framework

The RESPECT Approach:

R - Reduce sensory overload

Dim lights when possible, minimize alarm volumes, limit unnecessary traffic
Consider sensory sensitivities (textures, sounds, smells)

E - Establish communication method

Use the patient's typical communication tools
Employ visual supports: picture pain scales, choice boards, schedules
Consider augmentative and alternative communication (AAC) devices

S - Simplify language

Use concrete, simple sentences: "I will listen to your chest" not "I need to auscultate your lungs"
Give one instruction at a time
Allow extended processing time (10-30 seconds)

P - Prepare for procedures

Use visual schedules showing sequence of events
Practice with medical play (tourniquet before IV start)
Avoid surprises; maintain predictability

E - Empathetic body language

Position at eye level, non-threatening posture
Respect personal space preferences (some patients prefer more distance)
Consistent caregivers when possible

C - Calm, slow pacing

Avoid rushing through interactions
Allow time for processing and response
Recognize fatigue and sensory saturation

T - Trust family interpretation

Ask: "What is your loved one telling us right now?"
Defer to family expertise on communication signals¹²

Hack #2: Use a tablet with the patient's photos from home (family, pets, favorite places) and familiar music. This can be simultaneously comforting and a communication tool. Ask family to load preferred content on the first day.

Oyster #2: Absence of response is not absence of understanding. Many patients with IDD have receptive language that far exceeds their expressive abilities. Always assume the patient understands everything said in their presence. This is both respectful and clinically important—negative comments can cause genuine psychological harm.

Pain Assessment in Non-Communicative Patients

Pain assessment represents one of the most challenging aspects of care, as traditional self-report scales are often impossible to use.

Behavioral Pain Assessment

Several validated tools exist, though none are perfect:

FLACC Scale (Face, Legs, Activity, Cry, Consolability): Originally pediatric, but applicable¹³
NCCPC-PV (Non-Communicating Children's Pain Checklist - Postoperative Version): Useful for adults with severe cognitive impairment¹⁴
Pain and Distress Assessment Tool (PDAT): Specifically for adults with dementia, adaptable to IDD¹⁵

Individualized Pain Behaviors:

Work with family to identify the patient's unique pain indicators:

Vocalizations: Specific sounds, changes in typical vocal patterns
Facial expressions: Grimacing, eye squeezed shut, furrowed brow
Body movements: Guarding, thrashing, increased muscle tone, self-injurious behavior
Activity changes: Withdrawal, aggression, refusal to move
Physiological signs: Tachycardia, hypertension, diaphoresis (though unreliable in isolation)
Changes from baseline: Any new or increased challenging behavior should trigger pain assessment

Clinical Pearl #3: Create a personalized pain scale. Ask family: "On a scale where 0 is [patient's name] at their most comfortable and 10 is the worst pain you've ever seen them in, where are they now?" Rate and reassess after interventions. This respects individual variability while providing a semi-quantitative measure.

Hack #3: The "Treatment Trial" approach: If pain cannot be reliably assessed and clinical suspicion exists, provide time-limited analgesia and observe response. Improvement in distress behaviors suggests pain was present. Document this as a clinical observation tool.

Behavioral Management in the ICU

Understanding Behavioral Responses

Challenging behaviors in the ICU setting usually represent communication of distress:

Pain or discomfort
Fear and anxiety
Sensory overload
Disruption of routine
Inability to understand the situation
Separation from familiar people/environment
Medication effects or withdrawal

Fundamental Principle: *Behavior is communication. Before considering sedation or restraint, systematically address potential triggers.*¹⁶

The Hierarchy of Behavioral Intervention

Tier 1: Environmental Modification (First-Line)

Reduce stimulation: dimmed lights, minimize alarms, quiet times
Maintain routine where possible: consistent timing for cares, meals, sleep
Provide familiar objects: blankets, music, photos, comfort items
Ensure comfort: positioning, temperature, elimination needs

Tier 2: Presence and Comfort (Second-Line)

Family presence 24/7 if possible (requires ICU policy flexibility)
Consistent nursing assignments
Familiar activities: videos, music, sensory items
Distraction and redirection rather than confrontation

Tier 3: Continuation of Home Medications (Critical)

Continue home psychotropic medications unless contraindicated
Abrupt discontinuation of antipsychotics, benzodiazepines, or stimulants can cause withdrawal or behavioral decompensation
Coordinate with psychiatry or developmental medicine specialists

Tier 4: PRN Medications from Home

Use the patient's established PRN regimen for behavioral escalation
These medications have known efficacy and side-effect profiles for the individual

Tier 5: New Pharmacological Interventions

Consider only after above tiers exhausted
Consult developmental disabilities specialists when available
Start low, go slow with new psychotropics
Avoid excessive anticholinergic burden
Be aware of altered pharmacokinetics in some syndromes (e.g., Down syndrome)¹⁷

Oyster #3: Paradoxical reactions to benzodiazepines occur in up to 15% of patients with IDD, potentially causing increased agitation rather than sedation.¹⁸ If escalating a benzodiazepine makes behavior worse, stop it rather than increase the dose.

Hack #4: Create a "Behavioral Escalation Plan" card at the bedside with family input: Early Warning Signs → Specific Interventions → Medications (with doses) → Emergency Contacts. This functions like a code card but for behavioral crisis, ensuring consistent, individualized response across staff.

Physical Restraints: Last Resort

Restraints create significant risks in patients with IDD:

Increased agitation and psychological trauma
Risk of injury (restraint-related deaths are documented)
Impaired communication of needs
Ethical concerns regarding autonomy

When restraints are unavoidable:

Use the least restrictive method for the shortest duration
Document clear medical necessity and alternatives attempted
Provide 1:1 observation when possible
Frequent reassessment (every 15-30 minutes)
Consider specialty consultation (psychiatry, behavioral medicine)¹⁹

Clinical Pearl #4: Consider "therapeutic holding" by family members as an alternative to mechanical restraint for brief procedures. This provides comfort while ensuring safety, though requires family consent and emotional capacity.

Medical Management Considerations

Syndrome-Specific Physiological Concerns

**Down Syndrome (Trisomy 21):**²⁰

Atlantoaxial instability: careful neck positioning, cautious intubation
Congenital heart disease: up to 50% prevalence
Obstructive sleep apnea: baseline hypoxemia, altered ventilator weaning
Hypothyroidism: affects drug metabolism
Immune dysfunction: increased infection risk
Altered pharmacokinetics: may require dose adjustments

**Autism Spectrum Disorder:**²¹

Sensory sensitivities: profound impact on tolerance of ICU environment
Gastrointestinal issues: constipation, selective eating affecting nutrition
Seizure disorder: present in 20-30%
Psychotropic medications: complex regimens requiring continuation
Sleep disorders: may require home sleep medications

**Cerebral Palsy:**²²

Gastroesophageal reflux and aspiration risk
Seizure disorders
Contractures affecting positioning and pressure ulcer risk
Scoliosis affecting respiratory mechanics
Chronic pain from musculoskeletal issues
Nutrition via gastrostomy tubes

Fragile X Syndrome:

Cardiac: mitral valve prolapse, aortic root dilation
Seizures in 10-20%
Anxiety: severe reactions to ICU environment
Connective tissue laxity

Polypharmacy and Drug Interactions

Patients with IDD commonly take multiple medications:

Antiepileptics: Continue to prevent withdrawal seizures; check levels
Psychotropics: Antipsychotics, mood stabilizers, anxiolytics—continue unless contraindicated
Antispasmodics: Baclofen withdrawal can be life-threatening
Medications for GERD, constipation, osteoporosis

Hack #5: On admission, have pharmacy create a "Home Medication Continuation" order set specific to the patient. This prevents inadvertent omissions and ensures appropriate ICU routes (e.g., crushing tablets for feeding tubes, converting to IV equivalents).

Aspiration Risk and Nutrition

Dysphagia affects 60-90% of individuals with IDD, particularly those with cerebral palsy.²³

Assessment and Management:

Obtain history of aspiration, pneumonias, modified diet textures
Maintain NPO until swallowing assessment if any concern
Continue home feeding methods: gastrostomy, jejunostomy, thickened liquids
Elevate head of bed 30-45 degrees
Consider post-pyloric feeding if high aspiration risk
Collaborate with speech pathology early

Clinical Pearl #5: Don't assume the presence of a G-tube means the patient cannot eat orally. Many patients have both oral feeding (for pleasure, certain foods) and supplemental tube feeding. Clarify the home regimen to maintain quality of life where medically safe.

Ethical Considerations and Shared Decision-Making

Capacity, Consent, and Guardianship

Legal capacity status varies widely:

Some patients have full capacity for medical decisions
Some have partial capacity (can make some decisions but not others)
Some have legal guardians (family member, professional guardian, state guardianship)
Some have supported decision-making arrangements

Critical Actions:

Clarify legal decision-making status early
Involve the patient in communication to their maximum ability
Honor supported decision-making preferences
When guardians decide, incorporate patient's known values and preferences²⁴

Oyster #4: The presence of IDD does not automatically mean lack of decision-making capacity. Capacity is decision-specific and fluctuates. A patient may be able to consent to simple interventions but not complex ones. Always assess capacity for the specific decision at hand, providing information in accessible formats.

Goals of Care Discussions

Goals of care conversations require particular sensitivity:

Best Practices:

Early, repeated conversations (ICU admission, at changes in status)
Accessible language; avoid euphemisms
For patients with capacity: include them directly with communication supports
Explore: What makes life meaningful for this person? What would they want? What have they said?
Address misconceptions: IDD does not preclude meaningful life; avoid quality-of-life judgments based solely on baseline disability²⁵
Collaborative decision-making: shared understanding of prognosis, options, and values

Clinical Pearl #6: Ask: "Help me understand what brings [patient] joy in life." This opens conversation about quality of life from the patient's perspective rather than the clinician's assumptions about disability.

Bias and Health Equity

Unconscious bias affects care delivery:

Studies document that patients with IDD receive less aggressive treatment, earlier DNR orders, and have higher mortality independent of illness severity²⁶,²⁷
Clinicians may underestimate quality of life and overestimate burden
Communication barriers may be misinterpreted as lack of capacity or personhood

Addressing Bias:

Recognize and reflect on personal biases
Seek education on disability perspectives
Consult ethics committees when values conflicts arise
Apply prognostic tools based on acute illness, not baseline disability
Ensure equitable access to all therapeutic options

Hack #6: Implement a "Bias Check" in morning rounds: When discussing prognosis or goals for patients with IDD, explicitly ask: "Would we be offering/recommending this treatment if the patient did not have intellectual disability?" This creates space to examine assumptions.

Transitions of Care

ICU Discharge Planning

Early planning is essential given complex care needs:

Key Elements:

Assess post-ICU placement: Can patient return to previous living situation? Home with family? Group home? Skilled nursing facility?
Medical equipment needs: oxygen, suction, feeding pumps, specialized wheelchairs
Medication reconciliation: ICU changes, new prescriptions, restarting home medications
New care requirements: tracheostomy care, wound care, tube feeding management
Follow-up appointments: schedule before discharge with primary care, specialists
Caregiver training: hands-on teaching for complex care tasks
Care coordination: communicate with existing providers, case managers, developmental disability services²⁸

Clinical Pearl #7: Schedule a multidisciplinary family meeting 48-72 hours before anticipated discharge. Include ICU team, social work, case management, therapy services, and family/caregivers. Create a written discharge plan collaboratively. This prevents crisis discharges and readmissions.

Communication with Outpatient Providers

Provide comprehensive discharge summary:

Baseline functional status before ICU (for future comparison)
ICU course, diagnoses, complications
New medications or medication changes
New care needs or equipment
Behavioral changes or new concerns
Follow-up needs and timeline

ICU System and Cultural Changes

Policy Recommendations

To improve care for patients with IDD, ICU systems should consider:

Flexible Visitation Policies:
- 24/7 family presence for patients with IDD
- Designated family "care partner" role
- Accommodation for multiple caregivers
Environmental Modifications:
- Private rooms when possible
- Sensory-friendly spaces (dimming, quiet zones)
- Flexibility in adherence to strict routines when medically safe
Communication Resources:
- Picture boards and visual supports readily available
- Access to AAC devices and speech pathology
- Interpretation of communication behaviors
Education and Training:
- Staff education on IDD and communication strategies
- Disability awareness training addressing bias
- Specialty consultation access (developmental medicine, behavioral neurology)
Documentation:
- Templates capturing baseline functional status
- Patient passport/communication plans in the medical record
- Behavioral management plans²⁹,³⁰

Hack #7: Establish an "IDD Champion" on each ICU—a nurse or physician with special interest who serves as a resource for complex cases, maintains comfort items (picture boards, sensory tools), and leads staff education. This creates institutional expertise.

Building Competence: A Self-Assessment

Clinicians can assess readiness to care for patients with IDD:

Knowledge:

Do I understand common IDD conditions and associated medical comorbidities?
Am I familiar with behavioral pain assessment tools?

Skills:

Can I modify my communication for different cognitive levels?
Do I know how to involve family as expert consultants?
Can I recognize and address behavioral distress without defaulting to sedation?

Attitudes:

Do I recognize that patients with IDD deserve equitable intensive care?
Am I aware of my own biases about disability and quality of life?
Do I approach families as partners rather than barriers?

Case-Based Learning: Integrating Principles

Case Scenario

Patient: 32-year-old man with moderate intellectual disability (IQ ~45) secondary to unknown etiology, admitted with septic shock from pneumonia.

Baseline: Lives in a group home, nonverbal but uses picture board for basic needs, ambulates with assistance, seizure disorder on valproic acid, GERD on omeprazole, generally happy demeanor, enjoys music and swimming.

ICU Course: Day 3, requiring mechanical ventilation, vasopressors weaning, but persistently agitated despite sedation. Attempts to self-extubate. Placed in soft restraints. Family reports, "This isn't like him—he's never aggressive."

Application of Principles:

Behavioral assessment: Is this delirium, pain, fear, medication effect, or something else?
Systematic approach:
- Pain assessment: Using FLACC scale and family input—score suggests severe pain
- Medication review: Sedation includes high-dose benzodiazepines—could this be paradoxical agitation?
- Environmental: ICU is loud, bright, no familiar items
- Routine disruption: No predictability, unfamiliar caregivers
Interventions:
- Increase analgesia (fentanyl infusion), reassess pain
- Transition from midazolam to propofol (avoid paradoxical benzodiazepine effect)
- Family presence at bedside with his tablet playing favorite music
- Dim lights, minimize alarms where safe
- Continue home valproic acid and omeprazole
- Create visual schedule showing when suctioning will occur
- Consistent nurse assignment for next 48 hours
Outcome: Agitation resolves within 12 hours. Successfully extubated on day 5 with family at bedside. Discharged day 8 to group home with outpatient follow-up arranged.

Key Insight: Behavior communicated unmet needs. Systematic assessment and multimodal intervention prevented prolonged restraint and potential complications.

Conclusion: Toward Equitable Critical Care

Caring for patients with intellectual and developmental disabilities in the ICU demands clinical excellence, creative communication, ethical sensitivity, and systemic flexibility. These patients challenge us to expand beyond standardized protocols and engage in truly individualized care.

The principles outlined—comprehensive baseline assessment, family partnership, accessible communication, behavioral understanding, syndrome-specific knowledge, ethical awareness, and systemic advocacy—provide a framework for delivering high-quality intensive care to this vulnerable population.

As critical care practitioners, we have a professional and moral obligation to ensure that the ICU is accessible and responsive to all patients, regardless of cognitive ability. By embracing these principles, we not only improve outcomes for patients with IDD but also strengthen our practice for all patients, recognizing that person-centered care, clear communication, and holistic assessment benefit everyone.

Final Clinical Pearl: The question is never "Can we treat this patient in the ICU?" but rather "How can we adapt our ICU to best serve this patient?"

Key Takeaways: Pearls for Practice

Obtain comprehensive baseline functional assessment early—what's normal for this patient?
Embrace family as expert consultants—their knowledge is irreplaceable
Behavior is communication—systematically address triggers before sedation
Create individualized tools—patient passports, personalized pain scales, behavioral plans
Continue home medications—especially psychotropics and antiepileptics
Communicate accessibly—simple language, visual supports, processing time
Check your bias—disability does not define quality of life or treatability
Plan discharge early—complex needs require coordination
Advocate for system change—flexible policies, education, resources
Remember personhood—the patient is a unique individual, not defined by their diagnosis

References

American Association on Intellectual and Developmental Disabilities. Definition of Intellectual Disability. https://www.aaidd.org/intellectual-disability/definition. Accessed 2025.
Heslop P, Blair PS, Fleming P, et al. The Confidential Inquiry into premature deaths of people with intellectual disabilities in the UK: a population-based study. Lancet. 2014;383(9920):889-895.
Straetmans JM, van Schrojenstein Lantman-de Valk HM, Schellevis FG, Dinant GJ. Health problems of people with intellectual disabilities: the impact for general practice. Br J Gen Pract. 2007;57(534):64-66.
Maulik PK, Mascarenhas MN, Mathers CD, Dua T, Saxena S. Prevalence of intellectual disability: a meta-analysis of population-based studies. Res Dev Disabil. 2011;32(2):419-436.
Reichard A, Stolzle H, Fox MH. Health disparities among adults with physical disabilities or cognitive limitations compared to individuals with no disabilities in the United States. Disabil Health J. 2011;4(2):59-67.
Ouellette-Kuntz H, Shooshtari S, Temple B, et al. Estimating administrative prevalence of intellectual disabilities in Manitoba. J Dev Disabil. 2009;15(3):69-80.
Carey IM, Shah SM, Hosking FJ, DeWilde S, Harris T, Beighton C, Cook DG. Health characteristics and consultation patterns of people with intellectual disability: a cross-sectional database study in English general practice. Br J Gen Pract. 2016;66(645):e264-e270.
Balogh RS, Ouellette-Kuntz H, Brownell M, Colantonio A. Hospitalisation rates for ambulatory care sensitive conditions for persons with and without an intellectual disability—a population perspective. J Intellect Disabil Res. 2013;57(9):820-832.
American College of Emergency Physicians. Care of Patients with Intellectual and Developmental Disabilities in the Emergency Department. Ann Emerg Med. 2016;68(5):678.
Brown HK, Lunsky Y, Wilton AS, Cobigo V, Vigod SN. Pregnancy in women with intellectual and developmental disabilities. J Obstet Gynaecol Can. 2016;38(1):9-16.
Iezzoni LI, Rao SR, Ressalam J, et al. Physicians' perceptions of people with disability and their health care. Health Aff (Millwood). 2021;40(2):297-306.
Braithwaite J, Herkes J, Churruca K, et al. Comprehensive care for people with epilepsy and intellectual disability. Epilepsy Behav. 2019;96:150-154.
Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293-297.
Breau LM, Finley GA, McGrath PJ, Camfield CS. Validation of the Non-communicating Children's Pain Checklist-Postoperative Version. Anesthesiology. 2002;96(3):528-535.
Fuchs-Lacelle S, Hadjistavropoulos T. Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Manag Nurs. 2004;5(1):37-49.
Griffith GM, Hastings RP. 'He's hard work, but he's worth it'. The experience of caregivers of individuals with intellectual disabilities and challenging behaviour: A meta-synthesis of qualitative research. J Appl Res Intellect Disabil. 2014;27(5):401-419.
Mégarbane A, Ravel A, Mircher C, et al. The 50th anniversary of the discovery of trisomy 21: the past, present, and future of research and treatment of Down syndrome. Genet Med. 2009;11(9):611-616.
Livingston G, Kelly L, Lewis-Holmes E, et al. A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia. Health Technol Assess. 2014;18(39):1-226.
Joint Commission. Restraint and Seclusion Standards for Behavioral Health. https://www.jointcommission.org. Accessed 2025.
Bull MJ; Committee on Genetics. Health supervision for children with Down syndrome. Pediatrics. 2011;128(2):393-406.
Croen LA, Zerbo O, Qian Y, et al. The health status of adults on the autism spectrum. Autism. 2015;19(7):814-823.
Blair E, Watson L, Badawi N, Stanley FJ. Life expectancy among people with cerebral palsy in Western Australia. Dev Med Child Neurol. 2001;43(8):508-515.
Chadwick DD, Jolliffe J. A descriptive investigation of dysphagia in adults with intellectual disabilities. J Intellect Disabil Res. 2009;53(1):29-43.
Carrese JA, Mullin JL, Carrese MG, Moseley K. Planfulness in the medical care of persons with intellectual disabilities. Hastings Cent Rep. 2018;48(5):31-41.
Iezzoni LI. Why increasing numbers of physicians with disability could improve care for patients with disability. AMA J Ethics. 2016;18(10):1041-1049.
Hosking FJ, Carey IM, Shah SM, et al. Mortality among adults with intellectual disability in England: comparisons with the general population. Am J Public Health. 2016;106(8):1483-1490.
Lunsky Y, Elserafi J, Flint A, et al. Predictors of aggressive behaviour in psychiatric inpatients with autism spectrum disorders. J Autism Dev Disord. 2018;48(9):3018-3025.
Okumura MJ, Kerr EA, Cabana MD, Davis MM, Demonner S, Heisler M. Physician views on barriers to primary care for young adults with childhood-onset chronic disease. Pediatrics. 2010;125(4):e748-e754.
Iacono T, Bigby C, Unsworth C, Douglas J, Fitzpatrick P. A systematic review of hospital experiences of people with intellectual disability. BMC Health Serv Res. 2014;14:505.
Balogh R, Wood J, Lunsky Y, Isaacs B, Ouellette-Kuntz H, Sullivan WF. Care of adults with developmental disabilities: effects of a continuing education course for primary care providers. Can Fam Physician. 2015;61(7):e316-e323.

Wednesday, October 22, 2025