Key Mental Health Concerns in Down Syndrome
At least half of all children and adults with Down syndrome will face a serious mental health concern during their lifetime. Those who have multiple health conditions tend to have higher rates of mental health problems. The most common mental health concerns include:
- General anxiety
- Obsessive-compulsive behaviours
- Behaviours characterised by stubbornness, impulsivity and inattention
- Sleep difficulties
- Depression
- Autism spectrum conditions
- Neuropsychological problems characterised by progressive loss of cognitive skills
Many of these problems appear to occur as a reaction to psychosocial or environmental stressors such as illness, isolation or the loss of a loved one.
Symptoms of General Anxiety, OCD and Depression: Diagnosis and Treatment
General Anxiety
Anxiety manifests as an increase in both baseline and situational anxiety in response to identifiable stressors in both forms. Situational anxiety most commonly appears during transitions and in anticipation of new situations or events.
Obsessive-Compulsive Symptoms
High levels of agitation and anxiety may lead a child or adult to behave in a very rigid manner, becoming "stuck" and needing to follow familiar routines. Individuals may also engage in repetitive, compulsive behaviours suggesting the possibility of obsessive-compulsive disorder (OCD). The person typically tends to appear sad and fearful.
Symptoms of Depression
Depression in people with Down syndrome presents as marked social withdrawal, sadness, and an inability to enjoy activities they previously loved. Parents or caregivers often report that the person's behaviour was not like this before.
One of the most notable aspects of depression in children and adults with Down syndrome is its association with identifiable adverse triggers in the person's environment. These may include an undiagnosed illness or physical pain, or psychosocial stressors such as an older sibling leaving for university, the sudden or chronic illness of a family member, or the absence of a teacher. Such ordinary life events can feel anything but ordinary to children and adults with Down syndrome, and they carry a significant psychological impact. People with Down syndrome tend to be acutely sensitive to changes in their environment, which they often experience as unwelcome.
Symptoms of Inattention, Impulsivity, Hyperactivity and Disruptive Behaviour: Diagnosis and Treatment
Many people with Down syndrome experience notable difficulties with cognitive processing and task focus. This is often accompanied by impulsivity and hyperactivity consistent with a diagnosis of attention deficit hyperactivity disorder (ADHD), and many are consequently treated with stimulant medications.
However, these medications can trigger negative paradoxical reactions in a subset of individuals with Down syndrome. The most common adverse effects include irritability, agitation, aggression, transient anxiety, and sleep disturbances. Parents and caregivers should be warned in advance of these potential effects, as they can emerge shortly after treatment begins. A small group of children with ADHD-like symptoms may benefit from stimulant medications, though even these children may experience increased anxiety alongside OCD-like symptoms. For this reason, when addressing ADHD-like symptoms, the primary focus should be on behavioural and therapeutic strategies to improve coping and functioning at home and in the classroom.
Low-dose clonidine may be beneficial for children who display high levels of impulsivity and disruptive behaviour, though its usefulness may be limited as it can cause daytime drowsiness in some children. It should be noted that clonidine may only be effective for addressing impulsivity, hyperactivity and disruptive behaviour — not necessarily for improving primary attention. Administering clonidine at bedtime may also help the child settle to sleep more easily.
Key Environmental Triggers for Behavioural and Emotional Difficulties
People with Down syndrome are often highly sensitive to psychosocial and environmental stressors. The illness or death of a loved one or family member is deeply distressing for them and, in virtually all cases, triggers a complex grief response that may be accompanied by a decline in cognitive functions including reasoning, memory, information processing and learning. Psychosocial and environmental triggers can also give rise to general anxiety, OCD-like symptoms, depression and sleep difficulties, and may be associated with weight loss, poor self-care, and an inability to attend school or work. If the situation continues without intervention — through psychosocial counselling, medication or behavioural support — the psychological state may persist, leading to a more prolonged decline in psychosocial and cognitive functioning.
Is Oppositional Defiant Disorder Common in People with Down Syndrome?
Many people with Down syndrome have wonderful temperaments and enjoy playful interaction, including teasing, joke-telling and bouts of laughter, though this can sometimes lead to socially inappropriate behaviours. On occasion, these behaviours can become overwhelming, and the person may become increasingly oppositional and unable to listen to others — for example, sitting down and refusing to get up, or continuing an activity of their own choosing while completely ignoring mealtimes, bath time or bedtime.
Oppositional behaviours can be seen in individuals across a wide range of cognitive and language abilities, though they are more complex to manage in those with receptive-expressive communication difficulties. In the classroom, behaviour management strategies and one-to-one support can help keep the situation under control. Oppositional behaviour problems in children with limited cognitive and receptive-expressive abilities tend to coincide with elevated impulsivity and hyperactivity, and frequently overlap with ADHD-like symptoms.
Are Mood Disorders and Bipolar Disorder Common in People with Down Syndrome?
Mood instability in a person with Down syndrome warrants a thorough evaluation. It is essential to rule out any underlying medical or neurological conditions and to consider the possibility that the instability may be caused by the side effects of current medications.
If a young child with Down syndrome displays persistently oppositional, impulsive and disruptive behaviour alongside irritability and aggression, there is a possibility that they have a mood disorder. Whether true bipolar disorder can occur in people with Down syndrome remains unclear. Anticonvulsant medications used as mood stabilisers should only be used under close supervision. Similarly, atypical antipsychotic medications should be considered only as a last resort and with careful monitoring of side effects; these drugs can significantly increase appetite, which is particularly concerning given the tendency of people with Down syndrome to gain weight easily. Behavioural and dietary interventions should therefore always accompany such pharmacological treatments.
Source: Information in this section has been reproduced under an exclusive arrangement with the National Down Syndrome Society (NDSS). Available at: www.ndss.org