Guidelines for Managing the Client with Intellectual Disability in the Emergency Room Guidelines for Managing the Client with Intellectual Disability in the Emergency Room Prepared by Elspeth Bradley and the Psychiatry Residency Year 1 (PGY1) Intellectual Disabilities Psychiatry Curriculum Planning Committee University of Toronto 3 Preface Since 1995, the psychiatry residency curriculum at the University of Toronto has included systematic teaching in intellectual disabil- ities. This topic is introduced to residents during the first six months of their training in two core curriculum half-day seminars. At this stage, the residents are new to psychiatry. They are partic- ularly anxious about how to manage psychiatric emergencies, and for many, this is their first exposure to persons with intellectual disabilities. In their feedback to us, residents have consistently asked for more information on how to manage persons with intel- lectual disabilities when they are brought to the hospital in crisis. Guidelines for Managing the Client with Intellectual Disability in the Emergency Room There are few specialized mental health services for persons with ISBN 088868-434-7 intellectual disabilities in Ontario. Unfortunately, the first direct 2710/11-02 PR056 clinical experience the resident has with a person with intellectual Printed in Canada disability is often in the emergency room. This encounter, positive Copyright © 2002 Centre for Addiction and Mental Health, or negative, is likely to influence the psychiatry resident’s attitude University of Toronto, Surrey Place Centre toward persons with intellectual disabilities as a group. It is also No part of this work may be reproduced or transmitted in any form or by any likely to influence the resident’s inclination toward further profes- means electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system without written permission from the sional involvement with this population. publisher — except for a brief quotation (not to exceed 200 words) in a review or professional work. In writing these guidelines, we have therefore tried to address For information on other Centre for Addiction and Mental Health several issues that we feel, if not addressed, may create anxiety for resource materials or to place an order, please contact: Marketing and Sales Services health care providers, and lead to less than optimal intervention Centre for Addiction and Mental Health 33 Russell Street when treating persons with intellectual disabilities in crisis. Toronto, ON M5S 2S1 Canada Tel.: 1-800-661-1111 or 416-595-6059 in Toronto We start by outlining ways to optimize the clinical encounter. E-mail: [email protected] We then provide a framework for understanding and assessing Web site: www.camh.net the complex medical and mental health issues that often arise for 4 Guidelines for Managing the Client with Intellectual Disability in the Emergency Room Preface 5 persons with intellectual disabilities. Lastly, we provide a system- As we plan to update these guidelines on a regular basis, we would atic way to evaluate how best to approach treatment and triage. greatly appreciate your feedback. Please send any comments and Our hope is that these guidelines may contribute to a better out- suggestions to: come both for the client who comes to the emergency room and for the resident (or other health care worker) providing care. Dr. Elspeth A. Bradley Surrey Place Centre These guidelines have been prepared by members of the Intellectual 2 Surrey Place Disabilities Psychiatry Curriculum Planning Committee.* Members Toronto, ON M5S 2C2 of this multidisciplinary committee have been involved in teaching Canada first-year psychiatry residents over the past seven years. We would [email protected] like to thank all those residents who attended the core curriculum seminars on intellectual disabilities in their first year and brought to our attention their immediate concerns in working with this population. The committee is also indebted to the following individuals who kindly reviewed earlier drafts of the guidelines and made helpful suggestions for improving the manuscript: Dr. Carol Coxon, (fourth-year psychiatry resident), Dr. Laura McCabe (third-year psychiatry resident), Dr. Chris McIntosh (first-year psychiatry *Committee members were: resident), Dr. Nadine Nyhus (psychiatrist, Dual Diagnosis Program, Elspeth Bradley (chair), Intellectual Disability Psychiatrist, 1, 2, 3 Centre for Addiction and Mental Health (CAMH), Toronto), Lillian Burke, Psychologist, 3 Dr.Martin Breton (family physician, Dual Diagnosis Program, Caroll Drummond, Behaviour Therapist, 3 CAMH,Toronto), Mr. Neill Carson (Manager, Dual Diagnosis Marika Korossy, Librarian and Resources Coordinator, 3 Resource Service, Toronto) and Ms. Brenda Greenberg (Supervisor, Yona Lunsky, Psychologist,1, 2, 3 Special Projects, Griffin Community Support Network, Toronto). Susan Morris, Clinical Director,1, 2 Finally, we would like to express our appreciation to publishing 1 Department of Psychiatry, University of Toronto developer Caroline Hebblethwaite and editor Diana Ballon from 2 Dual Diagnosis Program, Centre for Addiction and Mental Health, the Centre for Addiction and Mental Health for their collegial Toronto assistance in helping us prepare these guidelines for publication. 3 Surrey Place Centre, Toronto 6 Guidelines for Managing the Client with Intellectual Disability in the Emergency Room 7 Contents 1 Assessment ........................................7 1.1 Optimizing the clinical encounter 1.2 Biopsychosocial understanding 1.3 Assessing symptoms and behaviours that may point to a new onset psychiatric disorder and assessing for the presence of ongoing (chronic) psychiatric conditions Assessment 1.4 Caution 1.4.1 Understanding significant changes in behaviour 1.4.2 Understanding aggression 1.4.3 Diagnostic limitations in the ER 1.4.4 Diagnosing psychosis 2 Interventions in the ER ............................19 1 2.1 Managing the immediate situation 2.2 Ruling out medical (and dental) disorders 2.3 Changing medications 1.1 Optimizing the clinical encounter 2.4 Treating a psychiatric disorder 3Triage ..............................................23 You should be aware of the following: 3.1 Deciding where further assessment and treatment can, and should, take place Persons with intellectual disabilities* vary greatly in their ability to 3.1.1 Inpatient admission required 3.1.2 Hospitalization not required but crisis requires understand and communicate their needs, discomforts and con- an alternative environment cerns. You will therefore need to adapt your approach to each 3.1.3 Return to home environment with follow-up supports client’s level of functioning and understanding. 4 Follow-up ..........................................29 4.1 Medication If the client is behaving disruptively, begin by meeting briefly with 4.2 Referral to specialized services the caregivers to inquire about their client’s level of functioning 4.3 Plan for next time 4.4 A final reminder and to get advice about how best to meet and interact with their client. Find out about any circumstances that might be specifically 5 Summary ..........................................34 upsetting for that individual (e.g., being asked too many ques- 6 References ........................................36 tions; being in a noisy/busy environment; someone moving too close to them; seeing reflecting surfaces, such as eyeglasses). 7Other resources ....................................36 *Intellectual disability is sometimes referred to as developmental disability (Ontario), learning disability (UK) or mental retardation (DSM-IV-TR, 2000). 8 Guidelines for Managing the Client with Intellectual Disability in the Emergency Room Section 1 | Assessment 9 Many individuals may be unable to communicate verbally but will Assessing a client with an intellectual disability takes time. be aware of non-verbal behaviours in others and are often sensitized Research indicates that the process may take four times longer to negative attitudes others have toward them. Some individuals than the time required for someone without such a disability. depend on others to help modulate their emotions and will quickly pick up fear and anxiety in you. A warm, accepting, calm and Practical tips on conducting the interview: reassuring attitude will help the client feel more relaxed. ■ Try to make the individual as comfortable as possible. The ER is generally a strange and unfamiliar environment for any- ■ one. For persons with intellectual disabilities, the experience may Familiarity helps. Suggest that someone familiar to the client be particularly scary because they may not understand what is (e.g., caregiver) remains present. happening around them. Getting to the ER may also have been ■ traumatic, both for the client and his or her family. Waiting can be Use suggestions previously identified by the caregiver to help the anxiety-provoking and contribute to behavioural disturbances. client be more at ease. Take a moment to explain to the client and his or her caregivers ■ the reason for the wait. If the wait is longer than you expected, Encourage use of “comforters” (e.g., Does the individual have a check in from time to time to reassure the client. This will con- favourite item he or she likes to carry or does the client like to tribute to a more effective interview. engage in self-soothing, such as rocking or standing?). ■ Always check to see if this is the client’s