Guidelines for Managing the Client with Intellectual Disability in the Emergency Room​

From Guidelines for Managing the Client with Intellectual Disability in the Emergency Room (© 2002)

Since 1995, the psychiatry residency curriculum at the University of Toronto has included systematic teaching in intellectual disabilities. 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 particularly 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 intellectual disabilities when they are brought to the hospital in crisis.  

 

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Contents

1. Assessment
   • Optimizing the clinical encounter 
   • Biopsychosocial understanding 
   • Assessing symptoms and behaviours that may point to a new onset psychiatric disorder and assessing for the presence of ongoing (chronic) psychiatric conditions 
   • 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
   • 2.1 Managing the immediate situation 
   • 2.2 Ruling out medical (and dental) disorders 
   • 2.3 Changing medications 
   • 2.4 Treating a psychiatric disorder 
3. Triage
   • 3.1  Deciding where further assessment and treatment can, and should, take place
     • 3.1.1 Inpatient admission required 
     • 3.1.2 Hospitalization not required but crisis requires an alternative environment 
     • 3.1.3 Return to home environment with follow-up supports 
4. Follow-up
   • 4.1 Medication 
   • 4.2 Referral to specialized services 
   • 4.3 Plan for next time 
   • 4.4 A final reminder 
5. Summary
6. References and other resources

There are few specialized mental health services for persons with intellectual disabilities in Ontario. Unfortunately, the first direct clinical experience the resident has with a person with intellectual disability is often in the emergency room. This encounter, positive or negative, is likely to influence the psychiatry resident's attitude toward persons with intellectual disabilities as a group. It is also likely to influence the resident's inclination toward further professional involvement with this population.

In writing these guidelines, we have therefore tried to address several issues that we feel, if not addressed, may create anxiety for health care providers, and lead to less than optimal intervention when treating persons with intellectual disabilities in crisis.

We start by outlining ways to optimize the clinical encounter. We then provide a framework for understanding and assessing the complex medical and mental health issues that often arise for persons with intellectual disabilities. Lastly, we provide a systematic way to evaluate how best to approach treatment and triage. Our hope is that these guidelines may contribute to a better outcome both for the client who comes to the emergency room and for the resident (or other health care worker) providing care.

These guidelines have been prepared by members of the Intellectual Disabilities Psychiatry Curriculum Planning Committee.* Members of this multidisciplinary committee have been involved in teaching first-year psychiatry residents over the past seven years. We would 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 resident), Dr. Nadine Nyhus (psychiatrist, Dual Diagnosis Program, Centre for Addiction and Mental Health (CAMH), Toronto), Dr. Martin Breton (family physician, Dual Diagnosis Program, CAMH, Toronto), Mr. Neill Carson (Manager, Dual Diagnosis Resource Service, Toronto) and Ms. Brenda Greenberg (Supervisor, Special Projects, Griffin Community Support Network, Toronto).

Finally, we would like to express our appreciation to publishing developer Caroline Hebblethwaite and editor Diana Ballon from the Centre for Addiction and Mental Health for their collegial assistance in helping us prepare these guidelines for publication.

As we plan to update these guidelines on a regular basis, we would greatly appreciate your feedback. Please send any comments and suggestions to:

Dr. Elspeth A. Bradley
Surrey Place Centre
2 Surrey Place
Toronto, ON M5S 2C2
Canada
e.bradley@utoronto.ca

*Committee members were:
Elspeth Bradley (chair), Intellectual Disability Psychiatrist,1, 2, 3
Lillian Burke, Psychologist,3
Caroll Drummond, Behaviour Therapist,3
Marika Korossy, Librarian and Resources Coordinator,3
Yona Lunsky, Psychologist,1, 2, 3
Susan Morris, Clinical Director,1, 2

1 Department of Psychiatry, University of Toronto
2 Dual Diagnosis Program, Centre for Addiction and Mental Health, Toronto
3 Surrey Place Centre, Toronto