From Guidelines for Managing the Client with Intellectual Disability in the Emergency Room (© 2002)
If medication has been prescribed, make sure that this is communicated to the GP or community psychiatrist. If the client does not have a community physician, connect the client to outpatient psychiatric services.
4.2 Referral to specialized services
Specialized assessment and consultation services may be needed if:
- the situation is complex
- several services are already involved
- there is a history of difficulty clarifying a diagnosis or determining effective intervention.
Identify what specialized services are available in the client's area. For example, individuals from the Toronto area can contact either of the following centres:
The Dual Diagnosis Resource Service at the Centre for Addiction and Mental Health (CAMH):
This service provides phone consultation on the same day of the call (between 9 a.m. and 5 p.m.), and it also provides more in-depth multidisciplinary assessment, diagnosis, and time-limited treatment and consultation services as needed. Call 416-535-8501 ext. 7809.
Surrey Place Centre (SPC):
The Infancy, Children and Youth Services Division at Surrey Place Centre serves individuals with intellectual disabilities from birth to age 22. The Division focuses on the interdisciplinary assessment and treatment of difficulties often associated with intellectual disabilities. Services include psychology, speech language pathology, audiology, behaviour therapy, family and individual counselling and social work. There are also life skills groups (e.g., anger management and sex education) and family-oriented groups for parents and siblings. Access to pediatrics, neurology and psychiatry comes from internal referral. Call Infancy, Children and Youth Services Intake at 416-925-5141.
The Adult Services Division at Surrey Place Centre serves individuals with intellectual disability aged 23 years and over. The disciplines represented in the Division include audiology, nursing, occupational therapy, psychology (e.g., counselling and behaviour therapy), psychiatry, social work and speech-language pathology. Services include assessment, intervention and service co-ordination. Families and the clients' other caregivers may also be offered support. There are waiting lists for all services; however, urgent cases will be prioritized. Call Adult Services Intake at 416-925-5141.
4.3 Plan for next time
As crises are common for many persons with a dual diagnosis, it is wise to have a proactive crisis management plan. Caregivers should be encouraged to develop such a plan, clearly indicating who to call or what service to contact in response to the issues of concern. For example, for someone who experiences periods of disruptive behaviours, caregivers should have available an escalation hierarchy protocol that indicates how to respond to the individual at each point of his or her behavioural escalation, including when to seek general medical advice. Caregivers will have identified at what point on this escalation hierarchy they need to seek help from the emergency services and when to take the client to the ER. It is often helpful for the caregivers to have a letter written by the community physician that they can take with them to the ER. This letter should briefly outline the psychiatric disorder and treatment being provided. The letter might also suggest preferred ways to manage general crises for that individual, based on past experiences.
Develop and update any existing proactive crisis management plan with caregivers based on the client's most recent experience in the ER. Encourage caregivers to keep a client binder for ER visits and doctor appointments and to bring this with them to the ER.
Make sure your recommendations from this ER visit are communicated to those supporting the client in the community and those who may be involved in future crises (e.g., caregivers, family members, community services). This can be done by giving a copy of your assessment, with clear recommendations, to the person accompanying the client to the ER and making arrangements for a copy to be provided to the caregiver who sees the client daily. For example, if the client is in a group home, a copy of your assessment recommendations (having obtained appropriate consent for release of information) should be sent to the client's primary residential caregiver at the group home and to the group home manager. These recommendations should be accompanied with a specific request that they be passed along to family members, other caregivers, the client's family doctor, psychiatrist and relevant community agencies. Where possible, you should try to make direct contact with the client's community physician and provide direct feedback.
4.4 A final reminder
If this was your first experience of a client with intellectual disability in a crisis, and it felt uncomfortable, that's OK. Relax. No matter how disastrous a situation was, review it with colleagues, learn from it, and try to understand the personal and professional distress you may have experienced. Don't react by denying further contact with this client, or by prejudging and rejecting other clients with intellectual disabilities. And don't be afraid to seek expert help.
Debriefing and training is available through the Dual Diagnosis Resource Service at 416-535-8501 ext.7809. Such training can be most useful when your team has had a recent experience with a client so that questions can be focused on the realities of your circumstances and the issues you encountered while responding to the client.