The Psychiatric Emergency Assessment of the Patient with Developmental Disability
Mark J. Hauser
Physicians who work in psychiatric emergency services (PESs) are likely to encounter people with a developmental disability (DD) at some point in their career. The term developmental disability encompasses many disorders that are defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV) in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” Keep in mind, though, that these disorders persist into adulthood and that people with DD are living longer and healthier lives. Persons with DD might pre-sent for emergency psychiatric evaluation at any point in the life cycle.
Developmental disability is a broad category that includes mental retardation as well as autistic disorder, Asperger disorder, and other developmental diagnoses. A significant change in nomenclature is taking place whereby mental retardation (a term heretofore commonly used in the United States) is increasingly referred to as intellectual disability. In light of this ongoing evolution of nomenclature, this chapter uses the new term intellectual disability (ID) interchangeably with the traditional term mental retardation (MR). ID, or MR, refers to the subset of people whose cognitive ability and adaptive functioning are substandard to a significant degree. In contrast, Asperger disorder refers to persons with deficits in social interaction, without ID. Persons with autistic disorder have deficits in social interaction and impairments in communication, and most have ID. Persons with ID or other forms of DD rarely present for emergency evaluation because of the DD diagnosis. Rather, they present because of an acute problem that has occurred in addition to their developmental disability. Typically, evaluation, assessment, and treatment are complicated by the impairments inherent in a DD diagnosis.
Mental retardation has a prevalence of between 1% and 3%, and between 40% and 70% of affected individuals have a comorbid axis I psychiatric disorder (1,2,3,4). In addition, persons with DD may present with adjustment disorders with behavioral or emotional disturbances, as well as relationship problems and acute functional impairments in occupational and educational domains. Anxiety disorders, especially social anxiety, may build to crisis proportions and lead to a visit to the PES. Einfeld and Tonge (4) studied persons aged 4 to 18 in Australia and found that 40.7% of those with an IQ of less than 70 had severe behavioral disorders, and less than one tenth were receiving psychiatric care. When one considers these statistics and takes into account the deinstitutionalization of people with mental retardation into community settings over the last several decades, it is not surprising that emergency psychiatric settings see a large number of DD patients in crisis.
Many physicians are made uncomfortable by the prospect of evaluating or treating patients with developmental disabilities. Medical education often lacks specific training about DD patients (5). During the initial encounter with such patients, physicians may feel as if they are not qualified to evaluate or treat the patient. Competent evaluation of the DD patient requires physicians to adapt their usual approach to account for the unique characteristics of the patient. This chapter focuses on mental retardation as the primary form of DD. The reader should be aware that the strategies and techniques presented are relevant and applicable with the other developmental disorders as well.
THE PATIENT WITH MENTAL RETARDATION
Mental retardation refers to deficits in cognitive and adaptive functioning with onset during the developmental period (up to age 18). The diagnosis of MR does not reveal the specific etiology; there are diverse etiologies, and in many cases the etiology is not known. MR is an enduring condition that persists over time. However, the person with MR continues to grow and develop over time and often displays developmental progress. Such development may at times be punctuated by developmental setbacks. The cognitive impairment itself is unlikely to be the cause of presentation for emergency psychiatric evaluation or visits to the emergency department. The relevant issue is how MR complicates the presenting problem, evaluation, emergency management, and treatment planning. This discussion presumes, then, that an acute condition is present that becomes the focus of evaluation and treatment, conducted in the context of a long-standing intellectual or other developmental disability.
DIAGNOSIS OF MENTAL RETARDATION OR INTELLECTUAL DISABILITY
The person with mental retardation has substandard cognitive functioning as measured by an IQ test and substandard adaptive functioning in such spheres as interpersonal relationships, daily living skills (grooming, hygiene, dressing, self-care, safety, and self-preservation), and managing interpersonal, recreational, and vocational aspects of life. Three criteria must be met for a diagnosis of mental retardation:
IQ (a measure of cognitive function based on verbal and performance measures) of 70 or below (equivalent to a cutoff of 2 standard deviations below the mean)
Deficits in adaptive functioning, and
Onset of the disorder before age 18
The severity of mental retardation is ranked by the degree of cognitive disability as measured by IQ. Mental retardation is specified on axis II of the DSM-IV, multiaxail formulation, along with its severity. The breakdown of the level of severity of MR is as follows:
Borderline intellectual functioning: IQ in the 71–84 range
Mild MR (85% of cases): IQ 50–55 to 70
Moderate MR (10%): IQ 35–40 to 50–55
Severe MR (3.5%): IQ 20–25 to 35–40
Profound MR (1.5%): IQ below 20–25
Unspecified MR: Severity undetermined
EPIDEMIOLOGY AND ETIOLOGY
MR is found in 2% to 3% of the population. It occurs in all socioeconomic groups around the world. MR is approximately 1.5 times more common in males than in females.
Advances in biology and genetic analysis have resulted in the detection of more than 2,000 known biologic causes of mental retardation. With testing, a biologic cause can be detected in a large proportion of affected individuals, yet the cause can remain unknown or be nonbiologic, as in the case of psychosocial factors.
Known etiologic factors include the following:
Clearly defined genetic causes
Prenatal factors (e.g., maternal nutrition, substance abuse with fetal toxicity)
Perinatal factors (e.g., cerebral anoxia during difficult delivery)
Acquired childhood diseases (e.g., encephalitis)
Head injury
Environmental factors (e.g., nutritional factors, toxins such as lead)
Psychosocial factors
PRESENTATION FOR EMERGENCY EVALUATION
Some PES clinicians may mistakenly not apply the usual goals of psychiatric emergency care for those patients with DD. The primary goals—namely, assessment of risk of harm to self or others; completion of biologic, psychological, and social assessment; development of a patient-centered treatment plan; and treatment in a less restrictive setting—apply to DD patients in the same way as other psychiatric emergency patients.
The presence of ID alone will not trigger an emergency evaluation. A person with ID may
demonstrate poor frustration tolerance, may become irritable and exhibit a behavioral decompensation, or may develop psychiatric symptoms that become the focus of evaluation. ID often results in increased vulnerability to stress and sensitivity to changes in the environment. Therefore, the presence of ID may lead to vulnerabilities or set the stage for a decompensation that leads to an emergency psychiatric evaluation. Lowry and Sovner (6) describe four functions of problem behavior that should be considered in any evaluation, as follows:
demonstrate poor frustration tolerance, may become irritable and exhibit a behavioral decompensation, or may develop psychiatric symptoms that become the focus of evaluation. ID often results in increased vulnerability to stress and sensitivity to changes in the environment. Therefore, the presence of ID may lead to vulnerabilities or set the stage for a decompensation that leads to an emergency psychiatric evaluation. Lowry and Sovner (6) describe four functions of problem behavior that should be considered in any evaluation, as follows:
Socioenvironmental control. Aggression and self-injurious behavior can be reinforced (e.g., removing a person from an unpleasant situation in response to such behavior will increase the probability that the person will react similarly in the future).
Communication. Problem behaviors can be a nonverbal means of communicating a variety of messages (e.g., attention, discomfort, needs).
Modulation of physical discomfort. Medical conditions, including adverse effects of medications, can cause physical discomfort, leading to aggression or self-injurious behavior.
Modulation of emotional discomfort. Problem behaviors can occur as a state-dependent function of disorders such as major depression or bipolar disorder, manic phase.
The following are among the reasons a person with MR may be brought to the emergency room:
A change in mental status—for example, confusion, agitation, or psychotic symptoms.
A change in mood, energy, or sleep patterns.
A change in behavior, such as a new onset of irritability or aggressive behavior toward others or self-destructive thoughts or behavior (e.g., head banging).
New physical complaints, such as pain, or behaviors, such as agitation, that might signify physical illness. Sorting out such problems can be extremely challenging. An unimpaired person might say, “My stomach hurts,” whereas a person with ID might become irritable and lash out at staff as a result of some physical pain.
Sudden loss of a favored relative or caregiver.
Table 30.1 lists short- and long-term stressors that may trigger behavioral problems or exacerbate a psychiatric disorder in individuals with mental retardation or dual diagnosis (7,8).
TABLE 30.1 Stressors That May Trigger Behavioral Problems | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |||||||||||||||||||||
CONDUCTING THE EVALUATION
When conducting an evaluation for a patient with a developmental disability, the psychiatrist must take into account both the underlying condition and the acute presentation. This does not require evaluators to completely alter their usual approach to patients; rather, psychiatrists should adapt their usual approach to fit the unique circumstances. Certain strategies can improve the likelihood of a successful emergency evaluation, thus leading to an effective treatment plan.
In approaching a patient with DD, the emergency psychiatrist relies upon his or her training in medicine as well as psychiatry. The search for an underlying medical cause of the presentation is perhaps the most important role of the emergency clinician. People with DD who are brought to the emergency department because of a change in mental status or a behavioral disturbance may actually have an underlying medical or surgical problem that has not previously been identified. Awareness of this possibility is a first step; conducting a physical exam and obtaining appropriate laboratory tests may result in a diagnosis. At times there are signs and symptoms of illness. Behaviors might provide clues, such as head banging that indicates a headache, or tugging at an ear that indicates an ear infection. In such cases the psychiatrist should make the appropriate medical or surgical referrals. Often the psychiatrist can contribute further as an advocate for the patient by helping nonpsychiatric physicians understand the patient’s behavior and the underlying precipitant. In this way the psychiatrist can help ensure that the patient receives the appropriate evaluation and treatment. Another strategy of the successful evaluator is to resist the temptation to reach a premature conclusion—specifically, to resist an inappropriate diagnosis of “behavioral outburst due to MR.” It can be disastrous to overlook an underlying medical cause of a change in mental status or behavioral decompensation.
This is not to say that there is always an underlying medical condition. Sometimes there are behavioral issues that are best dealt with by skilled behavioral staff conducting a functional assessment of maladaptive behaviors and implementing a thoughtful behavior plan. The assessment of maladaptive behaviors in a person with MR can be challenging—and rewarding. The staff in a PES should be given additional training in such behavioral interventions, especially in situations in which communication deficits or impaired social relatedness exist.
The first step of a successful evaluation is to identify an appropriate location for the evaluation. The ideal location is in a safe setting that is quiet and private, where possible. Being in the emergency department can be frightening, distracting, or overstimulating to the ID patient and the psychiatrist. A confounding variable is the fact that some ID individuals enjoy the attention they receive for disruptive behaviors (e.g., throwing a tantrum), especially when other patients, families, and staff constitute an audience. Although noise and distractions are inevitable in
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
