Essays academic service


Observation of diagnostic appointments by separately watching both the patient and interviewer

For persons with intellectual disabilities, the experience may be particularly scary because they may not understand what is happening around them. Persons with intellectual disabilities vary greatly in their ability to understand and communicate their needs, discomforts and concerns.

You will therefore need to adapt your approach to each patient's level of functioning and understanding. If the patient is behaving disruptively, begin by meeting briefly with the caregivers to inquire about the individual's level of functioning and to get advice about how best to meet and interact with the individual. Find out about any circumstances that might be specifically upsetting for that individual e.

  • Pharmacological or physical restraint may be required as with other patients in crisis;
  • Health Evidence Bulletins - Wales;
  • Our detailed outpatient evaluation can help identify causes and treatments for brain-related learning or behavioral difficulties;
  • Diagnostic and Statistical Manual of Mental Disorders 4th ed;
  • As well, behavioural markers should be identified and these behaviours monitored to substantiate or refute the provisional diagnosis.

Many individuals may be unable to communicate verbally but will be aware of non-verbal behaviours in others and are often sensitized to negative attitudes others have toward them. Some individuals depend on others to help modulate their emotions and will quickly pick up fear and anxiety in you. A warm, accepting, calm and reassuring attitude will help the patient feel more relaxed.

Waiting can be anxiety-provoking and contribute to behavioural disturbances. Take a moment to explain to the patient and his or her caregivers the reason for the wait. If the wait is longer than you expected, check in from time to time to reassure the patient. This will contribute to a more effective interview. Find out if a proactive crisis plan has already been set up by caregivers in the community and whether caregivers have brought a letter from the patient's physician outlining this plan.

Remember that appearances may be deceptive. Individuals with intellectual disabilities may appear to be hearing impaired or mute when this in fact is not the case. Overheard comments about them may exacerbate the presenting problems. Assessing a patient with an intellectual disability takes time. Research indicates that the process may take four times longer than the time required for someone without such a disability.

Practical tips on conducting the interview: Try to make the individual as comfortable as possible. Suggest that someone familiar to the patient e. Use suggestions previously identified by the caregiver to help the patient be more at ease. Encourage use of "comforters" e. Try to find a quiet spot, without interruptions.

Try to establish a positive relationship with the patient: Find ways to communicate effectively: Do not overload the individual with words.

Department of Neurology

For example, if the patient shows fear in response to your approach, consider what might be contributing to this fear e. Modify your approach as required e. Remember that persons with intellectual disabilities have a variable and limited ability to interpret their own internal cues and may not be able to give you an accurate picture of their internal state.

Involving caregivers who know the individual well may help you to better understand his or her subjective experiences. Expect the presenting problems to have multiple and complex etiological and contributing factors.

Be systematic in taking a history. Be sure to assess the influence of causes other than psychiatric disorder for the referral concerns. The overall goal is to understand contributions from: Emotional problems often arise when expectations and supports change e.

Note that grief can be delayed. Adjustment, mood, anxiety and post-traumatic stress disorders are the most frequent new onset psychiatric disorders. Autism is the most frequent chronic comorbid psychiatric disorder across the range of functioning. Stereotypies and self-injurious and compulsive behaviours are often seen as chronic comorbid conditions, especially in lower functioning individuals. In determining the relative contributions of circumstances 1 to 4, as listed above, all the basic areas of inquiry need to be examined: It is also important to gather more detailed information on the patient's usual level of functioning baseline and supports prior to this episode of disturbance.

Seek further information about: At the end of this inquiry, you should try to evaluate whether the expectations of the patient, and the supports provided, are appropriate given the patient's level of functioning and recent circumstances.

For example, are you sure that caregivers understand the challenges the patient has to face on a daily basis? In summary, assessing persons with intellectual disabilities involves not only a standard psychiatric assessment, but also a systematic approach designed to identify the contributions of other circumstances to the behaviours of concern.

These need to be pursued in more detail by the multidisciplinary team once the immediate crisis is past. Note that it is difficult to diagnose psychotic symptoms in persons with an IQ below 50. Provisional psychiatric diagnosis If the referral concerns or behaviour disturbance meet criteria for an episode of change, then an episode of psychiatric disturbance is established.

This is frequently difficult, particularly with lower functioning individuals, as subjective experiences needed to establish a DSM-IV diagnosis may be unavailable. From the clinical information available, generate the best provisional psychiatric diagnosis for the episode of psychiatric disturbance. Comorbid psychiatric conditions Document baseline self-injurious behaviours, tics, stereotypies, obsessive thoughts and compulsive behaviours, levels of attention, hyperactivity, impulsivity, fears and phobias: Ask whether there have been any changes i.

Documenting whether any comorbid conditions are present at this stage is crucial, as these conditions may also arise from the side-effects of medications used to manage the crisis, or to treat an underlying psychiatric disorder.

In Canada and in the UK, a person with intellectual disability and mental health disorder is often referred to as having "dual diagnosis". It is important to understand the contribution if any of such circumstances to the behaviour disturbance before making a psychiatric diagnosis or concluding that the problem is psychiatric.

Aggression of any severity can be the result of any of the four problem areas identified in Section 1. The severity of the aggression does not necessarily indicate the seriousness of the underlying cause of the aggression. This is necessary as a psychiatric diagnosis made from a brief assessment can stick for years or even decades, and can result in the patient being prescribed inappropriate medication for lengthy periods with considerable morbidity.

Your recommendations should include a clear outline as to follow-up and re-evaluation of diagnosis and treatment.

Guidelines for Managing the Patient With Intellectual Disability in Accident and Emergency

For example, due to limited cognitive function at baseline, stress can fragment thought form in a way that may appear psychotic, or the patient may express primitive thoughts that sound delusional but actually relate to poor coping more than to frank psychosis. If the patient is overwhelmed, treatment involves identifying and attending to the causative life events. However, if it is true psychosis, then antipsychotic treatment is required.

  • If this is not possible, ensure that alternatives other than hospitalization have been discussed;
  • Services are provided to children, adolescents, adults and the elderly;
  • Ensure that this documentation is available to the team who will provide further psychiatric assessment when the patient is triaged;
  • This is frequently difficult, particularly with lower functioning individuals, as subjective experiences needed to establish a DSM-IV diagnosis may be unavailable;
  • References American Psychiatric Association.

Note that in an emergency situation, medication, along with other interventions, may be required for immediate containment even if no psychosis is diagnosed. This includes drawing on not only the perspective of psychiatry, but also input from other disciplines, such as psychology, communication therapy, behaviour therapy, nursing, genetics and medicine, including neurology.

Patient Privacy in Mental Health: Balancing Rights while Trying to Ensure Appropriate Treatment

Ensure that this documentation is available to the team who will provide further psychiatric assessment when the patient is triaged. Only then can the assessment continue. Pharmacological or physical restraint may be required as with other patients in crisis. If you are concerned about a possible medical disorder, refer the patient for a medical assessment. Also inquire about when the last vision and hearing assessments were done, and about the outcome, as deterioration in sensory functioning can give rise to changes in behaviour.

Refer the patient for a dental checkup where indicated or when dental care has not been provided routinely. Resist the temptation to try the latest new medication just because it has not yet been tried for this patient. Limit your activities to dealing with the emergency and leave review of regular medication to the patient's usual treatment team. If you feel strongly that an alternative medication regime is more appropriate or should be tried, discuss this first with the regular treatment team.

Guidelines for Managing the Patient With Intellectual Disability in Accident and Emergency

As well, behavioural markers should be identified and these behaviours monitored to substantiate or refute the provisional diagnosis. You will need to discuss with caregivers the behaviours they should start to monitor.

  • Neuropsychological Assessment What is a neuropsychological assessment?
  • It is considered a specialty within the discipline of clinical psychology, which includes psychologists who treat clients or patients.

For instance, if the provisional diagnosis is a mood disorder, instruct caregivers on how to collect data on such variables as eating and sleep patterns, weight, behavioural equivalents of mood, anxiety and agitation. Such documentation is likely to be invaluable to the team to which the patient is triaged.

Patient Privacy in Mental Health: Balancing Rights while Trying to Ensure Appropriate Treatment

A behaviour therapist, available through the developmental service sector, can provide invaluable help with this monitoring. Also consider the assessment and treatment goals. Appreciate that caregivers are not medically trained and may be apprehensive about giving medications, monitoring side-effects and managing co-existing medical problems.

There are three main options for further assessment and treatment: The patient needs to be medically stable. If not, he or she is not suitable for a psychiatric inpatient unit. If the patient does not have sufficient expressive and receptive language skills to make his or her needs known, or is not independent in activities of daily living, find out if the referring agency, together with the hospital, can provide additional, needed caregiver support for the individual while an inpatient.

A behavioural disturbance is frequently the manifestation of a psychiatric disorder, and is an appropriate reason for admitting the individual for further observation.

In planning admission, consider how you would handle a patient with aggressive, self-injurious or other serious behavioural problems and whether additional support is available, such as consultation from specialized services.

  1. Practical tips on conducting the interview. References American Psychiatric Association.
  2. If this is not possible, ensure that alternatives other than hospitalization have been discussed.
  3. Do not overload the individual with words.
  4. Differences in neuropsychological test performance associated with age, education and sex.
  5. What about disclosure of information to family members or other persons? For instance, if the provisional diagnosis is a mood disorder, instruct caregivers on how to collect data on such variables as eating and sleep patterns, weight, behavioural equivalents of mood, anxiety and agitation.

Also see below, "Success of an inpatient admission" 5. Propose realistic treatment goals e. This provisional diagnosis would include identified target symptoms and behaviours that might be monitored in response to treatment interventions.

If this is not possible, ensure that alternatives other than hospitalization have been discussed. However, when leaving the structured environment of the hospital, these symptoms and behaviours may recur. This is valuable information that may only be obtained through admission. If the individual is admitted to an inpatient bed, consider how the trauma of such an admission can be reduced. Note that being admitted can be especially traumatic for lower functioning individuals whose emotional and support needs may be similar to the needs of infants and younger children.

Caregivers are often able and willing, with the support of their managers, to spend long periods with the individual in his or her hospital environment. Clinical experience has identified four factors resulting in a poor outcome associated with hospitalization Sovner and DesNoyers Hurley, 1991: The patient is prematurely discharged.

The patient is overmedicated.