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Assessment in an Acute Psychiatry Setting

Studies have demonstrated that people with intellectual disabilities stay longer in acute psychiatry units than other patients.

Neill Simpson

A patient seen in an acute psychiatry setting may have an intellectual disability. This may be because a person already known to have an intellectual disability is receiving a mental health service, or because an intellectual disability has not been recognized in someone who presents with mental illness (Figure 1).
Should people with intellectual disabilities receive services in acute psychiatry settings? This question ought to be answered on the basis of knowledge about outcomes, but there has been little research. Studies have demonstrated that people with intellectual disabilities stay longer in acute psychiatry units than other patients. This may simply reflect the fact that people who have a carer at home are unlikely to be offered admission unless the care arrangements have broken down. Tools to measure health outcomes have been developed, such as the Health of the Nation Outcome Scales - Learning [Intellectual] Disability (HoNOS-LD) (Roy et al., 2002). Systematic assessment of the patient is the key to obtaining the most appropriate service whether in a mental illness or intellectual disability service.

Examples of Clinical Problems Presenting to Services
People with intellectual disability may present to a range of services, at both primary (general practice) and secondary (hospital specialist) care level including acute psychiatry settings. Their presentations can be complex and challenging to any clinician, particularly those who are not comfortable in dealing with people who may have 'different' (sometimes non-verbal) communication skills. It is important to adopt a holistic approach in dealing with such situations by thinking of the full spectrum of medical (physical and psychiatric), psychological and social causes for the person's presentation. Figure 1 highlights four clinical problems that may present to services, in the form of 'clinical vignettes'. How would you tackle each of these situations? Click onto the links for articles that could help to guide you in tackling each of these situations (see Figure 1: Vignettes).

Policy - what are clinicians expected to do?
UK Government policy has promoted community-based and integrated services for people with learning disabilities for many years. Health policy may be paraphrased as 'ordinary services with support where possible, and special services where necessary' (Department of Health, 2001) (see also Greig 2003; pp 2 - 4).
The limits of what is possible and what is necessary are not prescribed by national policies. Unfortunately, there is often a lack of consistency, even within a single organization (e.g. the NHS as a whole or a local authority). One group may decide that it is not possible to support a person in using ordinary services, while another group decides that it is not necessary to provide specialist services. Consequently, people with intellectual disabilities often have the worst of both worlds, with no access either to ordinary services with support or to specialist services.
A working group of the Royal College of Psychiatrists (Royal College of Psychiatrists, 1997) recommended the development of specialist mental health teams for people with intellectual disability to enable support for adults with mild intellectual disabilities to be included in mental health services. Yet in spite of the enthusiasm of individual psychiatrists, NHS organizations have provided little support or investment in multidisciplinary staffing to develop inclusive services.

Why is it difficult for patients with intellectual disabilities to use an acute psychiatry service?
Many staff in acute psychiatry units are reluctant to admit people with intellectual disabilities. Reasons that staff give include:

  • vulnerable people with intellectual disabilities need to be protected from exploitation or abuse by others
  • the general needs for support and care (hygiene, nutrition, toileting, safety, etc.) arising from intellectual disability would be excessive for the staff and too time-consuming
  • assessments done by the unit would not be valid
  • activities offered in the therapy programme would not be appropriate
  • the 'patient mix' would be difficult to manage, and other patients would refuse admission to a unit with people with intellectual disabilities
  • vulnerable patients need to be protected from risks posed by people
    with intellectual disabilities
  • beds would become blocked by patients with intellectual disabilities who may have an extended duration of stay
  • staff lack necessary expertise, and their professional bodies have advised that they should not provide care for patients for whom they lack competence
  • specialized facilities for these patients, offering more suitable care, are somewhere else.

The strength with which these opinions are held bears little relationship to the actual needs and risks of the patients, but in fact reflects the confidence and experience of the staff, and the amount of stress they feel. Most of the issues listed above may be satisfactorily resolved by designing individual care plans that assess the actual risks and needs of patients, rather than relying on assumptions.
Nevertheless, providing a mental health service for patients with intellectual disabilities in acute psychiatry settings can be difficult. Assistance should be available from local intellectual disability services; for example, advice about valid assessment tools and the provision of support and information. Staff should also be able to obtain support, advice and information from a psychiatrist with specialist expertise in intellectual disability.

What assessments should be made?
The prevalence of intellectual disability in the general population is about 2%, and the prevalence of severe learning disability is about 0.4% (see also Prasher 2003, pp. 9-11). The majority of people with intellectual disabilities have mild or moderate intellectual impairment, and are able to provide information. In order to communicate successfully, staff need to understand developmental and contextual aspects of patients' communication ability and style, and need to reflect on and modify their own communication.

Communication problems may be complex, and the interviewer should be systematic about analysing the sources of difficulty. See Figure 2 which gives a framework showing common examples of problems arising from cognitive impairment, attitudinal and behavioural problems, and errors arising from unskilled interviewing. Brief suggestions are given for methods of dealing with each problem, including:

Mental illness in a person with mild intellectual disabilities can be assessed in an acute psychiatric unit, with support, skill and safeguards (epilepsy would not usually be assessed in such a unit). The capacity of acute psychiatric units to provide a safe and effective service for a person with intellectual disability may vary.

Developmental disorders are more common among people with intellectual disabilities, and clinicians should be prepared to encounter comorbidity (see 'Complex Disabilities'). For example, the majority of people with autism also have intellectual impairment and an increased risk of epilepsy, affective disorder and problem behaviour. This complexity may be daunting at first, and it is helpful to use a multi-axial approach to classification such as DC-LD (see also Cooper 2003; pp12-17). This publication also has useful advice about conducting assessments.

 

The first step is to determine what level of intellectual disability the person has, and to ascertain the cause of the disability. Next, assess whether there are additional developmental disorders present, such as an autistic spectrum disorder. Finally, identify mental illnesses and other health-related problems and risks.

Does the patient have an intellectual disability?
When a patient is referred, there may be no accurate information about whether or not he or she has an intellectual disability. Simply being told that the person has an intellectual disability (or 'learning difficulty') does not relieve the clinician of the need to find evidence to confirm it. (see 'Experience of a Cognitive Assessment').

  • Schools may describe a child who has a problem in following the curriculum in the classroom as having a learning difficulty, whether it is due to intellectual impairment, sensory impairment, emotional and behavioural disturbance or for other reasons. Although there is considerable overlap between the sets of people who had childhood learning difficulties and adults with learning [intellectual] disabilities, they are not identical.
  • The terminology of classification systems may cause confusion. In the DSM-IV classification, the term 'learning disability' refers to developmental academic disorders such as developmental dyslexia. This diagnosis would usually be made only if the person did not also have general intellectual impairment. Some authors have suggested distinguishing between 'specific learning disability' and 'generalized learning disability'.
  • Being a 'service user' is not a sufficient basis for concluding that a person has intellectual disabilities: some people who use services for people with intellectual disabilities do not have an intellectual disability. This may be because services did not assess the individual properly before offering a service, or because there were no other services available and a pragmatic decision was made.
  • Some people with intellectual impairment become able to function independently in adulthood.
  • Intellectual function may be temporarily or permanently impaired by illness, and it is insufficient to rely on an assessment based on current functioning. Some people acquire intellectual impairment in adulthood, and should be investigated for delirium or presenile dementia. Screening tests for dementia (such as the mini-mental state examination (MMSE)) are not valid in people with learning disabilities.

A confident diagnosis is almost impossible without a developmental history, so records of childhood assessments of people with developmental disabilities should be preserved indefinitely. (see Lindsey, 2003, pp. 47-50) In order to diagnose intellectual disability, all three criteria must be met (see Figure 3). These criteria were intended to be consistent with the requirements of ICD-10, and may be coded in chapter F70-F79.

Does the patient have another developmental disorder?
All psychiatrists should be able to identify the disabilities in adulthood that result from developmental disorders or childhood mental illness. Any of the disorders described in ICD chapters F80-F89 and F90-F98 may show continuing features in adulthood.
When recording the history, the heading 'developmental history' should be used, which may be combined with the traditional 'personal history'. It is convenient to list the adult features of developmental disorders in the same section as 'premorbid personality', which may be more appropriately headed 'premorbid functioning'. Just as a personality disorder should be identified (from ICD chapter F60-F69) when interpreting disturbed emotions and relationships, so disorders from ICD chapters F80-F89 or F90-F98 should be identified when there are disturbances of cognitive or motor function, communication, or other relevant impairments (see Figure 4).

Does the patient have a mental illness?
The methods of assessment are adapted from methods used for the general population.
History from self-report - parallel interviews with people with intellectual disability and their main carers have shown that around 25% of people with diagnosable disorders would be missed if information from carers was relied on alone. A similar proportion would be missed if information were obtained only from the person with intellectual disabilities.
History from informant - some informants have the skill to make and report observations, and to give their interpretations separately. Others do not, and clinicians should ask for examples and for documentary evidence. It is usually helpful to request information from several sources. For example, daytime support staff may have no information about the person's pattern of sleep, while staff of a residential service may lack information about the person's concentration or sociability.
Mental state examination should use the same headings as for any patient. The assessor should record only what occurs in his or her presence, and take care to separate observations from interpretation. He or she should be vigilant for involuntary movements (such as tics and stereotypies), perseveration, impairment of impulse control, emotional control and attention, and abnormalities of non-verbal communication and social interaction. Epileptic phenomena (such as absences or complex partial seizures) may be observed, or features of delirium (such as fluctuating consciousness, emotional volatility and distractibility). Such abnormalities should not be attributed to 'learning [intellectual] disability', which does not, in itself, cause these abnormalities. The assessor should determine whether they are developmental or acquired.

Achieving success
In the current author's experience, admission is most successful when there is one nurse within the unit who takes responsibility as 'named nurse' for patients with intellectual disabilities. It is not essential that the nurse has dual qualification: interest and a willingness to obtain assistance from others are sufficient. It is also important that there are community nurses with similar interests, who maintain links with patients in acute psychiatry settings. It is regrettable that nurse training programmes still result in mental health nurses who have no experience in nursing people with intellectual disabilities, and learning [intellectual] disability nurses with no mental health experience.

FIGURE 1: Vignettes

1. Patient A has been referred for assessment of acute emotional disturbance; there are problems with communication. What is the contribution of learning [intellectual] disability to the presentation?
www.intellectualdisability.info/how_to/clin_comms.htm
www.intellectualdisability.info/values/top_ten_tips.htm

2 Patient B receives support from a service for people with learning [intellectual] disabilities. She has been described as 'responding to hallucinations'. How do you assess whether she is mentally ill?
www.intellectualdisability.info/diagnosis/psychosis_rr.htm.

3 Patient C has used mental health services for a long time, but the diagnosis is uncertain. Could it be a developmental disability such as Asperger's syndrome?
www.intellelctualdisability.info/diagnosis/autism.htm

4. Patient D is mute. Is this due to illness or developmental disability?
www.intellectualdisability.info/how_to/clinc_comms.htm
www.intellectualdisability.info/values/top_ten_tips.htm
www.intellectualdisability.info/diagnosis/psychosis_rr.htm
www.intellectualdisability.info/mental_phys_health/key_highlights.htm
www.intellectualdisability.info/how_to/ae_guide.htm

FIGURE 2: IMPROVING COMMUNICATION

Source of problem Example Method for dealing with the problem
Cognitive (understanding or knowledge) Concept of time: temporal ordering is acquired before measurement of duration. Ability to use conventional ('clock and calendar') time develops from 6-9 years, although units may not be used until later, and only if taught. Pay attention to the person' sense of time concepts, and avoid demanding detail. Use ordering in preference to duration. Use a cross-sectional, not longitudinal approach to history-taking. For example, list all current symptoms, then investigate timing by identifying an 'anchor event' that the person can recall. Ask the person to recall what they were doing that day, and whether each of the symptoms mentioned were present.
Linguistic competence (restriction is often excused as protection) Focus on 'what, which, where', avoid 'when, why, how'. Attend to the grammar, vocabulary and complexity of your own language. Listen to yourself on recorded interviews, and work out how to simplify.
Consequences of lifestyle (restriction is often excused as protection) Find out how the person spends their time and who they meet, so that the context makes sense. Be aware of tertiary disability (responding to the expectations of others), and avoid having a conversation with the carer that excludes the patient.
Functional cognitive impairment (optimum performance is impaired by illness) Find out what the person's best level of ability has been. Avoid making excessive demands on the person's cognitive performance (e.g. by insisting on dates)
 
Attitudes or behaviour Response styles: disengagement, acquiescence, suggestibility and denial Be aware of the ways in which your behaviour elicits these responses. Build a positive interview by starting with topics that the patient knows about, e.g. what they like to do when well.
Conspicuousness of symptoms Be aware that people conceal topics that may produce an adverse reaction in their carers, so thoughts about sex, violence and self-harm may not be mentioned spontaneously.
Interpretation by others You and carers may observe agitation. Others may say 'aggressive', but you should separate observation from interpretation. Is it pain, anxiety, depression, etc.?
     
Interviewer skill Excessive reliance on informant Informants forget about the onset of long-term disorders and assume that symptoms are normal. Phobic disorders are greatly under-reported by carers.
Jargon What is 'challenging behaviour'? Is 'self-injurious behaviour' different from 'deliberate self-harm'? Don't make assumptions, ask.
Selection bias It is often ncessary to move quickly from open to closed questions, but be aware that the limited options you offer represent a selection of possible answers.

FIGURE 3: ASSESSMENT OF LEARNING [INTELLECTUAL] DISABILITY

Learning [intellectual] disability includes the presence of: Approaches to assessment
  • A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence)
  • At interview, attend to:
    • Vocabulary
    • Time concept
    • Decision-making capacity
  • Ask informant about understanding and learning.
  • Request previous assessments, such as:
    • Statement of Educational Need (SEN)
    • Educational psychology reports
  • Seek the opinion of a clinical psychologist
  • With a reduced ability to cope independently (impaired social functioning)
  • Ask the person about the support they have
  • Ask informant about understanding and learning
    • Dealing with complex information, such as managing finances
    • Dealing with unexpected events, such as illness
  • Ask informant about predictable risks if the person did not have support
  • Use a standard tool, such as the Vineland Adaptive Behaviour Scales
  • Which started before adulthood, with a lasting effect on development
  • Obtain a developmental history:
    • From contemporary childhood assessments
    • From a suitable informant

Definition of learning [intellectual] disability from Valuing People (Department of Health, 2001)

FIGURE 4: EXAMPLES OF DEVELOPMENTAL DISORDERS (ICD-10)

ICD-10 code ICD-10 term Other description code
F80.1 Expressive language disorder Developmental dysphasia
F81.0 Specific reading disorder Developmental dyslexia
F84.0 Childhood autism Autistic disorder (Kanner's syndrome)
F84.2 Rett's syndrome  
F84.3 Other childhood disintegrative disorder Heller's syndrome
F84.5 Asperger's syndrome  
F90.0 Hyperkinetic disorder with disturbance of activity and emotion Attention deficit hyperactivity disorder
F92.0 Mixed disorders of conduct and emotions  
F94.1 Reactive attachment disorder of childhood  
F95.2 Combined vocal and multiple tic disorder (de la Tourette)  
F98.3 Pica of infancy and childhood  
F98.4 Stereotyped movement disorders  

FURTHER READING
Chaplin R, Flynn A. Adults with learning disability admitted to psychiatric wards. Adv Psychiatr Treat 2000; 6: 128-34.
Cooper S-A Classification and Assessment of Psychiatric Disorders in Adults with Learning Disabilities. Psychiatry 2003 2:8, 12-17.
Department of Health. Valuing People: A New Strategy for Learning Disability for the 21st Century. London: The Stationery Office, 2001.
Greig R. The New Government Policy in England. Psychiatry, 2:8, 2003.
Hodges J R. Cognitive Assessment for Clinicians. Oxford: Oxford Medical Publications, 1994.
Lindsey M. Overview of Learning Disability in Children, Psychiatry 2003 2:9, 47-50.
Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002; 325: 697-700.
Moss S, Bouras N, Holt G. Mental health services for people with intellectual disability: a conceptual framework. J Intellect Disabil Res 2000; 44: 97-107.
Prasher V. Epidemiology of Learning Disability and Comorbid Conditions.
Psychiatry 2003 Vol 2:8, 9-11.
Roy A, Matthews H, Clifford P, Fowler V, Martin D. Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD). Br J Psychiatry 2002; 180: 61-6.
Royal College of Psychiatrists. Meeting the Mental Health Needs of People with Learning Disability. Council Report CR56. London: Gaskell, 1997.
Royal College of Psychiatrists. OP48: DC-LD: Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation. London: Gaskell, 2001.

INTERNET RESOURCES
www.intellectualdisability.info. A learning resource for medical and health-care students, and practitioners.
http://www.rcpsych.ac.uk/publications/gaskell/specLd.htm
(Publications relevant to learning disability from Gaskell Press/Royal College of Psychiatrists.)
http://www.bild.org.uk
(British Institute of Learning Disabilities; has links to National Electronic Library for Learning Disability, among many others.)

This article, which has been amended with the author's permission, was first published in Psychiatry; Volume 2:8, August 2003 and reprinted with the kind permission of the Medicine Publishing Company.


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An understanding of the nature of intellectual disability is essential for health care professionals, who are required to support equal access to their services for all disabled people.