Determining whether a patient has a learning disability

If a patient’s problems are thought to be psychiatric an appropriate evaluation is requested. From the point of entry for psychiatric evaluation, staff observe the patient broadly (watching actions and behaviour within the A&E department), to determine competence/capacity and the level of risk for patient and staff, and more specifically (within the context of a more traditional mental state examination), to determine whether behaviour and symptoms may alert to the underlying cause of the mental distress. While it may be obvious that the patient has some kind of cognitive impairment, the cause of this has to be determined (Tables 3 and 4).

Table 3 Screening for learning disability ¹

Questions	Comment
Early development
What grade did you go to in school? How old were you when you left? Did you repeat any grades?	Sometimes dropped out of school early, sometimes extended schooling
Did you attend special education classes? Were you identified as having special needs?	May have attended school for special needs, or schooling was in special needs class
Were you in a regular or a modified programme?
Did you have a psychological assessment as a child at school or at a hospital? What did they tell you about the results?	May know results of testing or if testing resulted in different schooling
Current functioning
Can you tell the time on a watch?	Show the person your watch and ask what time it says: may be able to read digital but not watch with hands
Do you travel alone on public transport? Did you come here by yourself today? What route did you take?	Get the person to describe how they got to the appointment
If you are going to a new place, do you need someone to show you how to get there?	Some can travel independently but journeys tend to be well-rehearsed routines; some have difficulty describing or planning new journey
Can you read the newspaper? What sections do you like the best? What is your favorite TV programme?	Often will say that comics is favourite part, or that they can read only some of the paper
Do you look after your own money? Do you pay bills? Which bills? How do you pay them (by cheque, bank machine)?	Ask them to describe what they do; most need assistance
How much does a cola and a bag of potato crisps cost? How much does a car cost? How much does a house cost?	Often will not be able to estimate well
Do you have a job? How many hours per week? Do you have a job coach? Have you ever had a job? What did you do? Can you fill out a job application by yourself?	Most often supported employment or sheltered workshop

Table 4 Cognitive impairment and deterioration: checklist of causes and differential diagnosis in the A&E

Diagnosis	Description	History and collateral	In the A&E
Learning disability	Impairment resulting from congenital cerebral injuries; impairments present since childhood, relatively stable, accompanied by stigmata of cerebral injury, e.g. syndrome, seizures	Delay in development, may be on a learning disability register, recipient of learning disability services in present or in past	Dysmorphic features (?syndrome), attends with care provider, unable to give own history, global delay in functioning
Dementia	Intellectual deterioration affecting several areas, including memory, and interfering with occupational and social functioning	History of decline in cognitive and adaptive functioning; may have family history of dementia, medical disorder associated with dementia.	Neurological signs of dementia and/or medical disorder associated with dementia. Administer the MMSE
Acute confusional states (delirium)	Impairment of consciousness with intrusive abnormalities in perception and affect caused by acute organic pathology	In children and elderly can develop from a relatively minor disturbance, e.g. dehydration	Continuously changing clinical picture, with acute to subacute shifts; may be disoriented, agitated, lethargic, inattentive. Signs of systemic illness
Acquired brain injury	Normal development up until brain injury, followed by deterioration in functioning: may be global or more discrete disability depending on the cause and extent of the brain injury. Causes include physical trauma (e.g. car accident, abuse) and cardiovascular events (e.g. stroke)	History of trauma followed by change in functioning level; if trauma occurred before 18 years old may be receiving learning disability services	Neurological dysfunction, usually specific deficits in learning rather than global delay. May be disinhibited, inappropriate and show mood lability
Mutism, stupor and the apparently inaccessible patient	Caused by organic brain disorder, physical illness, functional psychiatric disorder (e.g. psychomotor retardation of depression; catatonia associated with mood disorder, schizophrenia and autism; conversion hysteria)	History of physical or psychiatric illness, traumatic life event. Determine the history to the time of onset of the change in level of consciousness or onset of mutism; is this a familiar presentation with decompensation?	Unresponsive to usual social and environmental stimuli; signs of systemic illness, delirium, physical or psychiatric illness
Autism	Likely different causes, including genetic predisposition. Impairments in social interactions, verbal and non-verbal communication, ritualistic repetitive patterns of behaviour. Covers the spectrum of IQ from gifted to profound learning disability	See Box 1	At higher levels of cognitive functioning: one-sided social and verbal interactions, complex routines, manipulation of objects; at lower levels of cognitive functioning: hypersensitivity to sensory stimuli, abnormal movements, social aloofness
Other	Other causes include medication, abuse, sensory impairment (deafness, visual impairment), non-English speaking	Taking cognition-altering medication, recent immigrant	May show medication toxicity (e.g. drowsy, ataxic), fearfulness, watchfulness, injury (trauma, abuse), may be wearing hearing aid or respond to non-verbal communication (deaf) or another language (non-English speaking)
Learning disability and any of the above as a comorbid occurrence	See text	First establish evidence for learning disability and level of functioning, then evidence for comorbid disorder. Assess all behaviours against baseline behaviour (usual level of functioning) before behaviour change. Consider whether any other of the above conditions are present	Conduct examination with care provider present and ask them about current behaviour compared with usual behaviour. Screen for physical/medical disorder

Biopsychosocial understanding

The psychiatric assessment of people with learning disabilities involves systematic application of a biopsychosocial approach. Expect the presenting problems to have multiple and complex aetiological 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 aim is to understand contributions from the following four factors.

Assessing for episodic (new-onset) psychiatric disorders

It is important first to determine whether there has been a substantial change in baseline behaviours and functioning. An episode (or episodes) of changed behaviour can be identified as follows (Reference Bolton and RutterBolton & Rutter, 1994). First, determine usual/baseline behaviour (prior to onset of new disturbance) in the areas of: self-care, interest/involvement in school/work, play/leisure, social involvement, initiative and level of supervision required. Second, determine whether (a) there has been a change in behaviour outside the range of normal variation for the individual, lasting at least 1 week, and a definite diminution in level of functioning in at least two of the six areas outlined above or (b) psychotic symptoms (e.g. delusions, hallucinations, catatonia) are, or have been, present and have lasted at least 3 days. (Note that it is difficult to diagnose psychotic symptoms in people with an IQ below 50.)

Provisional psychiatric diagnosis

If the referral concerns meet the criteria for change, then an episode of psychiatric disturbance is established. The next step is to try to match this episode to a psychiatric diagnosis in accordance with DSM–IV–TR (American Psychiatric Association, 2000), ICD–10MR (World Health Organization, 1996) or DC–LD (Royal College of Psychiatrists, 2001). This is frequently difficult, particularly for lower-functioning individuals, as subjective experiences needed to establish such a diagnosis may be unavailable. From the clinical information available, the best provisional diagnosis for any episodic psychiatric disorder should be generated.

Assessing for non-episodic background conditions

Baseline self-injurious behaviours, tics, stereotypies, obsessive thoughts and compulsive behaviours, levels of attention, hyperactivity, impulsivity, fears and phobias should be documented, as these may represent comorbid chronic conditions. Ask whether there have been any changes (an increase in severity and/or frequency) in these comorbid conditions associated with the referral concerns. Documenting whether any comorbid condition is present at this stage is crucial, as these conditions may also arise from the side-effects of psychotropic medications used to manage the crisis or to treat an underlying psychiatric disorder (see Box 3 for further cautions in A&E).

Risk assessment

Risk of violence and suicide is part of every A&E assessment and needs to be documented clearly in the history, mental status and final impression. The care provider is a valuable source of information about a patient’s recent dangerous behaviour to self or others that would necessitate a hospital admission for further psychiatric assessment.

Managing the immediate situation

The first priority is to ensure the safety of the patient, care providers and hospital staff, consistent with the usual A&E protocols. Only then can the assessment continue. Pharmacological or physical restraint may be required as with other people in crisis. A general approach to the management of aggressive or agitated patients in the A&E department is outlined below. Modifications are required for patients with learning disabilities that depend on the nature of their disability (e.g. people with autism may show idiosyncratic responses to standard interventions) and level of cognitive and communicative functioning. For example, the more A&E staff appreciate the patient’s level of functioning and unique ways of communicating (either from direct observation and interaction or from reports from care providers), the more likely the escalation in aggression or agitation will abate and the less likely that excessive medication or restraint will be needed.

Dealing with aggression and agitation

Assessing aggressive or agitated patients is one of the most anxiety-provoking aspects of emergency psychiatry. Recognising early the progressive stages of agitation and aggression and intervening appropriately is a skill that is an essential part of training. Agitation and aggression occur along a continuum and will progress unimpeded unless you intervene to de-escalate the situation (Box 4).

Box 4 Approaching agitated or aggressive patients

The usual stages of violence and the appropriate intervention are as follows:

Stage		Intervention
1	Anxiety or agitation	Ensure safety of patient and staff
2	Verbal threats	Verbal de-escalation
3	Overt aggression	Physical interventions
4	Resolution	Medication

The situation may be different for patients with learning disabilities:

1. • they may behave atypically: for example, attempts to de-escalate the situation verbally may worsen the patient’s agitation

2. • care providers often have an effective protocol and recommendations for managing out-of-control behaviour in their clients; ask about these and use them if this can be done safely

3. • approaches in Box 2 generally help to engage the patients and avoid further escalation

4. • at each stage of your interaction with the patients make use of the care providers’ knowledge and experience of their clients

Before you begin any assessment, you should observe the patient to determine the level of agitation and talk with the care providers to benefit from their knowledge and experience in dealing with the client. The setting in which you conduct your interview needs to be safe. An anxious or agitated patient may be pacing and need more space than the tiny interview room allows. The noise and stimulation of an A&E waiting room may be further distressing, so it is helpful to triage quickly to a quiet interview room equipped with safety features such as video cameras, silent alarm buzzers, staff in close proximity, fixed furniture and two exit doors. Encourage the care provider to remain present, as he or she is likely to calm the patient and will probably be able to guide you in interacting with the client. You should feel comfortable in asking for a team member or psychiatric assistant to be in the room with you during your assessment. Make sure that both you and the patient (and care providers) can easily leave the room. Call periods of ‘time out’ if at any point you are concerned. Before you take the patient into the room, look for potential weapons – both on yourself and in the room. Ties, identification tags hanging from the neck and dangling jewelry should not be worn during psychiatric assessments. The room should contain no unfixed objects such as rubbish bins or telephones.

If police brought the patient to hospital, you should clarify if handcuffs were necessary. It is not recommended to assess patients wearing cuffs, as such restraint often makes it difficult to engage with them and develop a trusting relationship. If the patient is too agitated to be assessed safely without handcuffs, you should replace them with the medical equivalent – mechanical restraints. The police can help you and your team in transferring the patient from cuffs to restraints (and care providers may also be able to advise about effective ways to engage with the patient during this transfer).

Agitated patients may settle when you speak calmly, softly and with respect (even if they do not understand what you are saying): ‘Mr. Brown, I am sorry you are upset… I kept you waiting… I would like to help… Can you tell me what is upsetting you?’ Suspicious patients may need specific reassurances about safety: ‘We are here to help you… You are safe here… [Name of care provider] is here… He/she will stay with you’. If verbal threats become more evident, you may need to use verbal de-escalation to help the patient. However, some people with learning disabilities, particularly those with greater cognitive impairment and coexisting autistic-spectrum disorder, respond negatively to the usual verbal de-escalation procedure so, wherever possible, familiar de-escalation routines described by care providers should be used.

The patient may be unable to sit down and may be physically intimidating. You should not make yourself vulnerable by sitting when the patient is towering above you. If the patient is unable to sit, you should stand as well and gently attempt to set limits while still trying to understand what is of concern: ‘You seem to be upset and are talking loudly… Let’s see if we can both speak more slowly and softly … and we can both try to relax’. There is opportunity here to model the behaviour desired, for example by speaking more slowly and quietly and moving into a more relaxed body posture and relaxation routine. You should not make sustained direct eye contact with the patient, especially if he or she is paranoid. A non-threatening stance, angling your body away from the patient, is preferable. If the patient’s behaviour continues to escalate, you should anticipate overt aggression and be vigilant about potential assault. At this point, you will be making decisions about the type of physical intervention – mechanical and/or chemical restraint.

Once the anger is spent, the resolution phase is one in which you can often re-engage with the patient to explain what will be happening next, for example admission to hospital, police involvement and so on.

The patient’s agitation and aggression can move very quickly from one stage to the next and it may be almost impossible to de-escalate the situation when the patient is not able to hear you and appreciate the meaning of your reassurances. You will have to think quickly and be observant for signs of anxiety, cognitive disintegration, psychosis and disinhibition quite early in the assessment process. Physiological signs of anxiety, ataxic gait, incoherent or slurred speech and response to internal stimuli are all signs that the patient is distracted and may not be able to respond to your preliminary interventions.

If you need immediate assistance you may choose to call for extra specialist help. In Canada this is known as a ‘code’, an urgent request for extra staff trained in de-escalation procedures and comfortable using mechanical and chemical restraints for safety. In other countries a psychiatrist on-call might fulfil this function. It is a good idea to have medication close at hand, even if you do not need to use it. Before the patient can be medicated, the safety of all (the patient, staff and anyone else present) must be established and the immediate area cleared of unsafe features (e.g furniture that can be thrown). If the patient is severely agitated, it is preferable to secure him or her in mechanical restraints before giving the chemical restraint in an intramuscular dose. High-potency antipsychotics (such as intramuscular haloperidol in combination with lorazepam, or oral risperidone with lorazepam) have less risk of lowering the seizure threshold, have a lower anticholinergic load and are required in smaller doses. Lorazepam diminishes the risk of acute dystonia in the A&E, but the atypicals should be considered for long-term management. However, note that people with learning disabilities not infrequently show atypical responses to medications, which should therefore be used judiciously and with careful monitoring.

An episode of potential or actual violence is upsetting not only to the patient: care providers and A&E staff are also affected and such an incident might predispose them to deny further contact with the patient or, by prejudging, to reject future patients with learning disabilities. There should be an opportunity to debrief and review the event with colleagues, so that the personal or professional distress experienced can be examined.

Treating medical (and dental) disorders

If there are suspicions that behavioural disturbance has physical/medical causes the patient should be referred for a medical assessment and treatment. Similarly, referral for dental check-up should be made if there are concerns about dental pain or discomfort or where dental care has not been provided routinely.

Treating psychiatric disorder

Once the crisis has been managed, if it has been determined that a psychiatric disorder probably underlies the behavioural disturbance, treatment can be initiated in line with the provisional diagnosis. A&E staff should work with care providers to identify behavioural markers that can be monitored to substantiate or refute the provisional diagnosis. For instance, if the provisional diagnosis is a mood disorder, care providers can be instructed on collecting data on eating and sleep patterns, weight, and behavioural indicators of mood, anxiety, agitation and so on. Such documentation of a trial treatment started in the A&E department is likely to be invaluable to the follow-up team to which the patient is subsequently referred.

Changing medications

Changing a patient’s previous medications in this emergency situation should be avoided unless it is certain that they are contributing to the referral concerns. The temptation to prescribe the latest new medication just because it has not yet been tried for this person should be resisted; the A&E team should limit their activities to dealing with the emergency and leave review of regular medication to the patient’s usual treatment team. If the A&E team feels strongly that an alternative medication regimen should be tried, this should first be discussed with the regular treatment team.

Where should further assessment and treatment take place?

Consider what will be most helpful from the patient’s perspective (e.g. need for familiarity during crisis). Also consider the goals of assessment and treatment, bearing in mind that care providers in community settings may be apprehensive about giving medication, monitoring side-effects and managing coexisting medical problems. Behavioural disturbance is frequently a symptom of a psychiatric disorder, and is an appropriate reason for admitting an individual for further observation.

Medication

If medication has been prescribed, the patient’s GP and community psychiatrist should be informed. Those without a community physician should be connected to out-patient psychiatric services.

Referral to specialist services

Specialist assessment and consultation services may be needed where a coordinated interdisciplinary approach is necessary, for example if the situation is complex, if there is a history of difficulty clarifying a diagnosis or determining effective intervention, or if several services are already involved.

Informed consent

The diagnosis of learning disability does not imply that the patient is incompetent to consent to treatment. Competence must be assessed on a case-by-case basis. Capacity to consent is a dynamic interplay of intellectual capacity (with some education about the issue and support in decision-making, a person with a learning disability may develop consent capacity) and emotional status (a patient who normally has capacity may no longer be able to consent because of overriding anxiety associated with being in the A&E department). Also, the physician should be aware that an apparently competent patient may decline consent because of fear of a procedure associated with the treatment rather than declining the treatment itself (for further discussion of these issues see Reference Heng, Sullivan, Brown and PercyHeng & Sullivan, 2003).

When issues of treatment and consent are being discussed with them, patients with learning disabilities are likely to benefit from the presence of care providers who can support their decision-making. If a patient clearly does not have the capacity to consent, an involved family member or long-term care provider should be asked to give consent on his or her behalf.

In an emergency, life-threatening problems warrant emergency treatment even in the absence of informed consent. Chemical restraint of competent but non-consenting patients is permissible if their mental disorder is leading to dangerous behaviour.

Mandated reporting of abuse of disabled people

Some jurisdictions have requirements that medical personnel report any suspicion of abuse.

Guardianship

If a legal guardian has been appointed, this person must give consent to any evaluation and treatment except in life-threatening situations.