Crisis Assessment and Intervention

Jennifer McLaren, MD; L. Jarrett Barnhill, MD, DFAPA, FAACAP; Joan B. Beasley, PhD

Overview

This chapter gives an overview of emergency care for people with intellectual and developmental disability (IDD) and autism spectrum disorders (ASD). Acute crises are likely to occur when the intensity of stressors overwhelms the person’s social, cognitive, emotional regulation, and adaptive skills, concurrent with mental health symptoms. For people with IDD and mental health disorders, an adverse life event can trigger relapse, exacerbation of baseline challenges, or contribute to persistent vulnerability. The prescriber must focus on the relationship between preventative and resilience factors and adverse events. 

What is a Crisis and Who is Vulnerable?

  • Crises can be singular or recurring events that lead to difficulties for the person in adapting or resolving the situation, significant changes in emotional states (internalizing), expressed behaviors (externalizing) or relapses in pre-existing mental disorders.
  • Patients with IDD are heterogeneous with varying characteristics that need to be considered.
  • Etio-pathogenesis, genetic/metabolic/medical and behavioral comorbidities, temperamental traits, and patterns of attachment.
  • Vulnerable people may experience a relapse of pre-existing mental health condition, or the onset of a new diagnosis.
  • Unresolved crises can contribute to life-threatening circumstances or worsening physical or mental health conditions.

Triage

  • Rapid triage based on a quick assessment of nature, severity, and ecological context of the presenting symptom.
  • Rule out potentially life-threatening illness or injury.
  • Provide a protective environment to minimize any further physical or emotional trauma.
  • Conduct a more focused assessment (see section below for assessment).

Where is the Best Place to Evaluate?

  • The patient should be evaluated in the least restrictive setting that can safely manage their crisis (e.g., outpatient versus emergency department versus mobile crisis team).
  • Consider alternatives to unnecessary ED visits (ED environments are busy, loud, and overwhelming environments that can lead further stress for the person).

Consider non-pharmacologic strategies to minimize stress in ED or other settings.
Non-Pharmacologic Strategies to Minimize Stress in the Emergency Department and Other Settings

  • Attempt to verbally de-escalate the person through reassurance and positive engagement
    (trauma informed approaches are best).
  • Find out what is comforting (blankets, etc.), soothing (topics, snacks, music) or enjoyable to the person- consider utilizing strength-based approaches.
  • Reduce stimulation in setting: Quiet room, minimize non-essential monitoring equipment, dim fluorescent lighting.
  • Ensure safety, consult with, or have available people familiar with the patient’s and their history.
  • Ask the person how they prefer to communicate. If a family member or supporter is present, they can also assist.
  • Consistent staff, minimize intrusive or nonessential contacts.
  • Explain or demonstrate what is about to be done and consider utilizing a preferred person to do this.
  • Minimize physical restraints or PRN injections.5-7
  • See chapter on sensory considerations for prescribers in this guide for further recommendations.

Comprehensive Assessment

An assessment begins with obtaining enough history to determine deviations from previous functional baselines, a search for predisposing and precipitating factors. Three timelines are useful:

  1. Track the description of the emotional states or evolving signs/symptoms- time of appearance, escalation, frequency, and level of intensity.
  2. Develop biopsychosocial and ecological timelines and maps of current life stressors.
  3. Develop a timeline of interventions during this crisis and previous episodes.1,2 

Several sources of information are critical. Personal information can be from the person with IDD, care providers, parents/guardians, or other treatment team members familiar with the patient. The status of nonverbal people or those with severe-profound ID often hinges on careful observation of nonverbal and physiological expression of emotional and physical states. The purpose of data collecting is to address predisposing factors, precipitating events, circumstances that place the person for relapse or chronicity (persistence). Although sometimes difficult to carry out in a busy ED, it is also helpful to explore the relationship between protective/resilience factors and ongoing ecological/psychosocial stressors.3 The goal of this data collection is to develop an overall treatment plan that includes further diagnostic workup, putting acute strategies in motion, and developing long term programs to maximize wellness and adaptive functioning. The integration of psychotherapies and adjunctive pharmacotherapies is also part of this decision-making process. Table 2 outlines a useful mnemonic and key methodology in assessing patients in crisis. 

Key Components in Assessing Patients with IDD in Crisis

  • Understand the person’s baseline functioning (what do they look like when they are doing well and when did they last appear that way)
  • Assess for medical/neurologic disorders (use the HEAD TO TOESS acronym as a guide)1,2,4
    • Headache and other pain (ingrown toenails, calluses)
    • Epilepsy
    • Aspiration pneumonia or dysphagia
    • Drugs: Assess for adverse medication effects or interactions; ask about complementary and alternative medications; understand recent changes
    • Teeth: Examine the person’s teeth for dental pain, infection, abscesses, or impacted teeth
    • Ocular and otolaryngology Issues:  Earache, hearing issues, sinusitis, vision problems, and obstructive sleep apnea
    • Tummy: GERD, constipation, bowel obstruction, and volvulus
      • Osteoporosis and atypical fractures, pressure sores, spasticity
      • Etiology/cause of IDD: Genetic syndromes can have acute presentations
        • E.g., calcium disturbance in William’s syndrome
        • Serious or new onset illness can present atypically (hypothyroidism, DM I or II)
        • Look for subtle signs that the person is very ill such as not drinking/eating
        • Screen for abuse 2,4
  • Assess for psychosocial stressors including personal loss (e.g., caregiver, friend, staff, etc.), change in program, residence, etc.
  • Assess for comorbid substance use/abuse/dependence
  • Assess for comorbid psychiatric disorder
  • Physical examination: Conduct a full and comprehensive physical examination
  • Mental status examination: Assess suicidality and homicidality, psychotic symptoms, catatonic symptoms, and future orientation
  • Labs to consider thyroid stimulating hormone (TSH), complete blood count (CBC), vitamin D level, liver function tests (LFTs), renal function tests, urine drug screen, (any other pertinent labs based on exam and history).
  • Consider imaging based on history and physical examination (e.g., Abdominal imaging for constipation, etc.)

Psychotropic Medication in Crisis Stabilization 

The use of psychotropic drugs in crisis stabilization is both a balancing act and an art. In some contexts, the ED can be an overstimulating setting and the person’s expressed emotional state, and stress responses interfere with a thorough assessment. Unfortunately, sedation imposes severe limitations on data gathered by close observation of behaviors. On the other hand, a severely agitated person can disrupt comprehensive evaluation. Non-pharmacological strategies (noted in Table 1) can be extremely helpful in resolving this conundrum. 

When to Prescribe?

The decision to use psychotropic drugs in crisis intervention is a complex, context dependent process that exceeds the space allotted here. The algorithmic nature of the decision-making steps is outlined later in this guide. Each section in this guide provides guidelines for medication selection for psychiatric disorders. 

Who Should Get Psychotropic Medications?

Externalizing behaviors like aggression, self-injury, agitation, and loud vocalizations are heterogeneous and arise from many sources. There are no one-size-fits-all answers for pharmacological treatments. Table 1 provides an outline of many medical factors that can contribute to crisis. The presence of a psychiatric disorder does not eliminate the possibility that one or more of these medical issues is the culprit. Frequently, treating the underlying psychiatric disorder or medical condition will mitigate the crisis. The same approach applies to many internalizing symptoms. 

Irritability is a transdiagnostic pattern of behavior (occurring across many diagnostic categories) that may respond to a variety of medications. Evidenced-based choices frequently include broad-spectrum treatments such as risperidone and other second and third generation antipsychotics. Other options include anticonvulsant mood stabilizers, benzodiazepines, psychostimulant-type drugs for patients with comorbid emotional lability, SSRIs and SNRIs. 

One major issue involved in pharmacological crisis intervention hinges on factors such as patterns of co-occurring symptoms, lack of specificity of a drug for a specific presentation, delivery systems (IM, PO etc.), and a prolonged latency of absorption and response. Each of these factors can also limit the efficacy of many drugs as PRNs. Equally problematic is the challenge of polypharmacy, multiple complex patterns of drug-drug interactions, and the increased likelihood of an adverse drug reaction mimicking psychiatric symptoms.   

Unfortunately, there is a modicum of research on psychopharmacologic treatments for patients with IDD in crisis. We have the usual guidelines of “start low and slowly titrate” based on response to treatment with consideration of comorbid medical issues and drug-to-drug interactions. The patient should be closely monitored for response or adverse reaction to treatment. Selection of the medication is based on symptoms, comorbid diagnosis, safety, side effect profile, drug-to-drug interactions, and historical response to a medication/or class of medications.5 If the patient needs medication, the goal should be to calm the patient and not completely sedate them.6 Oral medication administration is preferred over intramuscular or intravenous route.7 Problems with maintaining IVs and the risk of prolonged QTc intervals and other cardiac side effects restrict the use of IV antipsychotics. Some combinations of IM antipsychotic and benzodiazepine are a mainstay for treatment of acute agitation. In the emergency department setting, these include haloperidol 5 mg with lorazepam 1-2 mg, or IM olanzapine or ziprasidone 10 mg.5 Side effects to consider when selecting a medication include the following. 

  • Antipsychotics: may cause acute dystonic reactions, akathisia, or QT prolongation.
  • Benzodiazepines: over sedation, respiratory depression, and some patients with IDD may have a paradoxical reaction to benzodiazepines and become more agitated instead of more calm/sedated.

While medications may calm the patient, it is important to recognize that they are not diagnostic tools. The real work requires establishing the cause for the emergency/crisis and then the team creates a plan of care and then takes steps to carry out that intervention.   

References

  1. Sullivan WF, Diepstra H, Heng J, et al. Primary care of adults with intellectual and developmental disabilities: 2018 Canadian consensus guidelines. Canadian family physician Medecin de famille canadien. 2018;64(4):254-279.
  2. Grier L. Commonly missed diagnoses: Head-to-toe assessment. 2015; Accessed February 2, 2021. https://www.porticonetwork.ca/documents/38160/893368/PC_Commonly+missed…
  3. Fletcher RJ Barnhill J, Cooper S-A (Eds). Diagnostic Manual-Intellectual Disability 2: A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability. Kingston, NY.
  4. Lunsky Y PA, Lake J, Lee J. Improving emergency are for adults with developmental disabilities: A toolkit for providers. 2016;. Accessed February 2, 2021. www.hcardd.ca. https://www.porticonetwork.ca/documents/38160/99698/Emergency+Dept+Tool….
  5. Sullivan WFaJ, D. Rapid tranquilization for adults with crisis behaviors. 2011;. Accessed February 2, 2021. http://ddprimarycare.surreyplace.ca/wp-content/uploads/2018/03/Rapid_Tr…
  6. Zun LW, M. and Nordstrom, K. . Treatment Goal for Agitation: Sedation or Calming. Annals of Emergency Medicine. 2017;70:751-752.
  7. Gottlieb M, Long B, Koyfman A. Approach to the Agitated Emergency Department Patient. The Journal of emergency medicine. 2018;54(4):447-457.