AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2015, Vol. 120, No. 1, 46–57

EAAIDD DOI: 10.1352/1944-7558-120.1.46

Predictors of Specialized Inpatient Admissions for Adults With Intellectual Disability Miti Modi, Carly McMorris, Anna Palucka, Poonam Raina, and Yona Lunsky

Abstract Individuals with intellectual disability (ID) have complex mental health needs and may seek specialized ID psychiatric services. This study reports on predictors of specialized inpatient admissions for 234 individuals with ID who received outpatient services at a psychiatric hospital. Overall, from 2007-2012, 55 of the 234 outpatients were triaged into the specialized inpatient unit. Aggression towards others and psychotropic polypharmacy significantly predicted these admissions. Unlike previous research, schizophrenia and level of ID did not predict admissions, suggesting that these factors may have a differential impact in specialized versus mainstream inpatient services. Findings are discussed in relation to how specialized inpatient units can be most responsive to these vulnerable patients and the factors that may impact clinical decision making. Key Words: intellectual disability; psychiatric hospitalization; health services; inpatients

The closure of institutions for individuals with intellectual disability (ID) in Ontario, Canada has resulted in approximately 7,000 individuals being transferred to community settings (Lemay, 2009). Generally, studies suggest that individuals with ID tend to have a better quality of life and improved adaptive behaviors in community settings than institutions (Kim, Larson, & Lakin, 2001; Lemay, 2009). However, when they experience psychiatric issues in addition to their ID, community living can be a challenge. They may encounter difficulties due to the limited availability of specialized mental health resources (Lunsky, Garcin, Morin, Cobigo, & Bradley, 2007), coupled with the insufficient training of staff in outpatient settings (Monaghan & Cumella, 2009). The shortage of specialized ID resources in community settings has resulted in a large number of individuals with ID relying on hospitals and emergency departments to meet their mental health needs (Lunsky, Balogh, & Cairney, 2012; Sealy & Whitehead, 2004). Adults with ID tend to have higher rates of emergency visits and psychiatric hospitalizations compared to the general population, along with more repeat hospital admissions (Lunsky & 46

Balogh, 2010). There continues to be a need for specialized services with expertise in assessing and treating individuals with ID and mental health issues (Balogh, Brownell, Ouellette-Kuntz, & Colantonio, 2010; Chaplin, 2009; MENCAP, 1998). Thus, it is important to understand more about this group of individuals and how their mental health needs are being met. In Canada, patients with ID can seek either mainstream psychiatric or specialized ID services which typically include interdisciplinary teams with expertise in both ID and psychiatric disorders (Lunsky, Gracey, Bradley, Koegl, & Durbin, 2011). Previous studies in Canada and the United Kingdom have described and compared individuals with ID who use mainstream psychiatric services to those who use specialized ID outpatient and inpatient services (Chaplin, 2009, 2011; Hemmings et al., 2009; Lunsky et al., 2011). In one Ontariobased study, adults who used specialized ID outpatient services tended to be younger, were more likely to have a diagnosis of mood or anxiety disorder, and displayed more aggression than patients receiving mainstream outpatient services (Lunsky et al., 2011). Individuals with ID who used Specialized Inpatient Admissions

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specialized inpatient units were more likely to have a diagnosis of autism spectrum disorder (ASD; Alexander, Piachaud, & Singh, 2001; White, Lunsky, & Grieve, 2010) and had higher rates of challenging behaviors (Lunsky, Bradley, Durbin, & Koegl, 2008; White et al., 2010) than patients receiving mainstream inpatient services. Although several studies have described patients in specialized ID units, we know very little about what predicts their hospitalizations. To our knowledge, only one study has explored the predictors of inpatient admission among individuals with ID. Cowley, Newton, Sturmey, Bouras, and Holt (2005) studied 750 adults with ID in London, UK and found that schizophrenia spectrum disorders, ID at the upper end of the spectrum, living independently, symptoms of psychosis, and the presence of physical aggression predicted inpatient admission. However, this study did not distinguish between whether adult admissions were to specialized ID or mainstream inpatient units, with the majority of admissions being to nonspecialized units. Since previous research has identified that there are differences in the demographic and clinical profiles of patients with ID who access specialized ID versus mainstream mental health services (Alexander et al., 2001; Lunsky et al., 2011; White et al., 2010), it would be important to explore whether these same variables also predict admission to specialized ID inpatient units. The purpose of this study was to investigate outpatients with ID seen in a specialized outpatient assessment and consultation service over a 6-year period. The specialized outpatient consultation services allows for triage into a specialized ID inpatient unit for more in-depth assessment and treatment. The present study examined which outpatients were triaged to inpatient units as a part of their first consultation with our outpatient services in period between the years 2007 to 2012. Our first question was what proportion of adults with ID referred to this specialized outpatient service were admitted to specialized inpatient care; and secondly, what factors predicted such admissions? Such information is important to hospital administrators and policy makers in planning and designing future services for this population.

Method Description of Service The hospital-based Dual Diagnosis service, located in Toronto, Canada provides specialized inpatient M. Modi et al.

EAAIDD DOI: 10.1352/1944-7558-120.1.46

and outpatient services to individuals ages 16 years and older with ID and mental health issues, through interdisciplinary teams including psychiatry, behavior therapy, occupational therapy, psychology, nursing, recreational therapy, and social work. The outpatient services offer diagnostic assessments, consultation, and time-limited treatment. A proportion of these patients are triaged into the service’s 10-bed locked inpatient unit. Patients are typically considered for inpatient admission when they cannot be safely managed in the community, are in need of intensive interdisciplinary assessment, and/or the recommended treatment cannot be safely completed in the community due to behavioral or support concerns.

Participants Two hundred and thirty-four unique individuals between the ages of 16 to 74 years received interdisciplinary clinical outpatient consultations from the Dual Diagnosis Service between January 2007 and December 2012. If cases closed in that timeframe were re-referred to the outpatient services, only the first referral was used in the analyses. Of the 234 outpatients seen at least once in that time period, 61.1% were males and 55.6% were older than 25 years of age. Sixty-seven percent were living in a family home or in a minimally supported independent or semi-independent housing. Just under half (45.2%) had ID at the upper end of the spectrum and 32.9% had a diagnosis of ASD. (See Tables 1, 2 and 3 for a detailed account of the demographic and clinical characteristics of the sample.)

Measures Demographic and clinical information was retrieved from the outpatient intake assessment, a standardized form completed by the clinical staff through interviews with the patient and caregivers at the time of intake. The following measures were also completed during the intake process by caregivers. Reiss Screen for Maladaptive Behaviour (RSMB; Reiss, 1988). The RSMB is an informant-based measure that is used to identify mental health symptoms in individuals with ID. This 38-item measure includes eight subscales, six special items, and a 26-item total. It is filled out independently by two or more raters and is routinely completed as part of the intake process. All the items in the RSMB are rated 47

EAAIDD DOI: 10.1352/1944-7558-120.1.46

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Table 1 Bivariate Comparison of Demographic Variables for Individuals With Intellectual Disability Receiving Specialized Outpatient Services Who Were Admitted to Specialized Inpatient Unit to Those Who Were Not Admitted Demographic Variable

Total (N 5 234) n (%)

AGE 26 and above 0-25 years

130 (55.6) 104 (44.4)

38 (69.1) 17 (30.9)

92 (51.4) 87 (48.6)

2.114

0.022* 1.112 – 4.019

GENDER Male Female

143 (61.1) 91 (38.9)

27 (49.1) 28 (50.9)

116 (64.8) 63 (35.2)

0.524

0.038* 0.284 – 0.965

RESIDENCE Supporteda Minimal supportb

77 (33.3) 154 (66.7)

26 (49.1) 27 (50.9)

51 (28.7) 127 (71.3)

2.398

0.006** 1.278 – 4.498

Admitted Not Admitted (N 5 55) n (%) (N 5 179) n (%)

Unadjusted OR

p

95% CI

a Supported housing includes supervised residence, hospital, long term care, and correctional facilities. b Minimal support housing includes family home, independent, and semi-independent housing. *p , 0.05. **p , 0.01.

on a 3-point scale (no problem, a problem, or a major problem). The RSMB has demonstrated good internal reliability, interrater reliability, and validity (Prout, 1993; Reiss, 1986). This study investigated the behavioral and psychiatric symptoms of patients, as assessed by the RSMB 26-item total score. Aberrant Behaviour Checklist (ABC; Aman & Singh, 1986). The ABC is also an informantbased measure that is routinely completed as part of the intake process. It is used to assess the behavior of individuals with ID and consists of 58 items that are organized into five subscales: Irritability, Lethargy, Stereotypy, Hyperactivity, and Inappropriate Speech. Each item is rated on a scale from 0 (not a problem at all) to 3 (the problem is in severe degree). The ABC has shown to have good internal consistency, interrater reliability and validity (Aman, Singh, Stewart, & Field, 1985). This study investigated patients’ scores on all five ABC subscales.

Procedure Retrospective chart reviews were conducted for patients who received specialized outpatient services between January 2007 and December 2012. Charts were reviewed with respect to the information available at intake: age, gender, place of residence, psychiatric diagnoses, presenting issues, level of ID, previous psychiatric hospitalizations, medications, and scores on the RSMB and ABC at intake. 48

Data Analysis Preliminary analyses (chi-square, Fisher’s exact tests, simple logistic regression, Levene’s test for equality of variances and independent samples ttests) were carried out to identify factors associated with being triaged to the specialized inpatient unit while receiving outpatient services. We compared patients triaged to inpatient units to those who were not on a number of demographic and clinical factors, including: patient’s age at intake, gender, residence, level of ID, aggression towards others, self-injurious behavior, presence of ASD, primary psychiatric diagnosis, previous psychiatric hospitalizations, types of psychotropic medications, psychotropic and non-psychotropic polypharmacy, psychotropic PRN use, and RSMB and ABC scores. Variables found to be associated with such inpatient admissions at the 0.05 significance level were subsequently included in a multivariate logistic regression analysis, allowing us to examine the relative effects of each of the predictors on inpatient admission while controlling for the effects of the other predictors in the model. Prior to conducting the multivariate analysis, we investigated the bivariate associations between the various independent variables to assess the extent to which independent variables were related to each other. To avoid or restrict problems with collinearity, only variables that were not significantly correlated with one another were included in the multivarSpecialized Inpatient Admissions

EAAIDD DOI: 10.1352/1944-7558-120.1.46

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2015, Vol. 120, No. 1, 46–57

Table 2 Bivariate Comparison of Psychiatric and Behavioral (Clinical) Variables for Individuals With Intellectual Disability Receiving Specialized Outpatient Services Who Were Admitted to Specialized Inpatient Unit to Those Who Were Not Admitted Psychiatric and Behavioral (Clinical) Variable

Total (N 5 Admitted (N 5 Not Admitted Unadjusted 234) n (%) 55) n (%) (N 5 179) n (%) OR

p

95% CI

LEVEL OF ID ID in the middle range to the lowest end of the spectrum 120 (54.8) ID at the upper end of the spectrum 99 (45.2) AGGRESSION Present Absent

34 (63.0)

86 (52.1)

1.562

0.166 0.831 – 2.936

20 (37.0)

79 (47.9)

164 (78.8) 44 (21.2)

48 (90.6) 5 (9.4)

116 (74.8) 39 (25.2)

3.228

0.020* 1.199 - 8.685

99 (55.0) 81 (45.0)

22 (56.4) 17 (43.6)

77 (54.6) 64 (45.4)

1.076

0.841 0.526 – 2.198

77 (32.9) 157 (67.1)

20 (36.4) 35 (63.6)

57 (31.8) 122 (68.2)

1.223

0.533 0.649 - 2.303

126 (54.3) 106 (45.7)

37 (68.5) 17 (31.5)

89 (50.0) 89 (50.0)

2.176

0.018* 1.142 – 4.149

1.29 (1.638)

1.80 (1.877)

1.18 (1.531)

SELF-INJURIOUS BEHAVIOR Present Absent ASD Yes No PREVIOUS PSYCHIATRIC HOSPITALIZATIONS Yes No Mean (SD) previous psychiatric hospitalizations

Note. ASD 5 autism spectrum disorder; ID 5 intellectual disability. *p , 0.05.

iate logistic regression analysis. All analyses were carried out using SPSS 20.0 for Windows (SPSS, 2011). This study was approved by the hospital Research Ethics Board.

Results Fifty-five (23.5%) of the total sample of 234 outpatients were triaged to the specialized inpatient unit during the study period.

Bivariate Analysis We compared patients admitted to the inpatient unit to those who were only receiving outpatient services with regard to demographics. Patients who were triaged into the specialized inpatient unit were significantly more likely to be female, M. Modi et al.

older, and living in supported non-familial residential settings (see Table 1). In terms of clinical profile, there were no differences in psychiatric diagnosis between the two groups. The two groups were also similar with regard to rates of ASD, presence of self-injurious behavior, and level of ID. Aggression towards others was more likely to be identified as a presenting risk behavior in those admitted. Those admitted to the inpatient unit were also more likely to have had at least one previous psychiatric hospital admission. (Refer to Table 2 for mean rates of previous psychiatric hospitalizations.) Those admitted to the inpatient unit were prescribed a greater mean number of psychiatric medications (M 5 2.25; SD 5 1.51) than those not admitted (M 5 1.51; SD 5 1.31). Using three 49

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Table 3 Bivariate Comparison of Medication (Clinical) Variables for Individuals With Intellectual Disability Receiving Specialized Outpatient Services Who Were Admitted to Specialized Inpatient Unit to Those Who Were Not Admitted Medication (Clinical) Variable

Total (N 5 Admitted (N 5 Not Admitted Unadjusted 234) n (%) 55) n (%) (N 5 179) n (%) OR

p

95% CI

PSYCHOTROPIC MEDICATION POLYPHARMACY 3 or more 0 to 2

64 (27.4) 170 (72.6)

24 (43.6) 31 (56.4)

40 (22.3) 139 (77.7)

2.690

0.002*

1.421 - 5.094

NON-PSYCHOTROPIC MEDICATION POLYPHARMACY 3 or more 48 (20.5) 0 to 2 186 (79.5)

14 (25.5) 41 (74.5)

34 (19.0) 145 (81.0)

1.456

0.301

0.714 - 2.969

PRN PSYCHOTROPIC MEDICATION Yes 54 (23.2) No 179 (76.8)

23 (41.8) 32 (58.2)

31 (17.4) 147 (82.6)

3.408

, .001*** 1.760 - 6.602

Note: PRN 5 pro re nata. *p , 0.05. ***p , 0.001.

or more medications as an indicator of polypharmacy, we found that those admitted to the inpatient unit were significantly more likely to be prescribed three or more psychotropic medications than those who remained outpatients. We further compared the two groups based on the types of psychotropic medications prescribed and found that those admitted to the inpatient unit were significantly more likely to be taking anxiolytics (unadjusted OR 5 2.52, p 5 0.004) and mood stabilizers (unadjusted OR 5 3.38, p 5 0.003) than outpatients, but were equally likely to be prescribed other medication classes: antidepressants, antipsychotics, sedatives, and stimulants. Inpatients were also more likely to be taking as needed or pro re nata (PRN) psychotropic medications. However, the two groups were equally likely to take either anxiolytic only PRN or other psychotropic PRN (including antipsychotic PRN) and thus did not differ in terms of the types of psychotropic PRNs that were prescribed to them. There were also no differences between the two groups in the mean number of or the proportion of prescribed multiple nonpsychotropic medications. (See Table 3 for rates of medication types.) 50

The RSMB 26-item and the ABC scores were completed at point of intake for outpatient services. When multiple caregivers completed these measures, a mean score for all the measures that were completed within 30 days from the earliest date of assessment were computed and used in the analysis. The RSMB 26-item total scores were available for 184 patients and included all 55 inpatients. Further chi-square analyses showed that younger outpatients (x2 5 4.41, p 5 0.036) with ID on the middle to lower range of the spectrum (x2 5 5.28, p 5 0.022) and presence of ASD (x2 5 6.13, p 5 0.013) were more likely to complete the RSMB measure. Equal variances in the RSMB scores were assumed for both outpatient and inpatient groups based on Levene’s test for equality of variances ( p . 0.05). Independent samples t-tests showed no significant differences in mean scores between the groups for the 26-item total score (see Table 4). The ABC scores were available for 177 patients and also included all 55 inpatients. Further chi-square analyses showed that the ABC scores were more likely to be completed for outpatients who were younger (x2 5 4.63, p 5 0.031) with an ASD diagnosis (x2 5 7.88, p 5 0.005). Equal variances Specialized Inpatient Admissions

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Table 4 Bivariate Comparison of Reiss Screen for Maladaptive Behaviour and Aberrant Behaviour Checklist (ABC) Scores for Individuals With Intellectual Disability Receiving Specialized Outpatient Services Who Were Admitted to Specialized Inpatient Unit to Those Who Were Not Admitted Admitted (n 5 55) Mean (SD)

Not Admitted (n 5 129) Mean (SD)

t-value (Equal variances assumed)

p

17.21 (7.58)

18.51 (8.96)

0.943

0.347

Admitted (n 5 55) Mean (SD)

Not Admitted (n 5 122) Mean (SD)

t-value (Equal variances assumed)

p

0.128 0.944 0.419 20.879 1.177

0.898 0.346 0.676 0.381 0.241

Reiss Subscale 26-Item Total Score

ABC Subscale Irritability Lethargy Stereotypy Hyperactivity Inappropriate speech

16.89 11.49 4.56 17.22 3.37

(10.72) (7.83) (4.61) (10.79) (3.09)

in the ABC scores were assumed for both outpatient and inpatient groups based on Levene’s test (p . 0.05) and independent samples ttests showed no significant differences in mean scores between groups for all the 5 ABC subscales: Irritability, Lethargy, Stereotypy, Hyperactivity, and Inappropriate Speech (see Table 4).

Multivariate Logistic Regression Analysis A multivariate logistic regression analysis was conducted to investigate the predictors of being triaged to the specialized inpatient unit. As indicated previously, all the variables included in the multivariate logistic regression analysis showed significant association with inpatient admissions at the bivariate level and included: (a) gender (female, male), (b) place of residence (housing with minimal support–family, independent and semi-independent housing, nonfamilial supported housing), (c) three or more psychotropic medications (yes, no), (d) aggressive behavior (yes, no), and (e) any previous psychiatric hospitalizations (yes, no). (See Table 5.) Due to missing data, 29 individuals from the cohort of 234 outpatients were not included in the multivariate logistic regression analysis. Anxiolytic and mood stabilizer medications use were significantly associated with psychotropic polypharmacy, where patients who were taking three or more psychotropic medications were significantly more likely to be prescribed anxiolytics and mood stabilizers ( p , 0.001). Therefore, both of these M. Modi et al.

17.11 12.83 4.89 15.68 4.04

(10.80) (9.16) (5.08) (10.79) (3.65)

variables were considered redundant in the presence of information regarding patients’ psychotropic polypharmacy use and were not included in the multivariate logistic regression analysis in order to avoid problems with collinearity. Similarly, patient age and psychotropic PRN use were significantly associated with patients’ residential setting where patients who were living in supported housing were more likely to be older (p , 0.001) and were also more likely to be prescribed psychotropic PRNs ( p 5 0.016). Therefore, patients’ age and psychotropic PRN prescription were considered redundant in the presence of information on their residential setting and were not included in the multivariate logistic regression analysis. Finally, residential setting was included in our multivariate logistic regression analysis over patient age and their psychotropic PRN use because the Cowley et al. (2005) study had found that living independently predicted inpatient admissions in their sample, and in our study we wanted to investigate if residence also predicted specialized inpatient admissions. Cowley et al. (2005) did not find patient age to be a predictor and they did not examine the impact of psychotropic PRNs on inpatient admissions. When all variables were entered simultaneously, only the presence of aggressive behavior ( p , 0.01), and taking three or more psychotropic medications concurrently ( p 5 0.01) remained significant predictors of inpatient admission. In addition, there was also 51

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Table 5 Multiple Logistic Regression for Predictors of Admission to Specialized Inpatient Services for Individuals With Intellectual Disability Receiving Specialized Outpatient Services Total Sample (n 5 205) Variable

n

%

B

Adjusted OR

128 77

62.4 37.6

20.560

0.571

0.121

0.282 - 1.158

138 67

67.3 32.7

20.556

0.574

0.121

0.284 - 1.159

PSYCHOTROPIC MEDICATION POLYPHARMACY 3 or more 0 to 2 (reference)

56 149

27.3 72.7

0.949

2.583

0.010*

1.251 - 5.334

AGGRESSION Present Absent (reference)

162 43

79.0 21.0

1.577

4.839

0.007**

1.540 – 15.208

PREVIOUS PSYCHIATRIC HOSPITALIZATIONS Yes No (reference)

111 94

54.1 45.9

0.694

2.002

0.059

0.975 – 4.114

GENDER Male Female (reference)

p

95% CI

RESIDENCE Minimal supporta Supportedb (reference)

a Minimal support housing includes family home, independent and semi-independent housing. b Supported housing includes supervised residence, hospital, long-term care, and correctional facilities. *p , 0.05. **p , 0.01.

a trend for outpatients with previous psychiatric hospitalizations to be more likely to be admitted ( p 5 0.059).

Discussion The aim of this study was to determine the predictors of admission to a specialized psychiatric inpatient unit for patients with ID. Nearly one in four outpatients was admitted at least once in the course of their outpatient service. At the bivariate level, several demographic and clinical variables differentiated between the two groups: age, gender, residence, aggressive behavior, previous psychiatric hospitalizations, psychotropic PRN use, and psychotropic polypharmacy. When controlling for the effects of the other predictors in the model, only aggressive behavior and taking three or more psychotropic medications remained significant predictors of specialized inpatient admissions. 52

According to the results of our study, selfinjurious behavior did not differentiate inpatients and outpatients. However, patients with ID who displayed aggressive behavior towards others were more likely to be triaged into the specialized inpatient unit. Aggression towards others as a predictor of inpatient admissions is consistent with the findings of Cowley et al. (2005). Therefore, aggression towards others predicts hospital admissions to specialized as well as mainstream psychiatric units. This finding is not surprising as several studies have reported on the lack of adequate resources and trained staff to manage challenging behaviors such as aggression in individuals with ID in community settings (Bouras & Holt, 2004; Edwards, Lennox, & White, 2007). It has been argued that more proactive outpatient clinical services need to be available if such behaviors are to be safely managed in community settings (Benson & Brooks, 2008; Specialized Inpatient Admissions

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Edwards et al., 2007; Joyce, Ditchfield, & Harris, 2001). As community-based services become better equipped to respond to aggressive behavior in individuals with ID, they may not have to remain as reliant on inpatient units to receive appropriate care. This study also found that patients who were taking three or more psychotropic medications concurrently were more likely to receive specialized inpatient care. Polypharmacy was not one of the predictors considered in the Cowley et al. (2005) study. Individuals with ID are sometimes prescribed multiple psychotropic medications to manage challenging behaviors, despite limited knowledge about effects and evidence of effectiveness of polypharmacy on such behaviors (Deb & Unwin, 2007; Edwards et al., 2007; Matson & Neal, 2009; McGillivray & McCabe, 2006). All psychotropic medications carry risk of significant side effects and polypharmacy significantly increases those risks (Bradley & Lofchy, 2005). Polypharmacy can be harmful and in fact may lead to further medical complications, which may result in worsening of the very behavior that these medications are supposed to treat (Deb & Unwin, 2007), making inpatient admission more likely. Polypharmacy of psychotropic medications may be a proxy indicator of clinical complexities and may signal a failure of previous interventions (either nonpharmacological or single-medication treatments). Such patients may be admitted to specialized inpatient units because the process of reducing and adjusting medications is more safely done under observation in specialized inpatient units than through outpatient services (Lunsky et al., 2008; White et al., 2010). In one study, specialized units were more likely to focus on medication reduction than in mainstream units where the number of medications prescribed to inpatients increased at discharge (White et al., 2010). Our study also found differences in specific psychotropic medication classes for both groups. Future research should more closely examine medication profiles of patients with ID to further understand the role that medications play in terms of health service use. Our study did not find any differences with regard to psychiatric diagnosis in admitted versus nonadmitted patients, whereas Cowley and colleagues (2005) reported schizophrenia and ID at the upper end of the spectrum to be predictors of inpatient admissions. Rates of psychotic disorders in our sample were much lower than what was reported in their study M. Modi et al.

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in both admitted and nonadmitted individuals. It is possible that individuals with schizophrenia and ID were more likely to be referred to schizophrenia inpatient and outpatient services in the current study rather than to the specialized ID unit, which is supported by previous research (Lunsky et al., 2008; White et al., 2010). We also did not find any differences between those referred and not referred to the inpatient unit with regard to level of ID, whereas Cowley and colleagues (2005) did. The proportion of individuals diagnosed with ID at the upper end of the spectrum in the total sample of the Cowley and colleagues (2005) study was higher (63%), compared to the rate of 45.2% of patients in our study. Although individuals with ID at the upper end of the spectrum may be more likely to be admitted to hospitals (Bouras & Holt, 2004; Cowley et al., 2005), our study suggests that they are not more likely to be admitted to specialized ID inpatient units. More research on different jurisdictions with different levels of clinical expertise should investigate the types of services that are accessed by individuals with ID at the upper end of the spectrum. Our study found higher rates of ASD in both inpatients and outpatients (32.9%) than the Cowley et al. (2005) study (20%). It is interesting to note that our study did not find that having ASD predicted inpatient admissions, despite several studies suggesting that psychiatric hospitalizations are more common in this group (Mandell 2008; Mouridsen, Rich, Isager, & Nedergaard, 2008). One explanation for ASD not predicting specialized inpatient admissions may be that studies that report differences in rates of psychiatric hospitalizations in ASD tend to compare those with ASD to the non-ID population. The only study that used an ID control group like our study, but in a sample of children, did not find the rates of hospitalizations to be higher in children with ASD (Bebbington, Glasson, Bourke, de Klerk, & Leonard, 2013). It may be that in our study, the proportion of ASD admissions was not higher because of the stress associated with such admissions (unfamiliar surroundings, sensory issues, communication challenges, change in routine; Gabriels et al., 2012; Scarpinato et al., 2010). Clinically, our unit attempts to avoid such admissions whenever possible and strives to conduct the assessment in a familiar environment, given the difficulty that individuals with ASD can have adjusting to an inpatient setting. 53

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Contrary to what we hypothesized, our study also did not find any significant differences in RSMB and ABC mean scores between inpatients and outpatients. Both RSMB and ABC have been shown to be sensitive to change in symptom severity after receiving specialized psychiatric inpatient treatment (Carminati, Gerber, & Constantin, 2005; Lunsky et al., 2010), but may be less sensitive measures in terms of differentiating which patients should be admitted to hospital when most patients under consideration have significant mental health or behavioral issues. Even the mean scores on the Irritability subscale of the ABC did not differ between outpatients and inpatients, in contrast to clinician-rated presence of aggression, which did differentiate the two groups. Similar RSMB and ABC mean scores suggests that clinician based ratings may be more important in predicting admission to specialized inpatient units than how severe caregivers perceive symptoms to be. Other considerations (i.e., availability of a bed, maintenance of inpatient milieu to avoid destabilization of the unit, parents not agreeing to inpatient admission) may also drive the decision to admit more than caregiver perception of symptom severity. Although difficult to measure, such considerations require further systematic study.

Limitations This study has some limitations that should be taken into account when interpreting its findings. The data on psychiatric diagnoses in this study were collected at intake for outpatient services. Commonly, patients who are referred to our outpatient services require clarification of their diagnoses. Therefore, the psychiatric diagnosis recorded at intake may not be fully representative of the challenges and symptoms presented by these patients and such diagnoses may be revised through specialized assessments. It would be important to study changes in diagnostic profiles of patients with ID following specialized assessment services. Results reported had to exclude certain individuals due to missing information, in particular RSMB and ABC analysis had to exclude 21.4% and 24.4% of outpatients respectively, who tended to be older and fell within the upper end to the middle range of the ID spectrum than those for whom their caregiver ratings were completed. The completion of these measures was not dependent on any other variables, including 54

the predictor variables aggression and psychotropic polypharmacy. However, in our study we cannot be certain of how the unavailability of these scores for some outpatients may have impacted our results. Our study found aggression towards others to be a significant predictor of inpatient admissions; however, we did not differentiate between aggressive threats and actual physical violence against others. Future studies should further refine measurement of aggressive behavior in ID to understand whether both threats and actual physical violence against others predict specialized inpatient admissions. Finally, our study only focused on predictors of inpatient admissions of patients with ID into specialized psychiatric units and the results may not apply in jurisdictions without specialized ID units. It is also unclear whether the differences between our study and Cowley and colleagues (2005) in the United Kingdom are because of the type of inpatient unit studied or due to the fact that these services were offered in different jurisdictions where services outside of hospital and professional training also vary. For example, in Canada we do not have local community-based outpatient teams for individuals with ID and nursing and psychiatric training in ID is quite limited, whereas the United Kingdom has ‘‘learning disability’’ community teams and every psychiatrist and nurse receives mandatory training with this population. In the United States, there are some specialized units, but similar to Canada, the availability of these units varies by state. There are university centers of excellence in each state which include training, research, and clinical services, but these centers do not serve every adult with ID and they may not focus specifically on psychiatric issues. Healthcare services in the United States also differ from Canada and the United Kingdom in terms of how services are funded. Therefore, future studies should compare the predictors of inpatient admissions into specialized and mainstream services in the same jurisdiction and additional efforts to understand how services vary by jurisdiction are also required.

Future Directions The results of our study should serve as a resource for hospital administrators and policy makers for improving the available outpatient and inpatient services in ID care. Our study suggests that there may be several predictors of admissions to Specialized Inpatient Admissions

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specialized inpatient care beyond just the clinical presentation. Caregiver measures of clinical presentation are not sensitive enough to predict care patterns and neither are psychiatric diagnoses at intake. Our study suggests that it might be difficult to meet the needs of individuals with ID who are aggressive and taking three or more psychotropic medications in community settings, which may result in them seeking specialized inpatient units. Therefore, in the future it is necessary to study and develop community-based services that can provide care for patients with aggression and use alternative treatments to reduce the use of multiple psychotropic medications and the most severe psychiatric symptoms. If community services could be more responsive to individuals with aggression, and if clinical treatment could be provided prior to the prescription of multiple psychotropic medications, then perhaps the need for some of these specialized admissions could be reduced.

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tario, Canada; Carly McMorris, York University, Toronto, Ontario, Canada; Anna Palucka, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Poonam Raina, University of Toronto, Toronto, Ontario, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Dual Diagnosis Service, Toronto, Ontario, Canada.

Received 7/12/2013, accepted 12/21/2013.

Correspondence concerning this article should be addressed to Yona Lunsky, Centre for Addiction and Mental Health, Dual Diagnosis Program, 501 Queen Street West, Toronto, Ontario M5V 2B4, Canada (e-mail: [email protected]).

Authors: Miti Modi, Centre for Addiction and Mental Health, Dual Diagnosis Service, Toronto, On-

M. Modi et al.

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