Know the Basics: Applying Telepsychiatry for Intellectual and Developmental Disabilities
People with intellectual (ID) and developmental disabilities (DD) and suffering from co-morbid psychiatric or behavioral disorders need specialized behavioral and psychiatric evaluation and intervention. This intervention is usually available within state-operated intermediate care facilities for the developmentally disabled (ICF/DD).
But what if there are not enough behavioral services for people with ID and DD?
We know there is a national trend to provide community residential placement and integration external to long-standing congregate, state-run centers. This means that the continuity and availability of these behavioral and psychiatric services for ID and DD is sparse. These services are necessary to reduce incipient disruptive behavior, identify newer underlying medical and psychiatric comorbidity, and adjust interventions as needed to optimize client participation in community habilitation.
Most ID and DD residential programs exist in rural areas where psychiatric services are lacking. This requires costly, supervised travel or visits made by psychiatrists through special arrangements. Psychiatric treatment for the developmentally disabled population is particularly challenging given that the communication and self-observational skills of people with DD often requires the use of “operationalized” criteria for the usual DSM-5 based diagnoses used in the general population. These criteria means that DSM-5 diagnoses are based on observable behavior and data derived from not only the clinical interview but staff as well.
Highly co-morbid medical problems can present as behavioral or psychiatric disorder exacerbations. In addition, there is continued development of the field of behavioral phenotypes in which behavioral and psychiatric disorders are characteristically associated with specific genetic syndromes such as Down, Prader-Willi, Lesch-Nyhan Syndromes; Fragile X Disorder; Phenylketonuria; and many others. These specific associations have led to syndrome-specific treatments composed of behavioral interventions, medical interventions (non-psychotropic medications, dietary regimens, and other interventions not characteristically considered “psychiatric”), as well as treatment with psychotropic agents.
The response of the population with developmental disabilities to various medications can be dramatic and highly individualized. But, as a rule, this population tends to be highly vulnerable to various medication side effects and the effects of a multidrug regimen with drug interactions. These effects are compounded by the inability of many clients to describe in detail their experience of the adverse effects of various medications.
Medical interventions must be coupled to behavioral interventions which work to differentially extinguish maladaptive behavior. Plus, carefully designed data collection plans can serve as feedback on treatment effectiveness. Telepsychiatry offers an opportunity to provide such services.
- Needs Assessment
Prior to developing and implementing such services, a project coordinator should assess local interest and ability of community group homes and local clinics or hospitals where clients from group homes are served to provide space, personnel, and equipment to coordinate a telepsychiatry clinic as well as local primary care provider interest. The coordinator can consider things like whether the originating site can control the remote camera’s pan and zoom features, since clients are usually accompanied by a healthcare team including several direct care workers, case managers, nursing staff, behavioral analysts, family or guardians, primary care providers, and others. Camera resolution can help with examination of sequelae of targeted behavior such as self-injury, scratches, bite marks, bruises, or other wounds as well as routine physical attributes, medication effects, and affective expression.
Preparation for a telepsychiatry session should stipulate the time limitations and desired information needed, such as behavioral data, recent changes in staff or other clients, and medical information.
- Consultation Requirements
To make the consultative process most effective, up-to-date records should be available to psychiatric consultants by the case manager at least a day in advance. This includes notes, labs, plans, and other data:
- Face-sheet (client name, demographics, guardian contact information, date of admission and discharge, name and location of community residence)
- History and Physical Examination (any significant findings)
- Medical and Surgical History (hospitalizations, surgical procedures, past and present medical condition or problem list)
- Psychiatric Evaluation (most recent)
- Medications (current and past)
- Allergies (medications or dietary or environmental)
- Family Medical and Psychiatric History
- Social and Developmental History
- Laboratory and Diagnostic Studies (most recent blood tests including CBC, differential, platelet count, CMP, lipid profile, therapeutic drug monitoring [e.g., valproic acid, carbamazepine levels, etc.], urinalysis, cultures and sensitivities, any past neuroimaging [CT, MRI of brain, head, spine], other X-rays, and others)
- Behavioral Intervention Plan and Behavioral Data
- Consultation Components
Telepsychiatry Consultation Components
Consultations with clients who have not previously been seen and evaluated via the telepsychiatry consultation sessions should be scheduled for 60 minutes. Established or follow up clients can be seen for 30 minute sessions.
Below is an example of a consultation sessions will ideally be 60 minutes in duration with the following breakout of each evaluative component. For shorter or follow-up sessions, these components can be shortened proportionally.
Time Session Component 5 minutes Greetings and Introductions 5 minutes Brief presentation of the client’s name, recent history, diagnoses, current medications 2-3 minutes Updates on any medical conditions, hospitalizations, lab tests 10 minutes Behavioral or psychiatric issue needing address 10 minutes Behavioral data review 15-20 minutes Psychiatric interview and examination 5 minutes Discussion and questioning 5 minutes Diagnosis and Treatment Recommendations (including any further needed records review, further medical consultations, diagnostic or laboratory testing, pharmacological interventions, psychosocial interventions, and follow-up schedule) 2 minutes Next appointment schedule
About the Author
Dr. Jeffrey I. Bennett attended medical school at New York University School of Medicine and completed general residency training in Psychiatry in 1991 and an additional year of fellowship training in Neuropsychiatry at the University of Chicago in 1992. He served as a consultant psychiatrist to Howe Development Center (an Illinois state operated ICF/DD), providing services and coordinating medical efforts during a time when that facility was under a consent decree by the Department of Justice. He subsequently served as the Medical Director to Jacksonville Developmental Center and Director of the Developmental Disabilities Division at Southern Illinois University School of Medicine (SIU SOM).
Dr. Bennett served as an Assistant Professor of Psychiatry at the University of Chicago from 1993 to 2003 when he became employed at Southern Illinois University School of Medicine as the Director of Psychiatry Residency Training. He is currently an Associate Professor and the Director of the Adult Services Division at SIU. Dr. Bennett developed an Adult Telepsychiatry Clinic in which residents participate in consultation with patients at remote sites in rural southern and central Illinois critical access hospitals. Dr. Bennett also developed an acute care psychiatric clinic in collaboration with the Mental Health Centers of Central Illinois (a community mental health center) in which residents receive direct supervision and which serves to divert patients from the local emergency departments. He currently directs the Special Needs Clinic at SIU Medicine serving adults with neurodevelopmental disorders and co-morbid mental health conditions. Dr. Bennett serves as past President of the Illinois Psychiatric Society and Chair of the Telepsychiatry and CME Committees. He is a member of the APA Telepsychiatry Committee and APA Membership Committee.
- Bouras, N, Holt, G (eds). Mental Health Services for Adults with Intellectual Disability: Strategies and Solutions. Psychology Press, (New York: 2010).
- Fletcher, R, Loschen, E, Stavrakaki, C, First, M. Diagnostic Manual-Intellectual Disability: A Clinical Guide for Diagnosis of Mental Disorders in Persons with Intellectual Disability. NADD Press, (Kingston, New York: 2007).
- Schalock, RL, Borthwick-Duffy, SA, Buntinx, WHE, Coulter, DL, Craig, EM. Intellectual Disability: Definition, Classification, and Systems of Supports (11th Edition). American Association on Intellectual and Developmental Disabilities, (Washington, DC: 2010).