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Brief reportjir_1417 714..718

Life events and emergency department visitsin response to crisis in individuals withintellectual disabilities

Y. Lunsky & J. Elserafi

Dual Diagnosis Program, Centre for Addiction and Mental Health,Toronto, Ontario, Canada

Abstract

Background Stressful life events have been linkedto psychopathology in the general population,but few studies have considered the relationshipbetween life events and psychopathology for peoplewith intellectual disabilities (ID), and the linkbetween particular life events and hospital use.Methods Informants provided data on 746 adultswith ID who had experienced at least one ‘crisis’.Informants completed a checklist of recent lifeevents from the Psychiatric Assessment for Adultswith Developmental Disabilities Checklist (PASADD checklist) and also indicated whether thecrisis resulted in a visit to the hospital emergencydepartment.Results Individuals experiencing life events in thepast year were more likely to visit the emergencydepartment in response to crisis than those whodid not experience any life events. Individualsexperiencing a move of house or residence, seriousproblem with family, friend or caregiver, problemswith police or other authority, unemployed for more

than 1 month, recent trauma/abuse, or a drug oralcohol problem were more likely to visit the emer-gency department.Conclusions Six specific life events were found tobe associated with use of emergency departments inresponse to crisis. We suggest intervention efforts betargeted towards people who experience life events,particularly these events, as they may be a riskfactor for hospital visits.

Keywords emergency departments, hospitals,intellectual disabilities, life events

Introduction

The relationship between life events and psychopa-thology has been extensively studied in the generalpopulation (Dohrenwend & Egri 1981; Wills et al.1992; Kendler et al. 1999). Less research has beenconducted on the relationship between life eventsand psychopathology for individuals with intellec-tual disabilities (ID), despite studies that demon-strate that individuals with ID are more likely tohave psychiatric disorders (Deb 2001) and thatindividuals with ID experience a greater number oflife events than individuals without ID (Hatton &Emerson 2004). The existing research demonstrates

Correspondence: Dr Yona Lunsky, Centre for Addiction andMental Health, 501 Queen St. West, Toronto, Ontario, Canada,M5V 2B4 (e-mail: [email protected]).

Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2011.01417.x

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© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd

an association between life events and psychiatricproblems in individuals with ID (see Hubert-Williams & Hastings 2008 for systematic review)with two studies demonstrating that life eventsprecede psychological problems (Monaghan & Soni1992; Esbensen & Benson 2006). The systematicreview called for further research to clarify thetemporal relationship between life events andpsychological problems in individuals with ID.

Previous studies have focused generally on therelationship between life events and well-being orpsychiatric symptoms. One study suggested a linkbetween life events and psychiatric hospitalisation inindividuals with ID, but this study lacked a controlgroup of people with ID who did not get hospital-ised (Stack et al. 1987). Another study of a clinicalsample did not find a relationship between lifeevent occurrence and inpatient hospitalisation(Tsakanikos et al. 2007), while a third study witha community sample found life event occurrenceto be more frequent in those living in a hospitalsetting (Hastings et al. 2004). No research hasexamined whether there is a link between life eventsand subsequent visits to the hospital emergencydepartment. The purpose of this study was todescribe the frequencies of specific life eventswithin a Canadian sample of individuals with IDwho had experienced a behavioural crisis and toexamine the relationship between life events andemergency department visits.

Methods

Participants

Informants provided data on 751 adults with IDliving in one large and two medium-sized urbancentres in Ontario, Canada, as part of a largerproject on crises and ID. Crisis was defined as ‘anacute disturbance of thought, mood, behaviour, orsocial relationship that requires immediate attentionas defined by the individual, family, or community’(Allen et al. 2002, p. 8). Medical crises were not thefocus of this study. Participants were 466 men and279 women and one transgendered individual,mean age of 36.32 (SD = 14.43, range = 10–82).Three hundred and seventy-three individuals wereliving in group homes, 191 individuals with family,and 182 individuals either independently or semi-

independently in a variety of minimal support set-tings. Sixty-five per cent of individuals were eitherworking, in school or participating in other struc-tured daytime activities at the time of their crisis.

Five individuals were excluded from this analysisbecause life events information was not providedby the informants. All of these adults were beingserved by social services or mental health agenciesthat support people with ID.

Materials and procedure

Life events experienced in the past 12 months camefrom the Psychiatric Assessment for Adults withDevelopmental Disabilities Checklist (PAS ADDchecklist; Moss et al. 1998) with three additionalitems added to this list: change in roommates,change in client’s primary staff/worker, recenttrauma/abuse. Using a standardised form, informa-tion on client background, life events and outcomeof crises (visit or no visit to an emergency depart-ment) was completed by staff after their clientsexperienced a crisis. Typically, this form was com-pleted within days of the event as part of the agencyprotocol. In some situations, however, the staffperson could only complete the form after hearingabout the crisis from the individual and could besome time later (particularly for individuals whoreceived very limited support). The decision to visitthe emergency department could have been madeby the person with the disability, the caregiver or amember of the public, but it was not the focus ofthe current paper. Agency level information wasforwarded to the research team and all crises werereviewed by two raters. If the crisis was strictlymedical in nature, it was excluded from analyses.No identifying information was provided to theresearch team at this stage. All participating agen-cies were trained in the completion of these formsby the two research project coordinators. This studyreceived ethics approval from the Centre for Addic-tion and Mental Health and Queens Universityresearch ethics boards.

Analyses

T-tests, chi-squared analyses and absolute riskincreases (ARIs) were used for comparisons. ARI isthe increase in risk caused by a given activity. It ispresented as a probability and varies from 0 to 1

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Y. Lunsky & J. Elserafi • Life events and emergency department visits


(Kraemer et al. 2003). Because of the relatively largenumber of comparisons in this study, we soughtto minimise Type I errors, by treating differencesas significant only at the probability level of 1%(Perneger 1998).

Results

Over two-thirds of the sample (69.4%) had experi-enced one or more life events in the year prior tocrisis and 42.9% had experienced two or more lifeevents. Men (69.7%) and women (68.8%) wereequally likely to be exposed to one or more lifeevents [c2(d.f. = 1) = 0.070, P = 0.791]. Individualsliving independently were more likely (84.1%)to have been exposed to at least one life eventthan those living in group homes (63.0%)[c2(d.f. = 1) = 25.797, P < 0.001]. Individuals livingwith family were equally likely (68.1%) to have beenexposed to at least one life event relative to thoseliving in group homes (63.0%) [c2(d.f. = 1) = 1.416,P = 0.234]. Individuals exposed to at least onelife event did not differ significantly in age(mean = 36.11, SD = 13.99) from individuals who

were not exposed to any life events (mean = 36.78,SD = 15.40) [t(743) = 0.576, P = 0.565]. Individualswho experienced one or more life events were morelikely to have an affective disorder than those whoexperienced no life events [ARI = 0.147, 95% confi-dence interval (CI) = 0.081, 0.205]. A similar trendwas found for psychotic disorders, but this trendwas not significant after correction was applied(ARI = 0.061, 95% CI = 0.006, 0.105).

Individuals who went to emergency departmentswere more likely (88.8%) to have experienced oneor more life events in the year prior to their inci-dent than those whose incident did not result in ahospital emergency visit (64.7%) [c2(d.f. = 1) =31.291, P < 0.001]. Furthermore, 65.0% of individu-als who went to the emergency departments experi-enced two or more life events compared to 37.6 %who did not visit the emergency department.Similarly, 40.6% of individuals who went to theemergency department experienced three or morelife events compared to 18.1% who did not visitthe emergency department.

We also compared rates of specific life eventsbetween those who did and did not visit the emer-gency department. The second column of Table 1

Table 1 Number of persons visiting and not visiting emergency departments by specific life event experienced

Life event% ofsample

ED visitn (%)

No ED visitn (%)

Absolute risk increase(95% CI)

Change in client’s primary staff/worker 29.1 43 (30.1) 174 (28.9) 0.009 (-0.050, 0.074)Move of house or residence 21.8 50 (35.0) 113 (18.7) 0.147 (0.074, 0.224)*Change in roommates 19.8 32 (22.4) 116 (19.2) 0.031 (-0.037, 0.108)Serious problem with family, friend or caregiver 13.3 39 (27.3) 60 (10.0) 0.232 (0.138, 0.332)*Death of relative or close family friend 11.7 23 (16.1) 64 (10.6) 0.082 (-0.005, 0.186)Serious illness or injury 10.7 20 (14.0) 60 (10.0) 0.065 (-0.023, 0.172)Problems with police or other authority 8.8 21 (14.7) 45 (7.5) 0.139 (0.034, 0.260)*Serious illness of close relative 8.6 18 (12.6) 46 (7.6) 0.098 (-0.002, 0.220)Unemployed for more than 1 month 5.5 22 (15.4) 19 (3.2) 0.365 (0.214, 0.510)*Recent trauma/abuse 5.0 18 (12.6) 19 (3.2) 0.310 (0.156, 0.467)*Breakup of steady relationship 3.9 7 (4.9) 22 (3.6) 0.052 (-0.071, 0.232)Sexual problem 3.8 6 (4.2) 22 (3.6) 0.023 (-0.092, 0.206)Drug or alcohol problem 3.4 14 (9.8) 11 (1.8) 0.381 (0.190, 0.557)*Laid off or fired from work 2.7 7 (4.9) 13 (2.2) 0.163 (-0.009, 0.381)Major financial crisis 2.5 7 (4.9) 12 (2.0) 0.181 (0.002, 0.404)Something valuable lost or stolen 2.0 5 (3.5) 10 (1.7) 0.145 (-0.040, 0.395)Separation or divorce 1.1 2 (1.4) 6 (1.0) 0.059 (-0.121, 0.401)Retirement from work 0.5 0 (0.0) 4 (0.7) -0.193 (-0.193, 0.298)

* P < 0.01.ED, emergency department.




refers to the percentage of individuals who visitedthe emergency department who experienced agiven life event. The third column provides asimilar percentage of individuals who did not visitthe emergency department who had experiencedthat life event. As Table 1 indicates, the two groupsdiffered in terms of six specific life events: move ofhouse or residence, serious problem with family,friend or caregiver, problems with police or otherauthority, unemployed for more than 1 month,recent trauma/abuse, drug or alcohol problem.Each of these life events occurred at higher ratesin the group that visited the emergency depart-ment relative to the group that did not visit theemergency department.

Discussion

The current study considered the relationshipbetween life events, demographics and clinical pro-files of a sample of individuals with ID who hadexperienced a crisis. Individuals with ID who expe-rienced life events were more likely to visit theemergency department in response to crisis relativeto those who did not experience life events. Thispattern was observed for six specific life events:move of house or residence, serious problem withfamily, friend or caregiver, problems with policeor other authority, unemployed for more than 1

month, recent trauma/abuse, drug or alcoholproblem. While a causal relationship between lifeevents and psychopathology or life events and emer-gency department visits cannot be established, ourstudy does add to the literature on the relationshipbetween life events and clinical impairment. Quali-tative examination of results identified a number ofindividuals whose life events clearly triggered thedistress and subsequent hospital visit (e.g. rape ledto a suicide attempt triggering visit to hospitalemergency department).

There are some similarities and differencesbetween our study and two other studies using thesame life events measure, one study with a commu-nity sample (Hastings et al. 2004) and another witha clinical sample (Tsakanikos et al. 2007). Similar toboth studies, we found no relationship between ageand life event occurrence. There was also no linkbetween life events and gender, similar to Hastings

et al. (2004). Similar to both studies, there was alink between life events and psychopathology, par-ticularly affective disorders. We also found a linkbetween life events and residential setting with indi-viduals living in less supported settings (either inde-pendently or semi-independently) being more likelyto have experienced a life event in the year priorthan individuals living in group home settings. Itmay be that independence leads to certain risks notpresent for those in more protected environments(e.g. trauma, substance abuse or job loss).

This study has several limitations which shouldbe taken into consideration when interpreting ourresults. Firstly, no ratings of impact were taken andlife event information was based only on the per-spective of informants. It is important to examinethe impact of life events from multiple perspectivesincluding those of the person with the disability(Hubert-Williams & Hastings 2008). Secondly,although life events preceded the crisis and thepotential visit to the emergency department, onecannot infer a causal relationship; it is possible thatother factors led to both life events and crises,such as worsening mental health which can leadto a crisis as well as a change of staff or residence.Future research could examine whether interven-tion for those who experience life events, particu-larly the events identified in this study as beingmore common in those who visit the emergencydepartment, reduces likelihood of future emergencydepartment visits. Longitudinal designs will likelybe required to investigate these issues.

Acknowledgements

This research was supported by a Canadian Insti-tutes of Health Research operating grant (FRNNo. 79539) along with a new investigator award,awarded to the first author. We wish to thankproject scientists and staff as well as participatingagencies.

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Accepted 1 March 2011


