The Mobile Outreach Team For Dual Diagnoses And Hearing Impairment 

(Presented by Stéphanie Symank Boileau, Physiotherapist)

The primary goal of this presentation is to present the services offered by the mobile outreach team for dual diagnoses (MOTFDD) of the Royal Ottawa Hospital. After the presentation of the services, I will share challenges related to providing care for persons with a dual diagnosis. In order to illustrate both aspects, I will present a case study with a clip from a video. Then, I will discuss the impacts of deafness in the lives of persons with a dual diagnosis. Finally, I will share some aspects and intervention strategies specific to my profession as a physiotherapist.

The MOTFDD is a program of the Royal Ottawa Hospital which was established in 2001 as a result of an increased awareness of the need to provide psychiatric care to persons with a developmental handicap. In fact, about 1% of the population of Ontario have a moderate to severe developmental disability. Conservative estimates indicate that 30% of persons with a developmental disability (some 24, 000 persons) also have mental health problems. Other studies even suggest that as many as 50 to 60% of these individuals have psychiatric problems. The mandate of the MOTFDD is to provide evaluation, consultation supports and to develop treatment plans for persons with a dual diagnosis. Furthermore, the mandate of the MOTFDD includes the provision of education and training to persons who work with this client population. The MOTFDD consists of a psychiatrist (half-time), a psychologist, two social workers, three nurses (one being the team manager), an administrative assistant, a physiotherapist and a speech therapist, a position which remains to be filled. The MOTFDD provides services to persons from 16 years of age and more, who have a developmental handicap as well as mental health problems and who live in the district of Champlain. This territory extends from Hawkesbury in the east to Pembrooke in the west. Screening for our services require a mild to profound intellectual disability as well as a mental health problem. It is not necessary that the mental health problem have been previously diagnosed. The identification of the mental health problem is part of the team psychiatrist’s role. The diagnostic criteria for intellectual deficiency adopted by the agency parallel those established by the DSN-IV ( manual of diagnostic criteria for mental disorders).

The diagnostic criteria adopted by the team are as follows: below average intellectual function, meaning a score lower than 70 and accompanied by functional deficiencies in the areas of communication, social interaction, activities of daily living and self-sufficiency. I.Q. tests help determine the degree of intellectual deficiency. The I.Q. scale is as follows: mild deficiency between 55 and 70; moderate deficiency between 35 and 55; severe between 20 and 35 and profound under 20. Note that we may presume intellectual deficiency even when it cannot be evaluated with these standardized methods. Anyone may refer an individual to our services, including a family member, a case manager or a care giver. It should be noted that a reference letter from a physician (family doctor, neurologist, psychiatrist or other) is required so that they may ensure follow-up to the recommendations from our team.

Also, the MOTFDD offers a short-term consultation service. This consultation process starts with a contact with the person requesting the service. Information is then collected to determine priorities. The name of the person referred is then placed on a waiting list which, unfortunately, means about one year before services become available. At the appropriate time, the person is assigned to a member of the team who begins the evaluation process. A few meetings are organized at the client’s home or other appropriate location with the client’s significant others. When sufficient information has been gathered, the data is presented to the MOTFDD team. Then, the psychiatrist will meet with the client to make a psychiatric evaluation. As needed, other members of the team will be invited to participate in the evaluation process. Finally, a final consultation report is developed and recommendations are made to the treating physician, family members and service providers. Recommendations may include strategies to better support the individual; education on personal needs (for example mental health problems and/or level of the person’s intellectual deficiency) as well as linking to other appropriate community services.

Now, let’s explore the challenges involved in providing services to persons with a dual diagnosis. First, there are systemic barriers that limit access to services for persons who have a developmental disability and a mental health problem. In fact, this client group receives services from two distinct systems: the Ministry of Health and Long-Term Care is responsible for the care of persons who have mental health problems, and the Ministry of Community and Social Services funds a range of services for persons who have an intellectual deficiency. Given that these funders have different budgets, missions and philosophies, it is difficult to respond to the needs of persons who have both diagnoses. Furthermore, there is a serious lack of resources and appropriate services for persons with a dual diagnosis, especially adults. As well, we observe that there are still many myths and misconceptions about persons with an intellectual deficiency. For example, we often hear that persons with a developmental disability cannot suffer from mental health problems and that they are always jovial. There is sometimes a tendency to believe that their needs are all identical and that limits the ability to consider them as individuals. Another challenge to the provision of services is that many health professionals perceive the intellectual deficiency as predominant. The service providers can then attribute all symptoms and problems to the intellectual deficiency. It is as if this diagnosis ‘eclipsed’ all other conditions and problems. Considering their limits (cognitive, verbal and others), these persons may exhibit ‘unusual’, even ‘strange’ behaviours. We believe that a better understanding of these persons improves the quality of services provided. Besides their intelligence quotient which is below the average, the intellectual handicap may also provoke developmental delays in the following areas: communication, general motor skills (movements of the body’s larger muscles), fine motor skills (movement of smaller muscles), activities of daily living as well as social skills. The further challenges occur in the presence of behavioural, medical, genetic and/or neurological problems. These persons may also have physical handicaps, visual and/or auditory limitations. Considering all of these possibilities specific to every individual and each environment, we must modify and adapt our methods of assessment. The preferred means of evaluation used with this client group consist of interviews with persons who know the person well, observation of the person in various live environments and strategic trials.

A presentation of Hilda’s story will help us demonstrate the provision of services by the MOTFDD and it will provide a starting point for a discussion of the impacts of deafness. Hilda is a 37 year old woman suffering from congenital German Measles. She is deaf-blind. It is estimated that she has a severe to profound intellectual disability. Furthermore, Hilda has a number of medical and orthopedic problems (for example, congenital heart disease, kyphoscoliosis, painful condition of the eye’s cornea). She lives in a home for seniors in a rural community. She was referred to the MOTFDD as a result of an increase in the frequency and intensity of her agitation and self-mutilating behaviours, striking her eye and biting her hand. Hilda was assigned to a social worker on the team who undertook the evaluation process. This involved meeting with members of the family as well as workers from the community agencies involved (Community Integration Agency and the CNIB’s Deaf-blind Program). Historical information and relevant reports (medical and other) were obtained. She was observed in her life and community environments. The team psychiatrist met with Hilda and significant others in her life in order to provide a psychiatric evaluation. The psychiatrist diagnosed her with depression and prescribed psychotropic medications. We also treated Hilda’s eye condition and painful menstruations. The result of these treatments resulted in significant reduction in her self-mutilation. Hilda became calmer and began to smile again. Afterwards an assessment in physiotherapy was undertaken in order to identify her strengths and needs. The strengths identified are as follows: Hilda has a very well developed spatial and tactile memory. In fact, she easily finds her way and remembers where objects were placed in a familiar setting. As well, she can identify persons from particular characteristics such as the shape of their nails or their rings. Also, Hilda utilizes touch and smell to learn, to communicate and to relate to her environment. Although her communication skills are limited, she succeeds in communicating through behaviours and sounds. However, these must be interpreted by the people around her. Hilda is interested in a few activities such as swimming, receiving a massage, manipulating brilliantly coloured objects and listening to music. Hilda’s limits and challenges include: significant cognitive limitations (her intellectual deficiency would range between severe and profound). She has significant sensory limitations (considered deaf-blind, although she responds to instructions combining hand gestures and loud words). Hilda has few significant activities. All changes in activity, environment and persons are difficult. Furthermore, community resources for persons with a dual diagnosis as well deaf-blindness are limited. The residence for seniors and the Alzheimer unit in which she lives are not well adapted to Hilda’s special needs.

In light of Hilda’s story and that of other MOTFDD clients who are hard of hearing or deaf, I would like to address the impacts of deafness on persons with a dual diagnosis. Considering the presence of numerous other deficits, it is difficult to isolated those impacts directly related to the deafness. Limitations must all be considered together. Deafness and blindness limit and even distort the understanding of the world. It is therefore not surprising that the world may appear unpredictable and menacing. As well, communication and comprehension difficulties may cause behavioural, emotional and psychiatric difficulties. Given these limits, learning occurs through functional senses and numerous repetitions. This combination of deficits necessarily engenders a dependency on others in order to understand and interpret the world, to be reassured, to move from one area to another and to manage the activities of daily living. Changes in daily routine can also cause difficulties. This is common in persons unable to express themselves orally or who have poor communication and comprehension skills. In fact, such changes cause unpredictability and the unknown, and thereby may appear menacing.

Finally, here are a few considerations and intervention strategies in physiotherapy with persons with an intellectual deficiency and sensory limitations, including deafness. Firstly, it is important to ensure that all medical conditions be treated since many of the behaviours and symptoms may be related to unidentified and untreated medical problems. (for example depression or the presence of pain). Also, in order to better understand the person’s aural or visual limits, it may be necessary to refer them to professionals such as audiologists and/or ophthalmologists. This information facilitates the evaluations and interventions of physiotherapists.

As a result of a psychotherapy assessment, here are some intervention strategies appropriate for this client group. Among other things, it is important to create a positive environment that responds to the needs of the individual. For example, providing access to a calm and restful place and offering a stable routine. Given the significant cognitive limitations, it is more realistic and efficient to modify the environment rather than attempting to change the individual. Another intervention strategy in physiotherapy is providing access to significant activities, that is to activities that are interesting and beneficial for the person. For example, swimming, massage and music. Since these persons have sensory limitations, it is important to incorporate strategies throughout the day so as to enrich their sensory environment. For example, providing access to music, to objects of various textures and colours, to a rocking chair or to selected smells. As described earlier, many exhibit signs of difficulties when subjected to changes in their daily routine. These changes can be made easier by facilitating comprehension which can be achieved with the help of simple words, signs or objects that the person may touch (in the case of blind persons). In order to facilitate these periods of change, it is often beneficial to introduce calming strategies such as massages, vibration and calm music before and during the changes. It is also important to educate service providers with regards to the person’s specific needs and appropriate intervention strategies.

Finally, we conclude by recalling that in order to provide efficient intervention strategies to persons with a dual diagnosis as well as a sensory deficiency, one must develop trust. It is also important that these persons, in their vulnerability, feel the sincere desire of service providers to guide them and accompany them. In short, they must feel appreciated and loved.

If you wish to reach us, please contact the administrative assistant at (613) 722-6521, ext. 7141. We will be pleased to answer your questions. You may also find more detailed information about our services on our web site: www.rohcg.on.