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Life Events and Emergency Department Visits in Response to Crisis in Individuals with Intellectual Disabilities

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Title: Life Events and Emergency Department Visits in Response to Crisis in Individuals with Intellectual Disabilities
Language: English
Authors: Lunsky, Y., Elserafi, J.
Source: Journal of Intellectual Disability Research. Jul 2011 55(7):714-718.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
Peer Reviewed: Y
Physical Description: PDF
Page Count: 5
Publication Date: 2011
Document Type: Journal Articles
Reports - Research
Descriptors: Mental Retardation, Adults, Hospitals, Medical Services, Psychopathology, Experience, Relocation, Problems, Unemployment, Trauma, Drug Use, Drinking
DOI: 10.1111/j.1365-2788.2011.01417.x
ISSN: 0964-2633
Abstract: Background: Stressful life events have been linked to psychopathology in the general population, but few studies have considered the relationship between life events and psychopathology for people with intellectual disabilities (ID), and the link between particular life events and hospital use. Methods: Informants provided data on 746 adults with ID who had experienced at least one "crisis". Informants completed a checklist of recent life events from the Psychiatric Assessment for Adults with Developmental Disabilities Checklist (PAS ADD checklist) and also indicated whether the crisis resulted in a visit to the hospital emergency department. Results: Individuals experiencing life events in the past year were more likely to visit the emergency department in response to crisis than those who did not experience any life events. Individuals experiencing a move of house or residence, serious problem with family, friend or caregiver, problems with police or other authority, unemployed for more than 1 month, recent trauma/abuse, or a drug or alcohol problem were more likely to visit the emergency department. Conclusions: Six specific life events were found to be associated with use of emergency departments in response to crisis. We suggest intervention efforts be targeted towards people who experience life events, particularly these events, as they may be a risk factor for hospital visits.
Abstractor: As Provided
Number of References: 16
Entry Date: 2011
Accession Number: EJ929077
Database: ERIC
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  Value: <anid>AN0061214682;eul01jul.11;2019Jun04.10:46;v2.2.500</anid> <title id="AN0061214682-1">Life events and emergency department visits in response to crisis in individuals with intellectual disabilities. </title> <p>Background  Stressful life events have been linked to psychopathology in the general population, but few studies have considered the relationship between life events and psychopathology for people with intellectual disabilities (ID), and the link between particular life events and hospital use. Methods  Informants provided data on 746 adults with ID who had experienced at least one 'crisis'. Informants completed a checklist of recent life events from the Psychiatric Assessment for Adults with Developmental Disabilities Checklist (PAS ADD checklist) and also indicated whether the crisis resulted in a visit to the hospital emergency department. Results  Individuals experiencing life events in the past year were more likely to visit the emergency department in response to crisis than those who did not experience any life events. Individuals experiencing a move of house or residence, serious problem with family, friend or caregiver, problems with police or other authority, unemployed for more than 1 month, recent trauma/abuse, or a drug or alcohol problem were more likely to visit the emergency department. Conclusions  Six specific life events were found to be associated with use of emergency departments in response to crisis. We suggest intervention efforts be targeted towards people who experience life events, particularly these events, as they may be a risk factor for hospital visits.</p> <p>Keywords: hospitals; intellectual disabilities; life events; emergency departments</p> <p>The relationship between life events and psychopathology has been extensively studied in the general population ([<reflink idref="bib3" id="ref1">3</reflink>]; [<reflink idref="bib15" id="ref2">15</reflink>]; [<reflink idref="bib8" id="ref3">8</reflink>]). Less research has been conducted on the relationship between life events and psychopathology for individuals with intellectual disabilities (ID), despite studies that demonstrate that individuals with ID are more likely to have psychiatric disorders ([<reflink idref="bib2" id="ref4">2</reflink>]) and that individuals with ID experience a greater number of life events than individuals without ID ([<reflink idref="bib6" id="ref5">6</reflink>]). The existing research demonstrates an association between life events and psychiatric problems in individuals with ID (see [<reflink idref="bib7" id="ref6">7</reflink>] for systematic review) with two studies demonstrating that life events precede psychological problems ([<reflink idref="bib10" id="ref7">10</reflink>]; [<reflink idref="bib4" id="ref8">4</reflink>]). The systematic review called for further research to clarify the temporal relationship between life events and psychological problems in individuals with ID.</p> <p>Previous studies have focused generally on the relationship between life events and well‐being or psychiatric symptoms. One study suggested a link between life events and psychiatric hospitalisation in individuals with ID, but this study lacked a control group of people with ID who did not get hospitalised ([<reflink idref="bib13" id="ref9">13</reflink>]). Another study of a clinical sample did not find a relationship between life event occurrence and inpatient hospitalisation ([<reflink idref="bib14" id="ref10">14</reflink>]), while a third study with a community sample found life event occurrence to be more frequent in those living in a hospital setting ([<reflink idref="bib5" id="ref11">5</reflink>]). No research has examined whether there is a link between life events and subsequent visits to the hospital emergency department. The purpose of this study was to describe the frequencies of specific life events within a Canadian sample of individuals with ID who had experienced a behavioural crisis and to examine the relationship between life events and emergency department visits.</p> <hd id="AN0061214682-2">Methods</hd> <p></p> <hd id="AN0061214682-3">Participants</hd> <p>Informants provided data on 751 adults with ID living in one large and two medium‐sized urban centres in Ontario, Canada, as part of a larger project on crises and ID. Crisis was defined as 'an acute disturbance of thought, mood, behaviour, or social relationship that requires immediate attention as defined by the individual, family, or community' ([<reflink idref="bib1" id="ref12">1</reflink>], p. 8). Medical crises were not the focus of this study. Participants were 466 men and 279 women and one transgendered individual, mean age of 36.32 (SD = 14.43, range = 10–82). Three hundred and seventy‐three individuals were living in group homes, 191 individuals with family, and 182 individuals either independently or semi‐independently in a variety of minimal support settings. Sixty‐five per cent of individuals were either working, in school or participating in other structured daytime activities at the time of their crisis.</p> <p>Five individuals were excluded from this analysis because life events information was not provided by the informants. All of these adults were being served by social services or mental health agencies that support people with ID.</p> <hd id="AN0061214682-4">Materials and procedure</hd> <p>Life events experienced in the past 12 months came from the Psychiatric Assessment for Adults with Developmental Disabilities Checklist (PAS ADD checklist; [<reflink idref="bib11" id="ref13">11</reflink>]) with three additional items added to this list: change in roommates, change in client's primary staff/worker, recent trauma/abuse. Using a standardised form, information on client background, life events and outcome of crises (visit or no visit to an emergency department) was completed by staff after their clients experienced a crisis. Typically, this form was completed within days of the event as part of the agency protocol. In some situations, however, the staff person could only complete the form after hearing about the crisis from the individual and could be some time later (particularly for individuals who received very limited support). The decision to visit the emergency department could have been made by the person with the disability, the caregiver or a member of the public, but it was not the focus of the current paper. Agency level information was forwarded to the research team and all crises were reviewed by two raters. If the crisis was strictly medical in nature, it was excluded from analyses. No identifying information was provided to the research team at this stage. All participating agencies were trained in the completion of these forms by the two research project coordinators. This study received ethics approval from the Centre for Addiction and Mental Health and Queens University research ethics boards.</p> <hd id="AN0061214682-5">Analyses</hd> <p> <emph>T</emph>‐tests, chi‐squared analyses and absolute risk increases (ARIs) were used for comparisons. ARI is the increase in risk caused by a given activity. It is presented as a probability and varies from 0 to 1 ([<reflink idref="bib9" id="ref14">9</reflink>]). Because of the relatively large number of comparisons in this study, we sought to minimise Type I errors, by treating differences as significant only at the probability level of 1% ([<reflink idref="bib12" id="ref15">12</reflink>]).</p> <hd id="AN0061214682-6">Results</hd> <p>Over two‐thirds of the sample (69.4%) had experienced one or more life events in the year prior to crisis and 42.9% had experienced two or more life events. Men (69.7%) and women (68.8%) were equally likely to be exposed to one or more life events [χ<sups>2</sups>(d.f. = 1) = 0.070, <emph>P</emph> = 0.791]. Individuals living independently were more likely (84.1%) to have been exposed to at least one life event than those living in group homes (63.0%) [χ<sups>2</sups>(d.f. = 1) = 25.797, <emph>P</emph> < 0.001]. Individuals living with family were equally likely (68.1%) to have been exposed to at least one life event relative to those living in group homes (63.0%) [χ<sups>2</sups>(d.f. = 1) = 1.416, <emph>P</emph> = 0.234]. Individuals exposed to at least one life 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) [<emph>t</emph>(<reflink idref="bib743" id="ref16">743</reflink>) = 0.576, <emph>P</emph> = 0.565]. Individuals who experienced one or more life events were more likely to have an affective disorder than those who experienced no life events [ARI = 0.147, 95% confidence interval (CI) = 0.081, 0.205]. A similar trend was found for psychotic disorders, but this trend was not significant after correction was applied (ARI = 0.061, 95% CI = 0.006, 0.105).</p> <p>Individuals who went to emergency departments were more likely (88.8%) to have experienced one or more life events in the year prior to their incident than those whose incident did not result in a hospital emergency visit (64.7%) [χ<sups>2</sups>(d.f. = 1) = 31.291, <emph>P</emph> < 0.001]. Furthermore, 65.0% of individuals who went to the emergency departments experienced two or more life events compared to 37.6 % who did not visit the emergency department. Similarly, 40.6% of individuals who went to the emergency department experienced three or more life events compared to 18.1% who did not visit the emergency department.</p> <p>We also compared rates of specific life events between those who did and did not visit the emergency department. The second column of Table 1 refers to the percentage of individuals who visited the emergency department who experienced a given life event. The third column provides a similar percentage of individuals who did not visit the emergency department who had experienced that life event. As Table 1 indicates, the two groups differed in terms of six specific life events: move of house or residence, serious problem with family, friend or caregiver, problems with police or other authority, unemployed for more than 1 month, recent trauma/abuse, drug or alcohol problem. Each of these life events occurred at higher rates in the group that visited the emergency department relative to the group that did not visit the emergency department.</p> <p>1 Number of persons visiting and not visiting emergency departments by specific life event experienced</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>Life event</bold></th><th><bold>% of sample</bold></th><th><bold>ED visit</bold><bold><italic>n</italic> (%)</bold></th><th><bold>No ED visit</bold><bold><italic>n</italic> (%)</bold></th><th><bold>Absolute risk increase (95% CI)</bold></th></tr></thead><tbody valign="top"><tr><td>Change in client's primary staff/worker</td><td>29.1</td><td>43 (30.1)</td><td>174 (28.9)</td><td>0.009 (−0.050, 0.074)</td></tr><tr><td>Move of house or residence</td><td>21.8</td><td>50 (35.0)</td><td>113 (18.7)</td><td>0.147 (0.074, 0.224)*</td></tr><tr><td>Change in roommates</td><td>19.8</td><td>32 (22.4)</td><td>116 (19.2)</td><td>0.031 (−0.037, 0.108)</td></tr><tr><td>Serious problem with family, friend or caregiver</td><td>13.3</td><td>39 (27.3)</td><td>60 (10.0)</td><td>0.232 (0.138, 0.332)*</td></tr><tr><td>Death of relative or close family friend</td><td>11.7</td><td>23 (16.1)</td><td>64 (10.6)</td><td>0.082 (−0.005, 0.186)</td></tr><tr><td>Serious illness or injury</td><td>10.7</td><td>20 (14.0)</td><td>60 (10.0)</td><td>0.065 (−0.023, 0.172)</td></tr><tr><td>Problems with police or other authority</td><td>8.8</td><td>21 (14.7)</td><td>45 (7.5)</td><td>0.139 (0.034, 0.260)*</td></tr><tr><td>Serious illness of close relative</td><td>8.6</td><td>18 (12.6)</td><td>46 (7.6)</td><td>0.098 (−0.002, 0.220)</td></tr><tr><td>Unemployed for more than 1 month</td><td>5.5</td><td>22 (15.4)</td><td>19 (3.2)</td><td>0.365 (0.214, 0.510)*</td></tr><tr><td>Recent trauma/abuse</td><td>5.0</td><td>18 (12.6)</td><td>19 (3.2)</td><td>0.310 (0.156, 0.467)*</td></tr><tr><td>Breakup of steady relationship</td><td>3.9</td><td>7 (4.9)</td><td>22 (3.6)</td><td>0.052 (−0.071, 0.232)</td></tr><tr><td>Sexual problem</td><td>3.8</td><td>6 (4.2)</td><td>22 (3.6)</td><td>0.023 (−0.092, 0.206)</td></tr><tr><td>Drug or alcohol problem</td><td>3.4</td><td>14 (9.8)</td><td>11 (1.8)</td><td>0.381 (0.190, 0.557)*</td></tr><tr><td>Laid off or fired from work</td><td>2.7</td><td>7 (4.9)</td><td>13 (2.2)</td><td>0.163 (−0.009, 0.381)</td></tr><tr><td>Major financial crisis</td><td>2.5</td><td>7 (4.9)</td><td>12 (2.0)</td><td>0.181 (0.002, 0.404)</td></tr><tr><td>Something valuable lost or stolen</td><td>2.0</td><td>5 (3.5)</td><td>10 (1.7)</td><td>0.145 (−0.040, 0.395)</td></tr><tr><td>Separation or divorce</td><td>1.1</td><td>2 (1.4)</td><td>6 (1.0)</td><td>0.059 (−0.121, 0.401)</td></tr><tr><td>Retirement from work</td><td>0.5</td><td>0 (0.0)</td><td>4 (0.7)</td><td>−0.193 (−0.193, 0.298)</td></tr></tbody></table> </ephtml> </p> <p>1 *  <emph>P</emph> < 0.01.</p> <p>2 ED, emergency department.</p> <hd id="AN0061214682-7">Discussion</hd> <p>The current study considered the relationship between life events, demographics and clinical profiles of a sample of individuals with ID who had experienced a crisis. Individuals with ID who experienced life events were more likely to visit the emergency department in response to crisis relative to those who did not experience life events. This pattern was observed for six specific life events: move of house or residence, serious problem with family, friend or caregiver, problems with police or other authority, unemployed for more than 1 month, recent trauma/abuse, drug or alcohol problem. While a causal relationship between life events and psychopathology or life events and emergency department visits cannot be established, our study does add to the literature on the relationship between life events and clinical impairment. Qualitative examination of results identified a number of individuals whose life events clearly triggered the distress and subsequent hospital visit (e.g. rape led to a suicide attempt triggering visit to hospital emergency department).</p> <p>There are some similarities and differences between our study and two other studies using the same life events measure, one study with a community sample ([<reflink idref="bib5" id="ref17">5</reflink>]) and another with a clinical sample ([<reflink idref="bib14" id="ref18">14</reflink>]). Similar to both studies, we found no relationship between age and life event occurrence. There was also no link between life events and gender, similar to [<reflink idref="bib5" id="ref19">5</reflink>]). Similar to both studies, there was a link between life events and psychopathology, particularly affective disorders. We also found a link between life events and residential setting with individuals living in less supported settings (either independently or semi‐independently) being more likely to have experienced a life event in the year prior than individuals living in group home settings. It may be that independence leads to certain risks not present for those in more protected environments (e.g. trauma, substance abuse or job loss).</p> <p>This study has several limitations which should be taken into consideration when interpreting our results. Firstly, no ratings of impact were taken and life event information was based only on the perspective of informants. It is important to examine the impact of life events from multiple perspectives including those of the person with the disability ([<reflink idref="bib7" id="ref20">7</reflink>]). Secondly, although life events preceded the crisis and the potential visit to the emergency department, one cannot infer a causal relationship; it is possible that other factors led to both life events and crises, such as worsening mental health which can lead to a crisis as well as a change of staff or residence. Future research could examine whether intervention for those who experience life events, particularly the events identified in this study as being more common in those who visit the emergency department, reduces likelihood of future emergency department visits. Longitudinal designs will likely be required to investigate these issues.</p> <hd id="AN0061214682-8">Acknowledgements</hd> <p>This research was supported by a Canadian Institutes of Health Research operating grant (FRN No. 79539) along with a new investigator award, awarded to the first author. We wish to thank project scientists and staff as well as participating agencies.</p> <ref id="AN0061214682-9"> <title> References </title> <blist> <bibl id="bib1" idref="ref12" type="bt">1</bibl> <bibtext> Allen M. H., Forster P., Zealberg J. & Currier G. (2002) Report and recommendations regarding psychiatric emergency and crisis services: a review and model program descriptions. American Psychiatric Association. Available at: <ulink href="http://emergencypsychiatry.org/data/tfr200201.pdf">http://emergencypsychiatry.org/data/tfr200201.pdf</ulink> (retrieved July 2010).</bibtext> </blist> <blist> <bibl id="bib2" idref="ref4" type="bt">2</bibl> <bibtext> Deb S. (2001) Medical conditions in people with intellectual disability. In: Health Evidence Bulletins – Learning Disabilities (Intellectual Disability) (eds L. Hamilton‐Kirkwood, Z. Ahmed, S. Deb, B. Fraser, B. Lindsey, et al.), pp. 14 – 17. NHS, Wales. Available at: <ulink href="http://hebw.uwcm.ac.uk">http://hebw.uwcm.ac.uk</ulink> (retrieved July 2010).</bibtext> </blist> <blist> <bibl id="bib3" idref="ref1" type="bt">3</bibl> <bibtext> Dohrenwend B. P. & Egri G. (1981) Recent life events and episodes of schizophrenia. Schizophrenia Bulletin 7, 12 – 23.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref8" type="bt">4</bibl> <bibtext> Esbensen A. J. & Benson B. A. (2006) A prospective analysis of life events, problem behaviours and depression in adults with intellectual disability. Journal of Intellectual Disability Research 50, 248 – 58.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref11" type="bt">5</bibl> <bibtext> Hastings R. P., Hatton C., Taylor J. L. & Maddison C. (2004) Life events and psychiatric symptoms in adults with intellectual disabilities. Journal of Intellectual Disability Research 48, 42 – 6.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref5" type="bt">6</bibl> <bibtext> Hatton C. & Emerson E. (2004) The relationship between life events and psychopathology amongst children with intellectual disabilities. Journal of Intellectual Disability Research 17, 109 – 17.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref6" type="bt">7</bibl> <bibtext> Hubert‐Williams L. & Hastings R. P. (2008) Life events as a risk factor for psychological problems in individuals with intellectual disabilities: a critical review. Journal of Intellectual Disability Research 52, 883 – 95.</bibtext> </blist> <blist> <bibl id="bib8" idref="ref3" type="bt">8</bibl> <bibtext> Kendler K. S., Krakowski L. M. & Prescott C. A. (1999) Relationship between stressful life events and the onset of major depression. American Journal of Psychiatry 156, 837 – 41.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref14" type="bt">9</bibl> <bibtext> Kraemer H. C., Morgan G. A., Leech N. L., Gliner J. A., Vaske J. J. & Harmon R. J. (2003) Measures of clinical significance. Journal of the American Academy of Child and Adolescent Psychiatry 42, 1524 – 9.</bibtext> </blist> <blist> <bibtext> Monaghan M. T. & Soni S. (1992) Effects of significant life events on the behaviour of mentally handicapped people in the community. British Journal of Mental Subnormality 38, 114 – 21.</bibtext> </blist> <blist> <bibtext> Moss S., Prosser H., Costello H., Simpson N., Patel P., Rowe S. et al. (1998) Reliability and validity of the PAS‐ADD checklist for detecting psychiatric disorders in adults with intellectual disability. Journal of Intellectual Disability Research 42, 173 – 83.</bibtext> </blist> <blist> <bibtext> Perneger T. V. (1998) What's wrong with Bonferroni adjustments. British Medical Journal 316, 1236 – 8.</bibtext> </blist> <blist> <bibtext> Stack L. S., Haldipur C. V. & Thompson M. (1987) Stressful life events and psychiatric hospitalization of mentally retarded patients. American Journal of Psychiatry 144, 661 – 3.</bibtext> </blist> <blist> <bibtext> Tsakanikos E., Bouras N., Costello H. & Holt G. (2007) Multiple exposure to life events and clinical psychopathology in adults with intellectual disability. Social Psychiatry and Psychiatric Epidemiology 42, 24 – 8.</bibtext> </blist> <blist> <bibtext> Wills T. A., Vaccaro D. & McNamara G. (1992) The role of life events, family support and competence in adolescent substance use: a test of vulnerability and protective factors. American Journal of Community Psychology 20, 349 – 74.</bibtext> </blist> </ref> <aug> <p>By Y. Lunsky and J. Elserafi</p> <p>Reported by Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib15" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib10" firstref="ref7"></nolink> <nolink nlid="nl3" bibid="bib13" firstref="ref9"></nolink> <nolink nlid="nl4" bibid="bib14" firstref="ref10"></nolink> <nolink nlid="nl5" bibid="bib11" firstref="ref13"></nolink> <nolink nlid="nl6" bibid="bib12" firstref="ref15"></nolink> <nolink nlid="nl7" bibid="bib743" firstref="ref16"></nolink>
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  Data: Life Events and Emergency Department Visits in Response to Crisis in Individuals with Intellectual Disabilities
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  Data: <searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Hospitals%22">Hospitals</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Services%22">Medical Services</searchLink><br /><searchLink fieldCode="DE" term="%22Psychopathology%22">Psychopathology</searchLink><br /><searchLink fieldCode="DE" term="%22Experience%22">Experience</searchLink><br /><searchLink fieldCode="DE" term="%22Relocation%22">Relocation</searchLink><br /><searchLink fieldCode="DE" term="%22Problems%22">Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Unemployment%22">Unemployment</searchLink><br /><searchLink fieldCode="DE" term="%22Trauma%22">Trauma</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Use%22">Drug Use</searchLink><br /><searchLink fieldCode="DE" term="%22Drinking%22">Drinking</searchLink>
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  Data: Background: Stressful life events have been linked to psychopathology in the general population, but few studies have considered the relationship between life events and psychopathology for people with intellectual disabilities (ID), and the link between particular life events and hospital use. Methods: Informants provided data on 746 adults with ID who had experienced at least one "crisis". Informants completed a checklist of recent life events from the Psychiatric Assessment for Adults with Developmental Disabilities Checklist (PAS ADD checklist) and also indicated whether the crisis resulted in a visit to the hospital emergency department. Results: Individuals experiencing life events in the past year were more likely to visit the emergency department in response to crisis than those who did not experience any life events. Individuals experiencing a move of house or residence, serious problem with family, friend or caregiver, problems with police or other authority, unemployed for more than 1 month, recent trauma/abuse, or a drug or alcohol problem were more likely to visit the emergency department. Conclusions: Six specific life events were found to be associated with use of emergency departments in response to crisis. We suggest intervention efforts be targeted towards people who experience life events, particularly these events, as they may be a risk factor for hospital visits.
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  Data: 16
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2011
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ929077
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ929077
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1111/j.1365-2788.2011.01417.x
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 5
        StartPage: 714
    Subjects:
      – SubjectFull: Mental Retardation
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Hospitals
        Type: general
      – SubjectFull: Medical Services
        Type: general
      – SubjectFull: Psychopathology
        Type: general
      – SubjectFull: Experience
        Type: general
      – SubjectFull: Relocation
        Type: general
      – SubjectFull: Problems
        Type: general
      – SubjectFull: Unemployment
        Type: general
      – SubjectFull: Trauma
        Type: general
      – SubjectFull: Drug Use
        Type: general
      – SubjectFull: Drinking
        Type: general
    Titles:
      – TitleFull: Life Events and Emergency Department Visits in Response to Crisis in Individuals with Intellectual Disabilities
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Lunsky, Y.
      – PersonEntity:
          Name:
            NameFull: Elserafi, J.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 07
              Type: published
              Y: 2011
          Identifiers:
            – Type: issn-print
              Value: 0964-2633
          Numbering:
            – Type: volume
              Value: 55
            – Type: issue
              Value: 7
          Titles:
            – TitleFull: Journal of Intellectual Disability Research
              Type: main
ResultId 1