NADD Bulletin Volume VIII Number 6 Article 3

Complete listing

Development of a Typology of Recommendations Posed by a Multi-Disciplinary Consultation Outreach Team for Clients with a Dual Diagnosis

Heather L. King-Andrews & Susan J. Farrell

Dual Diagnosis Consultation Outreach Team (DDCOT)

Royal Ottawa Health Care Group


  The Dual Diagnosis Consultation Outreach Team (DDCOT) is a multi-disciplinary team located within a specialty psychiatric health care group that serves the mental and physical health needs of dual diagnosed clients within the Eastern Ontario region of Canada. This study provides results of a typology developed from the recommendations made by the DDCOT. A review of 250 clients with completed consultations led to the statistical analysis of the recommendations made. A factor analysis to develop the typology comprised of five factors representing recommendations in the areas of: mental/physical health and behavioral support services, formal and informal support sources and skill training, medication affaires, legal and housing affaires and dosage alterations. Findings are compared to a systematic review of previous recommendations issued from other dual diagnosis outreach teams.

Consultation Team for Clients with a Dual Diagnosis

Individuals who are diagnosed with both a developmental disability and an axis I and/or axis II disorder are often termed as "dual diagnosed" (Lovell & Reiss, 1993). Specialty services such as community based mental health outreach services in the form of multi-disciplinary teams have been developed to respond to many dual diagnosis client needs (Dart, Gapen, & Morris, 2002). Studying the services and recommendations issued by outreach teams for this population helps service providers to further understand the population as needs and trends in the provision of effective care.


The purpose of this study is to investigate the recommendations made by a Dual Diagnosis Consultation Outreach Team and to determine a typology of recommendations. Secondly, the typology will be investigated for congruence with other recommendations made by related outreach teams.

Overview of Teams and Introduction to the Royal Ottawa Health Care Group (ROHCG) Dual Diagnosis Consultation Outreach Team (DDCOT)

Outreach teams that usually contain multiple team colleagues (2+) specifically serve and adhere to clients with a dual diagnosis of a pervasive developmental disability and a psychiatric disorder and function mainly to consult and provide thorough assessments and recommendations (i.e. treatments) to these sub-populations (Dowrick as cited in Summers et al., 2002). There is need for multi-disciplinary outreach teams for exclusive populations to issue social services and tertiary care ("Comprehensive Continuum of Supports and Services," 1999).

The Dual Diagnosis Consultation Outreach Team (DDCOT) of the Royal Ottawa Health Care Group (ROHCG) in Ottawa, Ontario, Canada which was created in November 2001 is a multi-disciplinary team designed to provide specialty outreach services to adolescents and adults with a developmental disability and a psychiatric illness (Farrell, 2002). In order to produce an efficient and effective consultation to a client the DDCOT team itself strives to encourage the use of community services and services within the hospital for personal enrichment, providing learning resources for care providers, recommends resources to support client deinstitutionalization, and thorough initial evaluations (Farrell, 2002). The team consists of an administrative assistant, two registered nurses, an occupational therapist, a psychiatrist, a psychologist, a psychometrist, two social workers, and a speech and language pathologist. The team's mandate is to provide tertiary services and consultance to individuals with a developmental disability and a psychiatric disorder (Farrell, 2002).

 Literature review of the beneficial outcomes to clients of service by outreach teams is presented. For instance, van Minnen, Hoogduin & Broekman, (1997) suggest that pharmaceutical and behavioral service team recommendations made were a more effective intervention source for dual diagnosed clients than to hospital treatment. Further, Singh et al., (2002), found that dually diagnosed clients have had most successful outcomes with the implementation of comprised types of interventions, such as pharmaceutical and social skills training. Bird, Sperry, and Carreiro, (1998) found a high behavioral success rate of dual diagnosed clients who were treated with specialized behavioral and social techniques as well as pharmacologic services that were issued by an interdisciplinary team. Although this previous research has focused on the conventional recommendation model (examining and reporting those recommendations that are most commonly issued) used by outreach teams, no research has focused on the full range of recommendations provided by outreach teams or determining a subsequent typology.

Outreach Team Recommendations

Recommendations issued by outreach teams are important to study because they provide an examination of service patterns and define the needs and prognostic criteria of the particular sample of clients (e.g. some samples of clients may require more social skill training or medication intervention depending on their diagnostic criteria). It is essential to study these specialized recommendations as they provide information about the need for enhanced intervention and rehabilitation to this specific population. They also give an indication of whether the appropriate and relevant recommendations are being issued to the corresponding sample by comparing with other like outreach team recommendations. Finally, these recommendations also indicate needed improvements to provide community involvement and discourage hospitalization.

 In this regard, the purpose of this study is to investigate the recommendations issued by DDCOT and examine the presence of a typology of recommendations to determine whether they are similar with those reported in the literature for dually diagnosed clients. Specifically, it is expected that the recommendations made by DDCOT will consist of those that cluster within the categories of social services, behavioral services, and medication interventions.



 All clients seen by DDCOT between November 2000 and May 2005 were included in the study. Overall, the initial sample size was 420 clients with 57% (n = 240) of the clients successfully receiving consultation from the team, 2% (n = 10) of clients seen by psychiatrist only, 29% (n = 123) of client referrals were cancelled by referral source, 4% (n = 16) of clients opened but not completed at the time of the review, and 7% (n = 31) of clients unopened on the DDCOT waiting list. In the present sample (n = 250), there were 143 (57%) males and 107 (43%) females. The mean age for both genders was 36 years with a broad range of 17-69 years. The majority of clients, 89%, (n = 222) preferred to speak English, 10% (n = 25) clients preferred to speak French, 1% (n = 2) preferred both languages, and only 0.4% (n = 1) spoke another language. Most clients (54%) (n = 134) lived with a non-kin care giver (such as in a group home) and 32% (n = 80) clients lived with their parents. The housing arrangement that was most prevalent among the sample was a special care home (e.g. group home) occupied by 38%, (n = 94) of clients, 31% (n = 77) of clients lived within a private housing unit (e.g. condominium), and the remainder of clients resided either within private housing (7%) or a government funded housing plan (22%).


 A checklist (recommendations tracked checklist) to record all recommendations provided by the team was completed at the end of each DDCOT consultation. The checklist was constructed by DDCOT team members to reflect the recommendations most frequently issued to clients. Additional recommendations were added to the checklist during the course of the project to accommodate all recommendations implemented.


Data collection involved the review of all recommendations checklists for the 250 clients completed for team or psychiatric consultation. Once all recommendations were recorded, demographic statistics were first calculated and then a factor analysis was conducted to assess the clusters of related recommendations and the presence of a typology.


Initial item analysis was performed with a factor analysis using principle components analysis with a varimax rotation. Five distinct factors were derived from the varimax rotation and these factors were in compliance with Kaiser's rule of eigenvalues with significant values above 1.0 (Green & Salkind, 2003). The factor loadings are shown in Table 1. Means and standard deviations of the items within the factor analysis are noted in Table 2.

Factor one had an eigenvalue of 2.10 (variance of 15%) and contained the highest factor loadings of items regarding mental/physical health and behavioral support services. Factor two had a 1.80 (13%) and contained items with the highest loadings of items those that represented supportive strategies from formal and informal sources as well as skill training. Factor three had a 1.67 (12%) and contained mostly items with high loadings that represented care sources and medication affaires. The fourth factor, had a 1.37 (10%) and dealt almost exclusively with legal and housing affaires. The final significant fifth factor, that had a 1.11 (8%), contained item(s) with high loadings that dealt with dosage alterations. In total, these 5 factors accounted for 58% of the variance within the analysis model.

  Within the current sample (n = 250) the typology contained recommendation cluster frequencies as follows: staff surveillance and staff care services (recommended 75% of the time for clients); medication recommendations and medication continuation (recommended 69% of the time for clients); general client supportive services and skills development (recommended 64% of the time for clients); referral to general medical services, specialists and sources (e.g. tests) (recommended 62% of the time); and referral to social and behavioral support services (recommended 56% of the time).


The primary purpose of this study was to investigate the typology of the recommendations made within DDCOT and to compare it with other like outreach teams to determine DDCOT's recommendation service patterns. Multiple recommendations of varied types were issued by DDCOT with the greatest recommendation pertaining to "mental/physical services and sources." The second most frequent recommendations made were related to medication interventions; and the third greatest recommendations made pertained to behavioral services and interventions as was equally shown in previous studies (e.g. Bird et al., 1998; van Minnen et al., 1997; Luiselli, Sperry, & Connolly, 2002; Shedlack, Hennen, Magee,& Cheron, 2005). Some of the other recommendations on the recommendations checklist that were recognized by DDCOT but did not relate to previous studies mentioned were "legal and housing affairs" and "medication alterations." The only slight difference that this study acquired over previous studies investigated was the high degree of medication termination within the clients incorporated (DDCOT, 2003). The factor analysis incorporated obtained dimensions that reflected these main recommendation categories.

Relation to other outreach teams

DDCOT is an effective mental health service in terms of serving those with developmental disabilities and a known psychiatric illness (Farrell, 2002). This finding is related with the finding from the study by van Minnen et al. (1997) in which the outreach team was found to be a preferred intervention strategy due to encouraging rehabilitation within the environment (outreach team). DDCOT also demonstrated to assign multiple diverse recommendations as was also shown in Singh et al. (2002) by co-ordinating different treatments. A multitude of referrals pertaining to different treatments (behavioral and social) were well represented within the analyses computed as was also demonstrated within the outreach team investigated in Bird et al. (1998).

 Review of past research specifying types of recommendations for this population were apparent due to the numerous social and personal behavioral recommendations assigned. Subsequent descriptions of these areas are provided below:

Mental/Physical Services and Sources

 The overall hypothesis of determining whether the DDCOT typology of recommendations was related to common recommendations made by like outreach teams and of DDCOT administering similar recommendations to those found within previous studies of clinicians and teams administering recommendations (e.g. social services, behavioral interventions and medication interventions) was confirmed. The only recommendations that did not fit with the three recommendation themes were "continuation of services" which pertain to the prolonging of present social and behavioral services and resources.

 Specialized social services are designed to foster behavioral rehabilitation and/or to incorporate social enrichment within the client's social environment; van Minnen et al. (1997) coordinated rehabilitation with the use of community treatment centers and other private home cares for those with a dual diagnosis. In a successful and effective study by Bird et al. (1998) the prime objective of the social services incorporated was to provide adequate client help for their well-being and to encourage the development of vocational abilities. Another study by Luiselli et al. (2002) with the incorporation of a local treatment service center that delivered a multitude of behavioral rehabilitation services to a dual diagnosed women reported successful results. Additionally, these social services concern those resources (e.g. Community Care Access Centers, Causeways, Day Programs) that are ultimately attuned to promoting the rehabilitation and behavioral improvement of dually diagnosed clients (DDCOT, 2003). Overall, most social services offered throughout a client's community concern those that are tailored to rehabilitate the social and behavioral functions of the individual (van Minnen et al.; Bird et al.; Luiselli et al.).

Medication Interventions

 As is quite customary among clinical samples, pharmaceuticals were recommended and administered quite prevalently with the objective of providing a marked increase within client behaviors. Within the study by Shedlack et al. (2005), it was reported that mentally disordered behaviors received a marked reduction within a dual diagnosed sample with the treatment of novel medications. Within the study by Bird et al. (1998) that implemented a behavioral regime within a similar sample and attained successful behavioral outcomes, one of the intervention techniques was the self-awareness and monitoring of ingesting their medication; DDCOT also made this recommendation to foster enhanced vocational skill training within the clinical population. Within the Luiselli et al. (2002) study already mentioned multiple medications were issued to a dual diagnosed single clinical sample under investigation with the objective of behavioral rehabilitation along with other therapeutic techniques implemented within their treatment protocol. As is demonstrated medications have been extensively incorporated within previous studies as a method of overall psychological treatment (e.g Shedlack el al.; Bird et al.; Luiselli et al.).

Behavioral Services and Interventions

 DDCOT provides dual diagnosis clients with effective behavioral interventions which are more socially related within their implication for treatment and that range from incorporating behavioral and social skills programs. This finding corresponds to that used within the study by van Minnen et al. (1997) of how the outreach team implemented a strategic successful behavioral intervention program that included social and behavioral skills development that fostered behavioral improvement and adaptation to their present environment. Two other studies which amplified the positive effects of behavioral therapy that was similar to that implemented with DDCOT's recommendations was within Luiselli et al. (2002), which fostered greater life improvement and used techniques for increasing adaptable social and life techniques; and, in another study by Bird et al. (1998) that implemented a behavioral technique for effective interpersonal purposes was the development of a social regime that would help the client to develop adequate social techniques. In essence, a multitude of behavioral techniques have been employed with various dual diagnosed clinical samples in the effort to build greater social skills (e.g. Bird et al.; van Minnen et al.; Luiselli et al.).

 An additional behavioral therapeutic technique that DDCOT implemented (DDCOT, 2003) was increased social support with significant others (non-kin, kin). In essence, acquiring a sense of social support is commonly well-known to support an individual's well-being and life satisfaction and hence to improve their behavioral status. To support this finding in a study by Lunsky and Havercamp (1999) it was noted that a positive correlation existed between social neglect and lack of social support with the incidence of increased mental and behavioral problems within a clinical sample of mostly individuals with a dual diagnosis; these clients were tested for the degree of social support and social neglect within their lives. DDCOT has demonstrated the usefulness of its typology of recommendations by providing community social services, pharmaceutical recommendations, and behavioral intervention services to dual diagnosed clients; additionally, it has been demonstrated to be an efficient outreach team to further help and serve the dual diagnosis clinical population.

Limitations of study

 Some potential limitations of this study concern the sample incorporated; a sample from a single team was used to develop the typology. A second limitation of the study is that it was not entirely demographically varied, thereby limiting generalizability; this limits the applicability of the typology until further testing is done. A final limitation within the study concerns the fact that due to the location of mental health resources the recommendations are not completely generalizable since each locale has its own attributable resources.

Future Directions

 Future directions that DDCOT could consider would be to implement a greater cultural, socioeconomic, diverse age-range representation. A final future direction would be to assess the variability of the typology to describe the needs of other outreach team's clients in both developed and under developed countries and other more geographically diverse areas.



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Comprehensive Continuum of Supports & Services (1999). In Making it happen: Operational framework for the delivery of mental health services and supports (MH Publication No. 0-7778-8565-4, pp. 8 - 19). Toronto, Ontario: Queen's Printer for Ontario, Ministry of Health.

Dart, L., Gapen, B., & Morris, S. (2002). Building responsive service systems. In D. M. Griffiths, C. Stavarakaki, & J. Summers (Eds.), Dual diagnosis: An introduction to the mental health needs of persons with developmental disabilities (pp. 283-323). Sudbury, Ontario: Facilitative Mental Health Resource Network.

Dual Diagnosis Consultation Outreach Team (DDCOT). (2003). List of DDCOT recommendations to be tracked. Ottawa, Ontario: Dual Diagnosis Consultation Outreach Team.

Farrell, S. (2002). Evaluation of the first year of the dual diagnosis consultation outreach team. Ottawa, Ontario: Dual Diagnosis Consultation Outreach Team.

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Luiselli, J. K., Sperry, J. M., & Connolly, N. M. (2002). Elimination of mechanical restraint, community-based behavior support, and seven-year maintenance evaluation in the treatment of a woman with mental retardation and multiple psychiatric disorders. Mental Health Aspects of Developmental Disabilities, 5, 69-77.

Lunsky, Y. & Havercamp, S. M. (1999). Distinguishing low levels of social support and social strain: Implications for dual diagnosis. American Journal on Mental Retardation, 104, 200-204.

Shedlack, K. J., Hennen, J., Magee, C., & Cheron, D. M. (2005). Assessing the utility of atypical antipsychotic medication in adults with mild mental retardation and comorbid psychiatric disorders. Journal of Clinical Psychiatry, 66, 52-62.

Singh, N. N., Wahler, R .G., Sabaawi, M., Goza, A. B., Singh, S. D., & Molina, E. J. (2002). Mentoring treatment teams to integrate behavioral and psychopharmacological treatments in developmental disabilities. Research in Developmental Disabilities, 23, 379-389.

Summers, J., Boyd, K., Reid, J., Adamson, J., Habjan, B., Gignac, V., et al. (2002). The interdisciplinary mental health team. In D. M. Griffiths, C. Stavarakaki, & J. Summers (Eds.), Dual diagnosis: An introduction to the mental health needs of persons with developmental disabilities (pp. 325-357). Sudbury, Ontario: Habilitative Mental Health Resource Network.

van Minnen, A., Hoogduin, C .A. L., & Broekman, T. G. (1997). Hospital vs. outreach treatment of patients with mental retardation and psychiatric disorders: A controlled study. Acta Psychiatrica Scandinavica, 95, 515-522.