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Guidelines for the Creation of Accessible Consent Materials and Procedures: Lessons from Research with Autistic People and People with Intellectual Disability.

Informed, voluntary, ongoing consent is a central tenet of ethical research. However, consent processes are prone to exclusionary practices and inaccessibility. Consent materials are often too long and complex to foster understanding and ensure that people make truly informed decisions to participate in research. While this complexity is problematic for all people, these challenges are compounded for autistic people and people with intellectual disability. Consent materials and procedures rarely incorporate accommodations for processing and communication differences common in autism and intellectual disability. Failure to provide such accommodations ultimately threatens the conduct of ethical research. We describe lessons learned across multiple major U.S. research institutions that improved informed consent materials and procedures, with the goal of fostering responsible inclusion in research for autistic people and people with intellectual disability. We used these alternative materials and procedures in multiple research projects with samples of autistic people and people with intellectual disability. Each contributing team partnered with university human research participant protections personnel, accessibility experts, community members, and researchers to develop rigorous procedures for improving the readability and accessibility of informed consent materials. We present guidelines for designing consent materials and procedures and assert that participatory methods are vital to the success of ongoing accessibility initiatives. Adoption of understandable consent materials and accessible consent procedures can cultivate more equitable, respectful, and inclusive human research practices. Future work should expand on this work to design inclusive practices for populations with additional considerations.

autism↗

Direct service staff and their perceptions of psychotropic medication in non-institutional settings for people with intellectual disability.

Previous studies have surveyed a variety of service providers in school and institutional settings, and reported a pervasive lack of education and training with regard to the use of psychotropic medication in people with intellectual disability. Because an increasing number of people with intellectual disability are living in the community and since many of these people receive psychotropic medications, the present study extended research in this area by surveying direct service staff to determine their perceptions, knowledge and opinions with regard to the use of psychotropic medication in non-institutional settings for individuals with developmental disabilities. Consistent with the findings of previous studies, a majority of the 334 respondents in the present study reported that they had not received adequate training in the area of drug treatment The knowledge and skills deficits of direct service staff appear to represent a significant barrier to the appropriate monitoring and management of pharmacotherapy for individuals with intellectual disability. Therefore, a systematic training programme to educate direct service staff about psychotropic medication needs to be designed, implemented and disseminated on a broad scale.

Attitude of Health Personnel↗

Sibling advocates of people with intellectual disabilities.

The aim of this study was to examine the experience of the first generation of sibling advocates in Hong Kong. A qualitative approach was adopted and six sibling advocates of people with intellectual disabilities from one non-government organization were interviewed. Data were analyzed using a constant comparative method and content analysis. Findings revealed that the six participants were reactive in the process of taking up the caregiver responsibility and they performed three functions: to advocate for more service provision, to improve service quality, and to facilitate communication between individual service units and family members of people with intellectual disabilities. All of the participants expressed that they needed support from service providers when they tried to function as the sibling advocates. Strategies to promote the involvement of siblings of people with intellectual disabilities as advocates are discussed and it is expected that more siblings of people with intellectual disabilities will be supported to have a higher level of involvement in advocacy.

Adult↗

Forensic aspects in people with intellectual disabilities.

PURPOSE OF REVIEW: The past few years have seen a growth in research of forensic issues relating to people with intellectual disabilities. This review examines a broad spectrum covering 2005 and 2006, for which articles are already available. Given the diversity of publications, reference will also be made to some of the main articles of 2004 to provide a context. RECENT FINDINGS: We are now at the stage where people are questioning the existing forensic psychiatry evidence base for people with intellectual disabilities. This review examines the assessment and treatment of three different groups, that is, fire setters, sexual offenders and those with problems of anger and aggression along with service outcome research, the criminal justice system, and a round up of other related research. SUMMARY: The growth of research in this area has aided the development of assessment and treatment instruments and treatment models for people with intellectual disabilities. This has helped to highlight the specialist and complex nature of this group. The review also looks at services from the point of delivery and the difficulty in research methodology and quantifying outcomes that take into account a changing society and current health inequalities.

Crime↗

Barbiturates in the treatment of epilepsy in people with intellectual disability.

Barbiturates are effective drugs in the treatment of epileptic disorder. The systemic side-effects are minimal. The main limiting factor is the presence of cognitive and behavioural problems. Relevant research is presented in this paper; however, it is somewhat difficult to extrapolate some of these experiences to a population of children and adults with intellectual disability and epilepsy. Recent reviews of this subject have suggested that, although the cognitive deficiencies seem to be a serious problem when phenobarbital is given in high doses, the problem is much less severe when the doses are on the low side. The most consistent findings with regard to behaviour are the exacerbation of behaviour disorders (mostly hyperactivity), as well as sleep disorders and depression in individuals who already have a predisposition to these disorders. However, the clinical experience of many professionals involved with the care of people with intellectual disability strongly suggests that barbiturates, and especially phenobarbital, produces intolerable side-effects at the point that the use of phenobarbital has been reduced to a minimum, and it is no longer considered a drug of choice. It is probably that the simultaneous presence of brain damage, epilepsy, intellectual disability and psychiatric disorders in people with intellectual disability is responsible for the high incidence of behaviour problems observed by clinicians.

Adult↗

Characteristics of people with intellectual disability admitted for psychiatric inpatient treatment.

The present prospective study describes the demographic, medical and psychosocial characteristics of 40 people with intellectual disability who were referred for psychiatric inpatient treatment in the special psychiatric unit of the Special Welfare District of Southwest Finland. Three different control groups were used to study: (I) demographic variables (n = 122); (2) medical history (n = 39); and (3) psychosocial factors (n = 20). The symptoms leading to an admission to inpatient care and the connections of these clinical signs with the discharge diagnosis were evaluated. The typical inpatients were young males with mild intellectual disability, psychosis and a previous psychiatric diagnosis. They had lived in several places during their lives and their economic situation was poor. Affective and/or disruptive symptoms were the most common causes of an admission to inpatient care. The largest diagnostic group at discharge consisted of patients with psychotic disorders. The people with intellectual disability who were admitted for inpatient care formed a subgroup with certain psychiatric symptoms and social problems. Specialist psychiatric expertise is absolutely necessary for the treatment of this subgroup.

Adolescent↗

A measure of engagement for children with intellectual disabilities in early childhood settings: a preliminary study.

BACKGROUND: The purpose of this study was to develop a measure of engagement that could be used in practice with children with disabilities, including children with severe intellectual disabilities. METHOD: The Individual Child Engagement Record (ICER) was designed to observe and record the engagement of individual children in order to identify optimal programs for them. Using the measure, 5 children with mild to severe disabilities were observed in an inclusive childcare setting across 4 types of ongoing activities: routine, one-to-one instruction, planned, and child-initiated. RESULTS: Generally, the children were better engaged in routine activities. The lowest level of engagement was found for planned activities. There were, however, differences across children with regard to the relative value of the different types of activities in promoting engagement. CONCLUSIONS: The measure allowed for the identification of activities that would provide better learning opportunities for children with significant disabilities.

Child↗

How do persons with intellectual disability manage in the open labour markets? A follow-up of the Northern Finland 1966 Birth Cohort.

BACKGROUND: The aim was to study how many of the individuals with intellectual disability (ID; IQ < or = 70) in an age cohort were not receiving a disability pension by the age of 34 years and what their life situation was like in terms of employment, education and morbidity. In 2000, the Northern Finland 1966 Birth Cohort (n=12,058 live-born) included 129 individuals with ID. METHOD: The outcome data on employment, education, pensions and morbidity were obtained from national registers. RESULTS: A total of 85.3% (n=110) of all the individuals with ID were on pension, and 66 of them had severe ID (IQ <50) and 44 had mild ID (IQ 50-70). Altogether 99 were drawing a pension because of ID, and 11 had a main diagnosis other than ID in the register of Social Insurance Institution. Nineteen individuals with mild ID were not on disability pension. The educational level of those without pension was low, and all whose occupation was known worked in low-level manual trades in the open labour market. During the past 8 years (1993-2000), their employment rate had been lower and unemployment rate correspondingly higher and unemployment periods longer than those of the reference group (IQ >85 or not measured). As to the morbidity, they had been hospitalized twice more often than those in the reference group and the mean of their hospitalization days was over fourfold. CONCLUSION: More attention should be paid to the vocational education and supported employment services of individuals with ID to help them to manage as independently as possible.

Adult↗

Prevalence of ocular diagnoses found on screening 1539 adults with intellectual disabilities.

OBJECTIVE: To study the prevalence of ocular disorders in adults with intellectual disabilities (IDs) in the Netherlands. DESIGN: Cross-sectional survey. SUBJECTS: A stratified random sample (for age more than 50 years and Down syndrome [DS]) of 1598 participants drawn from a base population of 9012 adult users of ID services with mild to profound intellectual disabilities in the Netherlands. METHODS: Participants underwent on-site visual screening on the basis of a protocol. Results were related to degree of ID, occurrence of DS, age, and a diagnosis of visual impairment or blindness. Referral to ophthalmologists followed when visual impairment was diagnosed. MAIN OUTCOME MEASURES: Diagnosis of ocular disorders and their prevalence. RESULTS: Refractive errors were most prevalent (60.6%), followed by strabismus (44.1%) and lens opacities (18.1%). Besides these, in participants diagnosed as visually impaired, cerebral visual impairment was the most common untreatable disorder (12.6%), followed by macular degeneration (5.4%). Compared with known figures from general populations, the prevalence of ocular diagnoses in adults with ID was significantly higher. The occurrence of refractive errors and strabismus was significantly related to DS (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.56 to 3.00; and OR, 2.47; 95% CI, 1.93 to 3.17, respectively). Lens opacities had an independent relation with age more than 50 years (OR, 4.23; 95% CI, 3.04 to 5.88) and DS (OR, 8.27; 95% CI, 5.95 to 11.49). Keratoconus was independently related to DS (OR, 7.65; 95% CI, 3.91 to 14.96) and degree of ID (OR, 5.56; 95% CI, 2.79 to 11.06). Corneal opacities also were related to DS (OR, 2.70; 95% CI, 1.41 to 5.18) and degree of ID (OR, 5.53; 95% CI, 2.66 to 11.48). The risk of ocular hypertension was increased by age more than 50 years (OR, 2.54; 95% CI, 1.16 to 5.57) and severe or profound ID (OR, 4.86; 95% CI, 2.06 to 10.63); DS decreased the risk (OR, 0.21; 95% CI, 0.05 to 0.94). CONCLUSIONS: In 1539 adults with ID in the Netherlands, high prevalences of ocular disorders were found. Adults with ID in general have an increased risk of severe myopia, strabismus, and lens opacities; DS, older age, or severe ID further increase the risk of specific ocular disorders.

Adult↗

Individual cognitive-behavioural anger treatment for people with mild-borderline intellectual disabilities and histories of aggression: a controlled trial.

OBJECTIVES: Anger is a significant predictor and activator of violent behaviour in patients living in institutional settings. There is some evidence for the value of cognitive-behavioural treatments for anger problems with people with intellectual disabilities. In this study, a newly designed treatment targeted at anger disposition, reactivity, and control was provided to intellectually disabled offenders with aggression histories living in secure settings. DESIGN: About forty detained patients with mild-borderline intellectual disabilities and histories of serious aggression were allocated to specially modified cognitive-behavioural anger treatment (AT group) or to routine care waiting-list control (RC group) conditions. METHODS: AT group participants received 18 sessions of individual treatment. The AT and RC groups were assessed simultaneously at 4 time points: screen, pre- and post-treatment, and at 4-month follow-up using a range of self- and staff-rated anger measures. The effectiveness of the treatment was evaluated using ANCOVA linear trend analyses of group differences on the main outcome measures. RESULTS: The AT group's self-reported anger scores on a number of measures were significantly lower following treatment, compared with the RC wait-list condition, and these improvements were maintained at follow-up. Limited evidence for the effectiveness of treatment was provided by staffs' ratings of patient behaviour post-treatment. CONCLUSIONS: Detained men with mild-moderate intellectual disabilities and histories of severe aggression can successfully engage in, and benefit from, an intensive individual cognitive-behavioural anger treatment that also appears to have beneficial systemic effects.

Adult↗

Intellectual disability and the myth of the changeling myth.

This article investigates the historical sources for the idea of the "changeling" or substitute child as an explanation for congenital intellectual disability. Pre-modern sources for this idea are elite and theological as much as popular and folkloric, nor do they refer to intellectual disability in any sense recognizable to us. Rather, both the concept of intellectual disability and the notion of a transhistorical changeling myth emerge from the historical core of modern psychology.

Child↗

Vision needs of people with intellectual disability in residential facilities and community-based homes for independent living.

PURPOSE: The purpose of this study is to assess the visual problems of people with intellectual disability in residential and community-based facilities. METHOD: A purposive sample of 146 male and female adults, aged 21 and older, living in residential facilities and community-based homes in the southern region of Israel was used to assess and compare vision problems. RESULTS: Among those screened, 77% were found to have a visual problem. Only astigmatism was found to differentiate the two groups. Those living in the community, particularly men, were more likely to have astigmatism. CONCLUSIONS: Addressing the eye care needs of people with intellectual disability is a difficult process. People with intellectual disability, however, need ophthalmological and optometric screening to determine whether they can benefit from such intervention, including cataract removal and eyeglasses, to improve their quality of life.

Adult↗

The general practice care of people with intellectual disability: barriers and solutions.

A questionnaire exploring general practitioners' (GPs') perceptions of the barriers and solutions to providing health care to people with intellectual disability was sent to 912 randomly selected GPs throughout Australia. A response rate of 58% was obtained. Results indicated that numerous barriers compromise the quality of health care able to be provided to people with intellectual disability. Communication difficulties with patients and other health professionals, and problems in obtaining patient histories stood out as the two most significant barriers. A range of other barriers were identified, including GPs' lack of training and experience, patients' poor compliance with management plans, consultation time constraints, difficulties in problem determination, examination difficulties, poor continuity of care, and GPs' inadequate knowledge of the services and resources available. General practitioners also suggested numerous solutions to these barriers, and emphasized the need for increased opportunities for education and training in intellectual disability. The GPs showed an overwhelming willingness to be involved in further education. Other major solutions included increasing consultation duration or frequency, proactively involving families and carers in patients' ongoing health care, and increasing remuneration.

Adult↗

Update on treatment of epilepsy in people with intellectual disabilities.

PURPOSE OF REVIEW: On the basis of the relevance of adequate epilepsy treatment (antiepileptic drugs, surgery and vagus nerve stimulation) for people with intellectual disabilities, all articles, published from the beginning of 2005 to March 2006 and searched by MEDLINE, on this topic were reviewed. RECENT FINDINGS: On pharmacological treatment of epilepsy in people with intellectual disabilities, there were two articles on topiramate and one on levetiracetam. Two studies described the effect of surgical interventions, one of epilepsy surgery in the narrow sense and one of vagus nerve stimulation. Two papers were published on clinical conditions and therapeutic aspects of Angelman syndrome. They highlight the importance of gamma-aminobutyric acidergic mechanism in Angelman syndrome and the antiepileptic drug effects in this syndrome. SUMMARY: A contradiction exists between the relevance of epilepsy treatment in people with intellectual disabilities and the small number of published studies on pharmacological treatment. Some of the reasons are addressed and some alternatives are proposed.

Anticonvulsants↗

Antiepileptic efficacy of vigabatrin in people with severe epilepsy and intellectual disability.

The short- and long-term clinical efficacy of add-on vigabatrin treatment was evaluated in a group of 36 patients with intellectual disability and drug-refractory epilepsy. The results were compared to the efficacy of vigabatrin in 75 non-retarded patients with drug-resistant complex partial and secondarily generalized seizures. After 3 months, 42% of the patients with intellectual disability had experienced a reduction in seizure frequency of more than 50% (responders). The percentage of responders was still 22% after 6 years. No impairment in psychological function was observed during vigabatrin treatment compared with baseline values. However, one patient was excluded from long-term treatment because of psychotic depression and two patients because of psychomotor slowing after 1-2 years of treatment The need for extra supervision appeared to diminish and three patients were able to be discharged from institutional care during the follow-up. In the group of non-retarded patients, the percentages of the responders were 55% and 27% after 3 months and 6 years of treatment, respectively. The results from these studies suggest that vigabatrin is effective and relatively well tolerated, and that the successful treatment of epilepsy also has socio-economic consequences in patients with intellectual disability and severe epilepsy.

Anticonvulsants↗

DSM-IV disorders in children with borderline to moderate intellectual disability. I: prevalence and impact.

OBJECTIVE: To assess the prevalence, comorbidity, and impact of DSM-IV disorders in 7- to 20-year-olds with intellectual disability. METHOD: A total of 474 children (response 86.8%) were randomly selected from a sample of students from Dutch schools for the intellectually disabled. Parents completed the anxiety, mood, and disruptive disorder modules of the Diagnostic Interview Schedule for Children. RESULTS: A total of 21.9% of the children met the DSM-IV symptom criteria for anxiety disorder, 4.4% for mood disorder, and 25.1% for disruptive disorder. Similar prevalence rates were found for children who screened positive or negative for pervasive developmental disorder. More than half of the children meeting the criteria for a DSM-IV disorder were severely impaired in everyday functioning, and about 37% had a comorbid disorder. Children with multiple disorders were more likely to be impaired across various areas of everyday functioning. Almost 27% of the diagnosed children received mental health care in the last year. Comorbidity and impairment in everyday functioning increased the likelihood of referral. CONCLUSIONS: Most disorders can be observed in intellectually disabled children. Impairment and comorbidity are high. The finding that less than one third of the children with a psychiatric disorder receive mental health care deserves attention.

Comorbidity↗

Health screening for people with intellectual disability: the New Zealand experience.

People with intellectual disability have considerable health needs and variable health care. The introduction of annual health screens for IHC residents in New Zealand resulted in some 73% of screened people requiring follow-up interventions. The introduction of the health screens raised a number of issues for management, staff, health professionals and clients who might subsequently be involved in an exercise of this type and magnitude. The importance of applying principles of management promoted by proponents of total quality management has been apparent throughout the whole exercise.

Community Health Services↗