Listening to people with intellectual disabilities who misuse alcohol and drugs

Understanding the effectiveness and underlying mechanisms of lifestyle modification interventions in adults with learning disabilities: a mixed-methods systematic review

Background

Adults with learning disabilities face increased risks of unhealthy lifestyle behaviours, including alcohol consumption, smoking, low physical activity, sedentary behaviour and poor diet. Lifestyle modification interventions that target health-risk behaviours can prevent or reduce their negative effects. The goal of this project was to investigate the effectiveness and underlying mechanisms of lifestyle modification interventions in adults with learning disabilities.

Methods

A systematic review and meta-analysis were conducted to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with learning disabilities. Major electronic databases, clinical trial registries, grey literature, and citations of systematic reviews and included studies were searched in January 2021 (updated in February 2022). We included randomised and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity only, sedentary behaviour and poor diet in adults (aged ≥ 18 years) with learning disabilities. Studies were also coded based on the extent of use of theories and behaviour change techniques in interventions. Risk of bias in studies was assessed using appropriate tools. A realist synthesis of qualitative, quantitative and mixed-methods literature was conducted to complement the systematic review findings by identifying key intervention mechanisms that are likely to improve the health of adults with learning disabilities. Data were synthesised in the form of a programme theory regarding complex causal mechanisms and how these interact with social context to produce outcomes. All findings were integrated into a logic model. A patient and public involvement group provided input and insights throughout the project.

Results

A total of 80 studies with 4805 participants were included in the systematic review. The complexity of lifestyle modification interventions was dismantled by identifying six core components that influenced outcomes. These components could be present in interventions targeting single or multiple health risk behaviors, either as individual elements or in various combinations. Interventions on alcohol and smoking behaviours were found to be effective, but this was based on limited evidence. The effectiveness of interventions targeting low physical activity only or multiple behaviours (low physical activity only, sedentary behaviours and poor diet) was mixed. All interventions had a varying level of statistical significance. The intervention-level network meta-analysis for weight management outcomes showed none of the interventions was associated with a statistically significant change in outcomes when compared to treatment as usual and each other. Similar findings were observed in the component network meta-analysis. A variety of theories and behaviour change techniques were employed in the development and adaptation of interventions. Most studies had a high and moderate risk of bias. A total of 79 studies, reporting the experiences of more than 3604 adults with intellectual disabilities and over 490 caregivers, were included in the realist synthesis. The resulting programme theory highlighted the contexts and mechanisms relating to support involvement, negotiating the balance between autonomy and behaviour change, fostering social connectedness and fun, the accessibility and suitability of intervention strategies and delivery, along with the broader behavioural pathways to lifestyle change. It also brought out the importance of working with people with lived experiences when developing and evaluating interventions. Our logic model, bringing together the findings of both syntheses, provides guidance on the design of future interventions.

Discussion

This study was the first comprehensive mixed-methods evidence synthesis to explore lifestyle modification interventions targeting multiple unhealthy lifestyle behaviours in adults with learning disabilities. We conclude that future research could benefit from codeveloping interventions and population-specific assessment frameworks with people with lived experiences. There is a need for more high-quality research with appropriate outcomes and a focus on qualitative and mixed-methods research to better understand what works for whom and why.

Trial registration

This trial is registered as PROSPERO CRD 42020223290.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128755) and is published in full in Health Technology Assessment; Vol. 29, No. 4. See the NIHR Funding and Awards website for further award information.

Supporting active engagement of adults with intellectual disabilities in lifestyle modification interventions: a realist evidence synthesis of what works, for whom, in what context and why

BACKGROUND

Lifestyle modification interventions for adults with intellectual disabilities have had, to date, mixed effectiveness. This study aimed to understand how lifestyle modification interventions for adults with intellectual disabilities work, for whom they work and in what circumstances.

METHODS

A realist evidence synthesis was conducted that incorporated input from adults with intellectual disabilities and expert researchers. Following the development of an initial programme theory based on key literature and input from people with lived experience and academics working in this field, five major databases (MEDLINE, EMBASE, CINAHL, PsycINFO and ASSIA) and clinical trial repositories were systematically searched. Data from 79 studies were synthesised to develop context, mechanism and outcome configurations (CMOCs).

RESULTS

The contexts and mechanisms identified related to the ability of adults with intellectual disabilities to actively take part in the intervention, which in turn contributes to what works, for whom and in what circumstances. The included CMOCs related to support involvement, negotiating the balance between autonomy and behaviour change, fostering social connectedness and fun, accessibility and suitability of intervention strategies and delivery and broader behavioural pathways to lifestyle change. It is also essential to work with people with lived experiences when developing and evaluating interventions.

CONCLUSIONS

Future lifestyle interventions research should be participatory in nature, and accessible data collection methods should also be explored as a way of including people with severe and profound intellectual disabilities in research. More emphasis should be given to the broader benefits of lifestyle change, such as opportunities for social interaction and connectedness.

Exploring the complex cognitive, affective and behavioural processes of individuals with intellectual disabilities in financially abusive situations

BACKGROUND

Understanding the cognitive processes of individuals with intellectual disabilities in financially abusive situations is critical to develop effective prevention strategies.

AIMS

This study investigated how persons with intellectual disabilities define and analyse financially abusive situations, and how they would feel and act in situations that they consider abusive.

MATERIALS AND METHODS

Twelve participants with intellectual disabilities participated in a semi-structured interview where they were asked to reflect on three vignettes illustrating financial abuse. We analysed the interviews using thematic analysis.

FINDINGS

The findings revealed that individuals with intellectual disabilities considered the type of relationship between the victims and the perpetrators, the behavioural patterns of the perpetrators, and their own experiences when interpreting the situation. Furthermore, they discussed their emotional and behavioural reactions to the vignettes.

CONCLUSION

This study has important implications in supporting the autonomy and decision-making rights of persons with intellectual disabilities regarding their finances and developing effective preventions against financial abuse among this population.

Exploring the predictive properties of the Hayes Ability Screening Index subtest background information in identifying individuals with MBID among in-patients with SUD

INTRODUCTION

For individuals with substance use disorder (SUD), mild to borderline intellectual disability (MBID) goes undetected in treatment clinics. The Hayes Ability Screening Index (HASI) has been found to be a valid, time-saving screening instrument for MBID in SUD treatment. MBID can have significant implications for treatment planning and outcomes. Therefore, it is important to have methods for the early recognition of these comorbid conditions. Because of less sensitivity to recent or ongoing substance use, the HASI subtest background information may be particularly valuable as an early screening of MBID. The main aim was to investigate the convergent, predictive, and discriminant validity of the HASI subtest background information in identifying in-patients with SUD as MBID or non-MBID.

METHODS

Eighty-four in-patients with SUD aged 19-64 participated in this multicentre study. MBID was diagnosed according to the ICD-10 using WAIS-IV, Vineland II, and self-reported childhood learning difficulties.

RESULTS

The main finding was that, among the HASI subtests, background information was the strongest predictor. A HASI background information cut between 6 and 7 showed a sensitivity of 78% and a specificity of 72%.

CONCLUSION

The HASI subtest background information has acceptable convergent, predictive, and discriminant validity as a screening for MBID among in-patients in SUD treatment.

Prevalence and Characteristics of Borderline Intellectual Functioning in a Cohort of Patients With Polysubstance Use Disorder

Objective: To determine the prevalence and associated demographic and clinical features of borderline intellectual functioning (BIF) among individuals with polysubstance use disorder (pSUD). Methods: We applied a cross-sectional analytical design to data from the Norwegian STAYER study (n = 162), a cohort study of patients with a pSUD from the Stavanger University hospital catchment area. We used Wechsler Abbreviated Scale of Intelligence Full Scale IQ (FSIQ) to define BIF (FSIQ = 70-85) and non-BIF (FSIQ = >85) and collected demographic and clinical data using semi-structured interviews and self-reports on the Symptom Checklist 90-Revised (SCL-90-R) and the Satisfaction With Life Scale (SWLS). Results: The prevalence of BIF was 18% in the present study. The presence of BIF was associated with higher SCL-90-R GSI scores than in the non-BIF group. There were no significant differences between the BIF and non-BIF groups regarding age, gender, participation in meaningful daily activity, years of work experience, years of education, satisfaction with life, level of care, treatment attempts, age at substance-use onset, years of substance use, history of injecting drugs, or age of onset of injecting drugs. Conclusion: The present study confirmed a higher prevalence of BIF among patients with pSUD than expected from the distribution of IQ scores in a general population. Elevated SCL-90-R GSI scores suggested that BIF is associated with increased psychological distress in patients receiving treatment for pSUD. Further studies on this association, and its effect on treatment procedure and outcomes are strongly warranted.

How do programmes to prevent intimate partner violence among the general population impact women with disabilities? Post-hoc analysis of three randomised controlled trials

INTRODUCTION

Women with disabilities experience higher rates of intimate partner violence (IPV) than women without disabilities. There remains limited evidence about whether IPV prevention interventions for the general population have benefits for women with disabilities that compare to those for women without disabilities. Using data from IPV prevention randomised controlled trials in diverse locations (Rwanda, South Africa and Afghanistan), we assess whether outcomes differed by disability status.

METHODS

We assessed disability at baseline in three IPV prevention trials. We performed post-hoc analysis of intervention impacts at endline (22 or 24 months post-baseline) stratified by disability status at study baseline and tested an interaction term for disability at baseline by intervention arm for three sets of outcomes: (1) past year experiences of physical, sexual and severe IPV; (2) economic and livelihood outcomes; and (3) health, mental health and substance use outcomes.

RESULTS

At baseline between 17.7% and 26.2% of women reported being disabled. For IPV prevention, in seven out of eight tests across three studies, women with and without disabilities had similar outcomes. For economic, health and substance use outcomes, there was more variation, with women with disabilities reporting both better and worse outcomes than women without disabilities; however there was no clear pattern in these differential results.

CONCLUSION

IPV prevention programmes targeting general populations can prevent IPV among women with disabilities participants with benefits that mirror those for women without disabilities. Benefits for participants with and without disabilities on secondary programme outcomes related to economic empowerment and health may be more varied and should be explicitly monitored.

Chronic alcoholism and all-cause mortality among disabled individuals: Findings from the Korea National Health Insurance Service-National Sample Cohort

BACKGROUND

Alcohol use among adults with mild to severe disability is an under-researched topic in the literature. Few studies have attempted to assess the impact of alcohol misuse, abuse, and chronic alcoholism among this target group. Thus, we investigated the association between chronic alcoholism and mortality among disabled individuals in South Korea.

METHODS

We used data from the National Health Insurance Service National Sample Cohort (NHIS-NSC) for the years 2003-2013, which included data on 61,013 disabled individuals. Among these patients, a multivariate Cox proportional hazards model was used to estimate the hazard ratio of mortality associated with chronic alcoholism.

RESULTS

A total of 800 individuals died during the study period. Individuals who had medical claims for chronic alcoholism following their disability diagnosis had greater risk of mortality than individuals without chronic alcoholism (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.06-2.31, p = 0.0244). Individuals with a physical disability (HR: 2.30, 95% CI: 1.06-4.95, p = 0.0342), brain lesion (HR: 1.96, 95% CI: 1.03-3.74, p = 0.0405), and/or kidney failure (HR: 4.98, 95% CI: 1.07-23.25, p = 0.0411) had greatest mortality risk when diagnosed with chronic alcoholism, compared to individuals who were not diagnosed with chronic alcoholism.

CONCLUSIONS

Chronic alcoholism following disability diagnosis was associated with greater mortality risk in a nationally representative population of disabled individuals, especially among individuals with a physical disability, brain lesion, and/or kidney failure. Such findings reveal that certain social and political measures must be implemented to help disabled individuals suffering from alcoholism, especially according to disability diagnosis.

Post-traumatic stress disorder and substance use disorder in individuals with mild intellectual disability or borderline intellectual functioning: A review of treatment studies

Individuals with mild intellectual disability or borderline intellectual functioning (MID-BIF; IQ 50-85) are at high risk for developing post-traumatic stress disorder (PTSD) and substance use disorders (SUD). In individuals without MID-BIF, Seeking Safety (SeSa) is found to be effective in treating PTSD and SUD simultaneously. However, little is known about integrated treatment of PTSD and SUD in individuals with MID-BIF. This review aims to provide an overview of studies about this type of triple psychopathology, as well as PTSD or SUD in individuals with MID-BIF (i.e. dual diagnosis). No studies were found on integrated treatment of PTSD and SUD in individuals with MID-BIF. Thirty-two studies were found on treatment of either PTSD (mostly Eye Movement Desensitization and Reprocessing and cognitive behavior therapy) or SUD (mostly cognitive behavior therapy and mindfulness) in individuals with MID-BIF. Only 9.4 % of these studies mentioned the co-morbidity of PTSD and SUD. Suggestions for adapting treatment to individuals with MID-BIF were provided on communication, structure, non-verbal elements, network, coping skills, therapeutic relationship and use of suitable and reliable instruments to measure treatment progress. More research is needed on the effectivity of EMDR or Imaginary Exposure (IE) combined with SUD treatment (CBT and mindfulness), and on the adaption of SeSa tot individuals with MID-BIF, as well as on this type of triple psychopathology in general.

Weighing up the risks and benefits of community gambling venues as recreational spaces for people with lifelong disability

BACKGROUND

Community gambling venues (pubs and clubs) are commonly associated with leisure and recreational options in Australian communities. While these venues offer a range of activities and facilities, including social opportunities, sporting facilities, live entertainment, they also contain gambling products that are known to cause significant harm to individuals, their families and communities. Although researchers have explored how adults and children engage with these venues, there is limited understanding about the potential risks and benefits of these venues for people with lifelong disability.

METHODS

Semi structured interviews were conducted with nineteen people aged 20-70 years with lifelong disability (includes in this context intellectual disability, autism spectrum disorder, ADHD, and learning disability), predominately intellectual disability. The interviews occurred in a large Australian city and explored interviewees' experiences and attitudes towards pubs and clubs. Using a range of visual prompts (if needed), participants were asked to describe their engagement in different activities offered within the venue. Interviews were audio-recorded and transcribed, with a thematic analysis used to identify themes across the group.

RESULTS

Most participants attended venues with family, friends, and supporters, with a few attending on their own. Participants described socialising in the venue, going for reduced price meals, and attended for a range of activities including recreational activities, live entertainment and sport. Some participants also valued being a member of venues, and the interactions with staff members. While participants were cautious about the consumption of alcohol, most had gambled, particularly on electronic gambling machines (EGMs, pokies, or slots). Some participants stated that they had experienced problems with gambling.

CONCLUSIONS

While many people with lifelong disability have positive experiences in pubs and clubs, some are vulnerable to the harms associated with risky products such as gambling within the venue. While it is important to acknowledge the positives associated with recreational facilities and encourage engagement in leisure activities for people with lifelong disability, further consideration is needed to ensure people are informed and protected from the harms associated with gambling and other products that are provided within these spaces.

Screening for intellectual disabilities: a validation of the Hayes Ability Screening Index for in-patients with substance use disorder

BACKGROUND

There is a reason to believe that many individuals with substance use disorder (SUD) in contact with services have an undiagnosed intellectual disability (ID). Assessing ID in persons with SUD can be challenging due to the influence of substances, time consumption, and specific requirements for the education of the assessor. On the other hand, an undiagnosed condition may lead to a lack of treatment adjustment and may result in drop-out from treatment or lack of treatment effect. There is a need for a time-saving, valid instrument to detect possible ID among people with SUD.

AIMS

To validate the Hayes Ability Screening Index (HASI) as a screening instrument for identifying ID in a population of in-patients with SUD using all three ICD-10/DSM5 criteria in classifying ID as the validation criterion.

METHODS

Eighty-four SUD in-patients aged 19-64 participated in this multicenter study. An ID was diagnosed according to the ICD-10 using WAIS-IV, Vineland II, and self-reported childhood learning difficulties.

RESULTS

HASI correlated well with both the WAIS-IV and Vineland II. At the recommended cut-off score, the HASI had a sensitivity of 100% and a specificity of 65.4%. A large number of the false positives had IQ or both IQ and adaptive scores in the borderline range.

CONCLUSIONS

The HASI has good convergent, discriminant, and overall construct validity in detecting ID in in-patients with SUD.

Pilot study: undetected post-traumatic stress disorder symptoms among intellectually disabled

Background: Individuals with intellectual disability respond differently to traumatic events, compared to the general population, which makes post-traumatic stress disorder (PTSD) symptoms difficult to recognize. The current study aims to examine the presence of undetected PTSD among individuals with intellectual disability and a known history of trauma exposure. Method: Nine individuals, who have not previously been diagnosed with PTSD, were evaluated for PTSD symptoms through case reports, which include descriptions of medical history, symptoms and behavior described in the former diagnostic reports, potential traumatic experiences, current symptoms and behavior in accordance to the Lancaster and North Gate Trauma Scale, and PTSD criteria from DM-ID. Results: Four out of the nine participants met the DM-ID criteria for PTSD. Conclusions: The current findings highlight the importance of including cognitive impairment and developmental level in the screening, referral and treatment process of PTSD.

Alcohol use disorders in people with intellectual disability

This article initially highlights that although the prevalence of alcohol use disorders in people with intellectual disability (PWID) appears to be low, it is a significant issue. This group can be more vulnerable to the adverse effects of alcohol and it is likely that many PWID who have alcohol use disorders are not being identified. We go on to review the limited existing literature on treatment for PWID who have alcohol use disorders and the challenges in meeting the needs of this patient group. We explore how assessment and treatment of alcohol use disorders in this population can be and needs to be tailored to the needs of PWID on an individual basis. There is also discussion about the use of incapacity legislation to treat this group.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Alcohol, tobacco and cannabis use: Do students with mild-intellectual disability mimic students in the general population?

Education policies encourage inclusion of students with mild-intellectual disability (mild-ID) in community/school life. However, such policies potentially increase exposure to substance use. This article examines tobacco, alcohol and cannabis use among French students enrolled in special units for students with disabilities (ULIS) at mainstream junior high schools compared to those of general population of the equivalent age; and explores factors associated with substance use among ULIS students, known to present mostly mild-ID. In 2014, a questionnaire adapted from the international HBSC/WHO study was administered to 700 ULIS students (mean-age 14.2). Comparative data were gathered from 7023 junior high-school students (mean-age 13.6) in the general population. Among students <14 years-old, tobacco and alcohol use rates were similar between ULIS and general population. For students ≥14, alcohol use remained comparable, while tobacco and cannabis use were higher in general population. Among ULIS students, low perceived health/life satisfaction, divorced/separated parents and high perceived academic demands were associated with tobacco use. Bullying, not liking school very much and attending schools outside a deprived area were associated with alcohol use. Having had sexual intercourse and not perceiving one's health as excellent were associated with cannabis use. Having dated was associated with using all three substances.

Substance use among individuals with intellectual disabilities living independently in Flanders

BACKGROUND

Over the past decades, there has been increased scientific and clinical interest in substance use among individuals with intellectual disabilities (ID). Despite raised interest and awareness in the topic, lack of supportive data on prevalence and risk factors highlights the need for ongoing research. The aims of this cross-sectional multicenter study were to examine the nature and extent of substance use in individuals with ID living independently, to investigate group differences in substance use and related problems, and to explore the role of substance-related knowledge and attitudes in substance use behaviors.

METHOD

Participants were 123 individuals with mild to moderate ID receiving support from independent living services. Data were gathered by means of a structured interview strategy (i.e. the Substance Use and Misuse in Intellectual Disability-Questionnaire; SumID-Q).

RESULTS

Findings revealed that rates of lifetime use of licit and illicit substances were higher than those found in earlier studies among individuals with ID and the general population. While cannabis use was the only illicit substance reported, current tobacco and alcohol use were shown to be highly prevalent (48%-45.5%). Rates for the latter were similar to earlier studies among community samples of individuals with ID. In contrast to our hypotheses, few group differences in substance use behaviors were observed. Male gender was associated with age of onset of alcohol and tobacco use and tobacco use-related problems, while younger age was found to be associated with lifetime use of cannabis. No evidence was found regarding the role of knowledge; however, smokers and alcohol users rated tobacco and alcohol use more positively.

CONCLUSION

This study demonstrated that individuals with ID living independently use a wide range of licit and illicit substances and present divergent levels and patterns of substance use. Notwithstanding the role of personal choice in substance use, more research is needed to better understand the nature and extent of substance use and related problems, as well as the role of substance-related knowledge and attitudes in individuals with ID.

Assessment and Treatment for Persons with Coexisting Ability and Substance Use Issues: A Review and Analysis of the Literature

Persons with ability issues are at considerably higher risk to develop substance use problems when compared to the general population. Yet, little is known about the current status of substance use treatment for this population. A comprehensive search of the literature revealed a need for (a) population-specific instruments for screening and assessment of the use of alcohol and drugs, including the misuse of prescription medication; (b) tailored treatment methods and individualized treatment plans that meet diverse literacy or cognitive needs;

Pretreatment for substance-abusing people with intellectual disabilities: intervening on autonomous motivation for treatment entry

BACKGROUND

Despite a lack of consensus regarding prevalence rates of substance abuse, people with intellectual disabilities (ID) on average use substances slightly less often than their non-disabled peers. However, their use of substances is more often problematic. Avoidance of treatment is a crucial problem among substance-abusing people with ID. This study tested a motivational intervention to facilitate autonomous motivation (i.e. wanting to change substance abuse because of a sense of free choice and volition) for engaging with a subsequent addiction treatment.

METHOD

A multiple-case experimental design (N = 6) was conducted to measure day-to-day motivation to change substance abuse among individuals with mild ID (N = 3) and borderline level of intellectual functioning (N = 3) in the Netherlands. The participants (five men, one woman) lived in the community (except one, he lived in a residential facility) and abused cannabis, alcohol or hashish. During the intervention phase, the 10-session treatment programme 'Beat the kick' was delivered by an experienced psychologist, based on motivational interviewing techniques adapted for people with mild to borderline ID. Participants completed an adaptive self-reported inventory based on self-determination theory (SDT) two to three times a week during baseline, intervention and 1-month follow-up.

RESULTS

The results of five of the six participants (one dropped out) showed that the type of motivation changed from more controlled types of motivation (i.e. external motivation and introjected motivation) at baseline to more autonomous types of motivation after completion of the intervention. In addition, the participants reported a significant increase in overall need satisfaction and autonomy satisfaction and a significant decrease of overall need frustration.

CONCLUSIONS

The implementation of SDT and motivational interviewing principles in the treatment programme 'Beat the kick' reliably changed the type of motivation. In addition, the experimental effects provide initial proof of the use and applicability of SDT among people with ID.

Extended brief intervention to address alcohol misuse in people with mild to moderate intellectual disabilities living in the community (EBI-ID): study protocol for a randomised controlled trial

Background

There is some evidence that people with intellectual disabilities who live in the community are exposed to the same risks of alcohol use as the rest of the population. Various interventions have been evaluated in the general population to tackle hazardous or harmful drinking and alcohol dependence, but the literature evaluating interventions is very limited regarding intellectual disabilities. The National Institute for Health and Clinical Excellence recommends that brief and extended brief interventions be used to help young persons and adults who have screened as positive for hazardous and harmful drinking. The objective of this trial is to investigate the feasibility of adapting and delivering an extended brief intervention (EBI) to persons with mild/moderate intellectual disability who live in the community and whose level of drinking is harmful or hazardous.

Methods/Design

The study has three stages, which include the adaptation of the Extended Brief Intervention (EBI) for people with intellectual disability, a single blind, randomised controlled trial of an individual Extended Brief Intervention to test the feasibility of the intervention, and a qualitative study that will assess the perceived acceptability and usefulness of the intervention. Fifty participants in total will be recruited from community intellectual disability services and social care or third sector organisations. The main outcome is a reduction in alcohol consumption measured by the Alcohol Use Disorders Identification Test.

Discussion

Alcohol misuse is a relatively under-researched mental health problem in people with intellectual disabilities. Therefore, the study addresses both diagnostic issues and the delivery of a simple first stage intervention, which is available to the population of average intelligence and young persons in particular. The findings from the study will guide the preparation of a large-scale study to test whether this treatment is clinically and cost-effective in this population.

Trial registration

ISRCTN58783633 (19 December 2013).

Modification of motivational interviewing for use with people with mild intellectual disability and challenging behaviour

BACKGROUND

Motivational interviewing is a promising method to increase treatment motivation for people with mild intellectual disability and challenging behaviour. The purpose of the present study was to identify how professionals could adapt motivational interviewing techniques for use with clients.

METHOD

We conducted semistructured qualitative interviews and focus groups with 26 clients, parents, and professionals. A general inductive approach led to the identification of multiple core themes.

RESULTS

The authors recommend several modifications to accommodate motivational interviewing for use with clients: adapt to language level, adjust to cognitive abilities, and control for social desirability of responding. In addition, certain characteristics of professionals were also found to be critical for effective motivational interviewing: trustworthiness, engagement, acceptance, empathy, and honesty.

CONCLUSIONS

Concrete recommendations for the adaptation of the motivational interviewing techniques for use with people with mild intellectual disability and challenging behaviour are identified. Certain characteristics of professionals are also critical for maximising the treatment motivation of clients.

Sexual and reproductive health care for women with intellectual disabilities: a primary care perspective

Adults with intellectual disabilities (ID) face multiple health disparities and challenges to accessing health care. Little is known about sexual health care of this population and about how to optimize women's reproductive health care for women with intellectual disabilities. Women with ID face important barriers to care, including lack of provider training and experience, hesitancy to broach the topic of sexual health, a lack of sexual knowledge and limited opportunities for sex education, disability-related barriers, higher prevalence of sexual abuse and assault, often underreported, lack of dialogue around this population's human right to consensual sexual expression, undertreatment of menstrual disorders, and legal and systemic barriers. We conducted a limited literature review related to six aspects of sexual health care of women with ID, including barriers to sexual health care, sex education, sexual abuse and consensual sexuality, contraception, screening for sexually transmitted infections and cervical cancer, and pregnancy and parenting. After providing background information about each topic, we suggest practice recommendations for primary care clinicians, using a rights-based framework.

Problematic alcohol use and mild intellectual disability: standardization of pictorial stimuli for an alcohol cue reactivity task

The present study focused on the first step in developing a cue reactivity task for studying cognitive biases in individuals with mild to borderline intellectual disability (ID) and alcohol use-related problems: the standardization of pictorial stimuli. Participants (N=40), both with and without a history of alcohol use-related problems and varying in IQ, were admitted to a forensic setting and were all abstinent. They were asked to rate familiarity, complexity, valence and attractiveness of pictures portraying both alcoholic and non-alcoholic beverages. There was a tendency to rate non-alcoholic beverages as more pleasant and attractive than alcoholic beverages. In participants with mild to borderline ID, this difference reached statistical significance, even when controlling for alcohol use-related problems in the past. The overall result of the study is a large database of 255 pictures portraying both alcoholic and non-alcoholic beverages that will be used to validate an implicit measure of cognitive biases for alcohol in individuals with mild to borderline ID.

Substance abuse among individuals with intellectual disabilities

Individuals with disabilities are a growing population that confronts multiple disadvantages from social and environmental determinants of health. In particular, the 7-8 million people in the U.S. with an intellectual disability (ID) suffer disproportionately from substance use problems, largely because of a lack of empirical evidence to inform prevention and treatment efforts for them. Although available research could inform future research efforts, studies are scattered across disciplines with the last review synthesizing findings written more than five years ago. To consider more recent findings with earlier works, PubMed, PsychINFO, and Google Scholar were searched and produced 37 peer-reviewed texts across multiple disciplines, 15 from 2006 or later. While the prevalence of alcohol and illicit drug use in this population are low, the risk of having a substance-related problem among ID substance users is comparatively high. Gaps in the research and population subgroups that warrant special attention are identified, such as individuals with borderline and mild ID, individuals with co-occurring mental illness, and individuals who are incarcerated. Compared with substance abusers without ID, ID substance abusers are less likely to receive substance abuse treatment or remain in treatment. Research is needed to better gauge the magnitude of substance use problems, identify prevention strategies, and specify treatment components that meet the unique needs of individuals with ID.

Recreational substance use patterns and co-morbid psychopathology in adults with intellectual disability

There is very limited evidence on the patterns of recreational substance use among adults with Intellectual Disabilities (ID) who have co-morbid mental health problems. In this study we collected clinical and socio-demographic information as well as data on substance use patterns for consecutive new referrals (N = 115) to specialist mental health services for adults with ID in South-East London. The data were recorded from active clinical case notes. About 15% of patients had a history of substance use, however only 8% were currently using substances. Alcohol was the most frequently used substance (80%) followed by cannabis (28%) and cocaine (12%). Overall, substance use was significantly more likely among male patients, those with a mild level of ID and those with a forensic history. Substance use was less likely among patients with autism and more likely among those with schizophrenia spectrum disorders. Logistic regression analyses revealed that those with a forensic history were about five times more likely to have current substance use problems. Male gender was the only predictor for legal substance (alcohol) use. Illicit substance use was about three times more likely among patients with schizophrenia spectrum disorders. The present results highlight the role of illicit substance use as a health risk factor for adults with ID as well as the need to increase awareness within specialist mental health services.

Traumatic experiences and life events in people with intellectual disability

PURPOSE OF REVIEW

The aim of this article is to present and critically evaluate recent research on life events and traumatic experiences as predictors of psychopathology in people with intellectual disability.

RECENT FINDINGS

The area has not developed significantly in the last years. Although life events have been associated with a range of mental health problems, only few studies have tried to clarify their role in psychopathology. It is often the case that differences between life events and traumatic experiences have been overlooked, mainly because establishing a clear cut-off point between the two types of events is not always possible. In addition, traumatic experiences per se, and as potential predictors of psychopathology, have been scarcely investigated in people with intellectual disability.

SUMMARY

The role of recent life events and traumatic experiences across the life-span of people with intellectual disability deserves more research. An outstanding question is whether these events are risk factors or triggering factors, as well as how to differentiate between traumatic and life events. Identifying possible protective factors for mental health seems to be a very promising line for future research with important clinical implications.