What Is Right? Ethics in Intellectual Disabilities Research

Responsible inclusion: A systematic review of consent to social-behavioral research with adults with intellectual disability in the US

BACKGROUND

In recognition of their status as a health disparities population, there is growing emphasis on conducting research inclusive of adults with intellectual disability to generate new knowledge and opportunities to improve health and equity. Yet they are often excluded from research, and human research participant protection experts and researchers lack agreement on effective consent protocols for their inclusion.

OBJECTIVE

We sought to identify approaches to consent in US-based social-behavioral research with adults with intellectual disability.

METHODS

We conducted a systematic review on approaches to self-consent with adults with intellectual disability published between 2009 and 2023, identified via searching eight databases and reference list hand searches. We identified 13 manuscripts and conducted a thematic analysis.

RESULTS

Our analysis identified themes related to guiding principles, strategies to enhance informed and voluntary consent, approaches to consent capacity, involving individuals subject to guardianship, and strategies for expressing decisions and enhancing ongoing decisions.

CONCLUSIONS

Manuscripts largely reflected an emphasis on identifying approaches to consent that reflect disability rights principles to promote the right to be included and make one's own decisions based on assessment of relevant information, risks and benefits, and to employ reasonable modifications to achieve inclusion. To avoid the risks of exclusion and advance the responsible inclusion of adults with intellectual disability, we make recommendations to align consent approaches anchored in contemporary thinking about human research participant protections, including through integration with disability rights.

Trust, respect, and training: Principles of care for service professionals supporting adults with intellectual disabilities in community residential programs

Background: Adults with intellectual disabilities in community residential programs receive services from direct support professionals (DSPs) intended to facilitate community engagement. As part of a rate study for Washington State's Developmental Disabilities Administration on community residential services, adults in these programs were asked to provide their perspective on the quality and effectiveness of their care.Method: Twenty-five adults with intellectual disabilities were interviewed focusing on daily activities, staffing, and living situations. Interview transcripts were coded and analyzed for dominant themes.Results: Participants emphasized the desire for trustworthy, caring, and respectful DSPs; DSPs trained in behavioral management techniques made participants feel safe and supported. Nearly all participants called for greater staffing stability.Conclusions: People living in community residential programs are profoundly impacted by the stress and uncertainty of DSPs facing limited resources and high staff turnover. Stable, consistent support makes it easier for participants to engage in community integration.

Research ethics for all: Development of a social-behavioral research ethics education program for community research partners with developmental disabilities

BACKGROUND

People with developmental disabilities make important contributions to research. However, inaccessible research ethics trainings present a barrier to them taking on some research roles.

OBJECTIVES

We developed a social-behavioral research ethics training that leads to certification tailored to the accessibility needs and roles of community research partners with developmental disabilities.

METHODS

We collaborated with diverse partners (people with developmental disabilities, a disability service provider, health researchers, human research participant protections experts) to develop the research ethics training. To identify potential training content, we conducted a rapid scoping review of ethical, legal, and social issues in social-behavioral research with adults with developmental disabilities and reviewed national research ethics curricula. Through discussions and a modified Delphi process, we worked with partners to identify content to teach; partners also provided guidance on accessibility.

RESULTS

The training and rapid scoping reviews and input from partners resulted in 93 potential educational content elements to include. After completing the modified Delphi process, partners recommended inclusion of 83 of these content elements in the educational training and provided input on depth and approach to teaching this content. Research Ethics for All is a freely available training that includes 5 units, delivered via didactic and active learning, and assessment activities to verify understanding. Research Ethics for All should be facilitated by an experienced researcher.

CONCLUSIONS

Research Ethics for All includes foundational social-behavioral research ethics content designed to support community research partners with developmental disabilities to take on new research responsibilities.

Inextricably tied: Nonbinary autistic individuals' views on how their gender identity and autism are connected

LAY ABSTRACT

This study explores the experiences and identities of nonbinary autistic people. The relationship between autistic and nonbinary identities has not been researched in detail. Few studies focus specifically on nonbinary autistic adults. We interviewed 44 nonbinary individuals for this study. Participants had thought-out opinions on gender identity and emphasized identifying with fluidity rather than traditional gender roles. Participants discussed the connection of their autistic and nonbinary identities and how it affected how people saw them and how they saw themselves. We have recommendations for programming, policy, and research from these findings.

Same Transition, Different Perspectives: Comparing Dyadic Interviews with Autistic Young Adults and Parents

Introduction

The transition to young adulthood can be a turbulent life stage, and this is often magnified for autistic youth. Young adults frequently profess different goals and values than their parents. While there is some indication in autism research about how parents, and to a lesser extent, autistic young adults, feel about this transition, little research leverages dyadic interviews with both populations or has used this method with Black and/or low-income families.

Method

We conducted four sets of dyadic interviews with autistic young adults and their parents who live together.

Results

We identified three key themes that both groups found important to the transition: independence, structured transition, and interpersonal relationships. However, we found that how the groups conceptualized these themes were divergent and revealed differences in goals and values. Parents were more oriented toward long-term normative views of fulfillment, whereas young adults spoke about what was meaningful to them currently.

Conclusion

This work has implications for changes to how autism research will conceptualize the transition to young adulthood and how we can create better social opportunities for this population.

Community brief

Why is this an important issue?: Autistic adults are at risk for difficulties getting work and education, which can lead to them feeling alienated or unfulfilled. Most research on autistic people becoming adults is based on White people with more cultural and financial resources and does not ask autistic people themselves or their families with them. Research is needed to improve transition outcomes for these underresearched and underserved groups.What was the purpose of this study?: This study explored how autistic youth and their parents thought about and experienced the transition to adulthood out of an urban, low-resourced school district.What did the researchers do?: Researchers interviewed four parents and four autistic youth. Three families were Black, and one family was White and from a low-income household. All autistic youth had received special education services, needed support to transition to adulthood, and had finished high school 1 to 6 years before the study. The young adults lived with their mothers and received support from them for daily tasks. We interviewed the parents and then the youth. In some cases, youths joined parents' interviews or parents joined youths' interviews to provide help with remembering information or giving answers.What were the results of the study?: Researchers identified three themes. First, parents and youth thought about independence differently. Parents focused more on work and financial independence. Youth focused more on social aspects of work and having independence in daily activities such as shopping. The second theme was that youth and parents approached ongoing structured supports differently. Youth reported positive experiences with a range of services but did not discuss the need for ongoing supports like their parents did. Third, youth emphasized the importance of social relationships and opportunities to connect with peers through shared interests.What do these findings add to what was already known?: We learned that standard questions about transition may not reflect how autistic youth and their parents think about becoming an adult. Interviewing families coming out of a predominantly Black and low-income urban school district helped us to understand how these groups experience and think about the transition to adulthood, even though they did not use these identities as a logic for how they thought about young adulthood. This suggests that parent and youth perspectives differ in groups that are not usually well represented in research studies related to transition for autistic youth.What are potential weaknesses in the study?: This study only included a small number of youth and parents. These results do not represent all Black autistic youth or low-income autistic youth coming from urban school districts. Families who are less connected to services may have been less likely to hear about or take part in the study.How will these findings help autistic adults now or in the future?: These findings could inform the development of better interviewing approaches and research to address the needs of diverse autistic youth entering adulthood. This work could improve transition support. Parents, youth, support providers, and researchers may think about adulthood differently. Improved support could help build mutual understanding and coordination around youths' and their families' goals.

Facilitating the inclusion of adults with intellectual disability as direct respondents in research: Strategies for fostering trust, respect, accessibility and engagement

BACKGROUND

Adults with intellectual disability experience disparities in social determinants of health and health outcomes. While new knowledge can advance health equity, adults with intellectual disability are frequently excluded from being direct respondents in research. Their inclusion requires addressing scientific and ethical challenges that contribute to their exclusion.

METHOD

We describe our multi-phased process, inclusive of community-engagement, to develop a self-report survey for adults with intellectual disability and share findings from an institutional ethnography conducted to identify strategies for facilitating inclusion. We also assessed indicators of the quality of these strategies.

RESULTS

We identified building trust, showing respect, designing in accessibility, maximising flexibility and allowing individualised accommodations as strategies that foster inclusion. Multiple indicators validate the effectiveness of these strategies.

CONCLUSIONS

Researchers can promote first-person decision-making and direct research participation by focusing on promoting accessibility, trust, respect and engagement.

Advancing the Personalization of Assessment and Intervention in Autistic Adolescents and Young Adults by Targeting Self-Determination and Executive Processes

As autistic adolescents and young adults navigate the transition to adulthood, there is a need to partner with them to identify strengths and needed supports to enable goal-directed actions. This article conceptually integrates research on self-determination, defined by Causal Agency Theory, and executive processes in autism to provide direction for future research and practice. We describe how integrating research on self-determination and executive processes could enable autistic adolescents and young adults to be engaged in the process of assessing executive processes and self-determination. We discuss how this can better inform personalization of supports for self-determination interventions by focusing on support needs related to executive processes, including inhibitory control and cognitive flexibility, from a strengths-based perspective. We discuss how this can enable self-determination interventions that promote outcomes aligned with the values of the autistic community.

Health and Access to Health Services for People with Disability in Australia: Data and Data Gaps

The right of people with disability to enjoyment of the highest attainable standard of health without discrimination on the basis of disability is enshrined in the United Nations Convention on the Rights of Persons with Disabilities (CRPD). Among its obligations as a signatory to the CRPD, Australia is required to collect appropriate information, including statistical and research data, to inform development and implementation of policies to give effect to the Convention. In this commentary, we first describe how the International Classification of Functioning, Disability and Health (ICF) conceptual model of disability can be operationalised in statistical data collections, with a focus on how this is achieved in key Australian data sources such that people with disability can be identified as a population group. We then review existing statistical data on health and health service use for people with disability in Australia, highlighting data gaps and limitations. Finally, we outline priorities and considerations for improving data on health and access to health services for people with disability. As well as conceptual, practical, and ethical considerations, a key principle that must guide future disability data development is that people with disability and their representative organisations must be involved and participate fully in the development of disability data and statistics, and in their use.

A survey study of the attitudes and experiences of adults with intellectual disability regarding participation in research

BACKGROUND

Historically, people with intellectual disability have been exploited in and excluded from scientific research. To facilitate greater representation of adults with intellectual disability as research respondents, we sought to understand their interest in research participation and factors affecting their willingness to volunteer to participate, such as the core value of trust.

METHODS

Our survey measured attitudes of adults with intellectual disability towards research in general and research specifically involving adults with intellectual disability as respondents, as well as their prior research experiences, trust of researchers and interest in future research participation.

RESULTS

Participants reported positive attitudes towards research and strong interest in future participation opportunities, and trust of researchers was positively correlated to both. The belief that 'research about adults with intellectual disability is very important' also predicted participants' interest in future research participation.

CONCLUSIONS

Our findings indicate that adults with intellectual disability support the direct involvement of adults with intellectual disability in research as respondents. Trustworthy rapport with researchers and positive views about research foster greater inclusion of this population.

Parental perspectives on research for Down syndrome

BACKGROUND

Down syndrome is the most common genetic disorder associated with intellectual and developmental disabilities. Research to improve health care outcomes in Down syndrome lags significantly behind other disease categories. Among these reasons are funding, recruitment and availability of research studies being conducted.

METHODS

We surveyed 228 parents of individuals with Down syndrome to understand their perceptions of research, study design, how they seek out information and topics they would like to see researched.

RESULTS

Parents with children 18 years and younger responded to our survey. Parents indicated their willingness to participate in research (72%), yet few have (36%). Parents identified barriers to participation, research they feel would help their child, and interests in seeing new therapies and drug studies.

CONCLUSION

These findings identify recommendations and insights from parents on future research agendas, studies and recruitment strategies that may help researchers improve outcomes for individuals with Down syndrome.

Decisional Capacity for Informed Consent in Males and Females with Fragile X Syndrome

Although informed consent is critical for all research, there is increased ethical responsibility as individuals with intellectual or developmental disabilities (IDD) become the focus of more clinical trials. This study examined decisional capacity for informed consent to clinical trials in individuals with fragile X syndrome (FXS). Participants were 152 adolescents and adults (80 males, 72 females) with FXS who completed a measure of decisional capacity and a comprehensive battery of neurocognitive and psychiatric measures. Females outperformed males on all aspects of decisional capacity. The ability to understand aspects of the clinical trial had the strongest association with the ability to appreciate and reason about the decision. Scaffolding improved understanding, suggesting researchers can take steps to improve decisional capacity and the informed consent process.

Incidence and prevalence of falls in adults with intellectual disability living in the community: a systematic review

OBJECTIVE

The objective of the review was too synthesize the best available evidence on the incidence and prevalence of falls among adults with intellectual disability (ID).

INTRODUCTION

Falls among adults with ID frequently cause physical injury and may negatively impact on their quality of life. Studies investigating falls among people with ID have used differing methods and populations, making it difficult to determine the scope and extent of this problem.

INCLUSION CRITERIA

This review considered all studies that included adults with ID aged 18 years and over and which reported percentage/numbers of individuals who fell, and the total number of falls and injurious falls sustained from a fall. Studies were included if they were conducted within community or residential settings. Studies that were conducted in hospitals were excluded. Cohort studies, case-control and cross-sectional studies were included. Studies that used an experimental design, both randomized controlled and quasi experimental design, were also included.

METHODS

A three-step search strategy was undertaken for published and unpublished literature in English from 1990 to 2017. An initial search of MEDLINE and CINAHL was undertaken before a more extensive search was conducted using keywords and index terms across 11 electronic databases. Two independent reviewers assessed the methodological quality of the included studies using the Joanna Briggs Institute standardized critical appraisal instrument for prevalence studies (Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data).Data was extracted using the Joanna Briggs Institute's standardized extraction tool. Data that directly reported or could be used to calculate the incidence and prevalence of falls were extracted. Quantitative data for the number (proportion) of people who fell were pooled in statistical meta-analysis using STATA version 14 (Stata Corp LLC, Texas, USA). Data measuring incidence of falls (rate of falls for the duration of the study) and incidence of injurious falls (rate of falls resulting in one or more injuries for the duration of the study) could not be pooled in meta-analysis, hence results have been presented in a narrative form including tables. Standard GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence assessment of outcomes is also reported.

RESULTS

Nine studies were eligible for inclusion in this review. Eight articles were observational cohort studies which reported on the incidence/prevalence of falls as outcome measures, and one article was a quasi-experimental study design. Overall the methodological quality of the included studies was considered moderate. The pooled proportion of people with ID who fell (four studies, 854 participants) was 39% (95% CI [0.35%-0.43%], very low GRADE evidence). The rate of falls (eight studies, 782 participants) ranged from 0.54 to 6.29 per person year (very low GRADE evidence). The rate of injurious falls (two studies, 352 participants) ranged from 0.33 to 0.68 per person year (very low GRADE evidence).

CONCLUSIONS

Synthesized findings demonstrate that people with ID, who live in community or residential settings, may fall more frequently, and at a younger age, compared to general community populations. Studies should take a consistent approach to measuring and reporting falls outcomes. Further research is recommended to identify the impact of falls on health related outcomes for people with ID and subsequently evaluate falls interventions for their efficacy.

Ethical, Legal, and Social Issues Related to the Inclusion of Individuals With Intellectual Disabilities in Electronic Health Record Research: Scoping Review

Background

Data from electronic health records (EHRs) are increasingly used in the field of genetic research to further precision medicine initiatives. However, many of these efforts exclude individuals with intellectual disabilities, which often stem from genetic conditions. To include this important subpopulation in EHR research, important ethical, legal, and social issues should be considered.

Objective

The goal of this study was to review prior research to better understand what ethical, legal, and social issues may need further investigation when considering the research use of EHRs for individuals with genetic conditions that may result in intellectual disability. This information will be valuable in developing methods and best practices for involving this group in research given they are considered a vulnerable population that may need special research protections.

Methods

We conducted a scoping review to examine issues related to the use of EHRs for research purposes and those more broadly associated with genetic research. The initial search yielded a total of 460 unique citations. We used an evaluative coding process to determine relevancy for inclusion.

Results

This approach resulted in 59 articles in the following areas: informed consent, privacy and security, return of results, and vulnerable populations. The review included several models of garnering informed consent in EHR or genetic research, including tiered or categorical, blanket or general, open, and opt-out models. Second, studies reported on patients’ concerns regarding the privacy and security of EHR or genetic data, such as who has access, type of data use in research, identifiability, and risks associated with privacy breach. The literature on return of research results using biospecimens examined the dissension in the field, particularly when sharing individualized genetic results. Finally, work involving vulnerable populations highlighted special considerations when conducting EHR or genetic research.

Conclusions

The results frame important questions for researchers to consider when designing EHR studies, which include individuals with intellectual disabilities, including appropriate safeguards and protections.

Using video vignettes in research and program evaluation for people with intellectual and developmental disabilities: A case study of the Leadership for Empowerment and Abuse Prevention (LEAP) project

People with intellectual and developmental disabilities (IDD) are often excluded from meaningful participation in research and program evaluation for various reasons, including protocols and measures that are inaccessible for people with varying cognitive and communication abilities. Emancipatory research models emphasize the importance of inclusive research practices. Video vignettes are a promising tool for research and program evaluation with people with IDD because they are standardized, they use visual imagery rather than relying on written or verbal communication, and they allow for distance from sensitive topics. The Leadership for Empowerment and Abuse Prevention (LEAP) project used video vignettes to evaluate a healthy relationship program for people with IDD. The authors discuss the process of piloting various protocols and measures, which then ultimately led to the use of video vignettes in the evaluation.

Partnership with social care professionals as a context for promoting self-determination among people with intellectual disabilities

BACKGROUND

People with intellectual disabilities who live in residential facilities may need social support to express self determination. Relationships with social care professionals provide an important context for promoting self-determination. Adopting a socioecological perspective, our study aimed to better understand the nature of these relationships.

METHOD

Over a period of ten months, we held 13 focus group discussions with a total of 20 participants, including both residents and staff at facilities for people with intellectual disabilities. Using transcripts of these discussions, we analysed expressions of self-determination among people with intellectual disabilities and the responses of social care professionals.

RESULTS

Our results highlight the importance of relational adjustment in fostering self-determination among people with intellectual disabilities and underline the importance of respective roles within relationships between people with intellectual disabilities and social care professionals.

CONCLUSION

The partnership between people with intellectual disabilities and professionals seems to be the most effective type of relationship in order to support the self-determination of people with intellectual disabilities. This paper provides a fresh perspective on the role played by people with intellectual disabilities in their relationships with social care professionals. By engaging people with intellectual disabilities as partners in fostering self-determination, social care professionals can encourage social participation and feelings of empowerment. Relationships based on partnership offer people with intellectual disabilities a form of hetero-regulation that can help them overcome challenges to behaving in a fully self-determined way. However, partnership also requires changes in professional practices and attitudes.

Aging With Intellectual Disabilities in Families: Navigating Ever-Changing Seas-A Theoretical Model

Life expectancy is increasing for people with intellectual disability, many of whom live with family. While there has been research about aging and future planning, there is limited evidence about the characteristics of the caregiving relationship. The aim of this study was to examine perspectives of caregiving for older people with intellectual disability and their family. A constructivist grounded theory approach was used, and 19 people with intellectual disability and 28 family members were interviewed. Caregiving was informed by transitions across the life course. Three interrelated concepts, Riding the Waves, Shifting Sands-Changing Tides, and Uncovering Horizons comprise the core components of the theoretical model-Navigating Ever-Changing Seas. This model informs complex, trans-generational relationships that impact decision-making for people with a long-term condition. Applications within health care indicate a need for systems to include individuals and their networks of care in policy, practice, research, and service delivery across the lifespan.

Perceptions of ageing and future aspirations by people with intellectual disability: a grounded theory study using photo-elicitation

Internationally, 1 per cent of the general population are living with an intellectual disability and life expectancy is increasing in line with global trends. The majority of people with an intellectual disability live with family. This represents a growing and largely ‘hidden’ population who have, or will have, additional needs as they and their family age. There is limited research about what is important for people with intellectual disability when thinking about getting older. This article reports on a study which explored the concept of ageing and future aspirations with 19 people living with an intellectual disability, aged 37–58 years of age (mean 48 years) and living with someone they identify as family. Using Charmaz's constructivist grounded theory approach and photo-elicitation, constant comparative analysis generated four themes: reciprocating relationships, emerging (in)dependence, configuring ageing and entertaining possibilities. As part of the interview process, photo-elicitation facilitated the expression of associations and perspectives about ageing and conceptualising the future for participants. The findings demonstrate the engagement of people with intellectual disabilities in research and provided unique insights into both their experiences and perspectives on ageing in the context of family. The need for greater flexibility in service planning and delivery are identified, alongside ensuring the meaningful inclusion of people with intellectual disability in decision-making about their own lives as they age.

Adjusting a mainstream weight management intervention for people with intellectual disabilities: a user centred approach

Background

People with intellectual disabilities (ID) may not be able to access and respond to uniformly delivered health interventions. Public bodies have a legal duty to make ‘reasonable adjustments’ to policies and practices to provide fair access and treatment for people with ID. This study aimed to identify adjustments to the Slimming World weight management programme to improve accessibility and assess acceptability and feasibility for this population.

Methods

This user-centred qualitative study was carried out with a steering group of people with ID (n = 4). Barriers and facilitators to using Slimming World were identified through interviews and focus groups with people with ID (n = 54), carers (n = 12) current members with ID (n = 8) and Slimming World group leaders (n = 11). Adjustments were made and their feasibility and acceptability were explored in a before-and-after mixed methods study where people with ID attended Slimming World for eight weeks. Participants (n = 9), carers (n = 7) and Slimming World group leaders (n = 4) were interviewed to explore their experiences of the adjustments. Participants were weighed at baseline then each week.

Results

Four key adjustments were identified and addressed by Slimming World who developed prototype Easy Read materials and a letter for carers. Six of the nine participants attended Slimming World for eight weeks and lost weight (1.4 kg to 6.6 kg, reduction in BMI between 0.5 and 1.7 kg/m2), indicating that the adjustments were feasible and acceptable. Two participants dropped out because they felt uncomfortable in a mainstream group and another left because they lacked control over food choice in their residential setting.

Conclusions

This user-centred approach identified reasonable adjustments that were feasible to implement. In a small uncontrolled feasibility study, people with ID were positive about the adjustments and lost weight. However, issues in the wider context of people’s lives, such as obesogenic environments and concerns about joining mainstream groups, limited the acceptability of Slimming World even with these adjustments. These findings have important implications for policy and suggest that environmental and organisational level interventions are needed alongside those targeting individual behaviour to tackle the obesogenic environment in which many people with ID spend their time, in order to reduce inequalities associated with the consequences of obesity.

The POMONA-ESP project methodology: Collecting data on health indicators for people with intellectual developmental disorders

BACKGROUND

People with intellectual developmental disorders have significant health disparities and a lack of proper attention to their health needs. They have been underrepresented in scientific research, and very few studies have been carried out using a representative randomized sample. The aim of this study was to describe the methods used in the POMONA-ESP project to recruit a representative and randomized sample of participants with intellectual developmental disorders.

METHODS

The POMONA-ESP project is an observational cross-sectional study. It aims to explore the health status of people with intellectual developmental disorders across Spain and the use they make of health services.

RESULTS AND CONCLUSIONS

The results of the POMONA-ESP project may have a major impact on people with intellectual developmental disorders and society in general. It is the first study to obtain geographically representative epidemiological data from a large sample, information that is fundamental to improving care and healthcare planning for people with intellectual developmental disorders.

A systematic review of the methodological and practical challenges of undertaking randomised-controlled trials with cognitive disability populations

Approximately 10% of the world's population have a cognitive disability. Cognitive disabilities can have a profound impact on a person's social, cognitive or mental functioning, requiring high levels of costly health and social support. Therefore, it is imperative that interventions and services received are based upon a sound evidence-base. For many interventions for this population, this evidence-base does not yet exist and there is a need for more Randomised Controlled Trials (RCTs). The process of conducting RCTs with disabled populations is fraught with methodological challenges. We need a better understanding of these methodological barriers if the evidence-bases are to be developed. The purpose of this study was to explore the methodological and practical barriers to conducting trials with adults with cognitive disabilities. As a case example, the literature regarding RCTs for people with intellectual disabilities (ID) was used to highlight these pertinent issues. A systematic literature review was conducted of RCTs with adults with ID, published from 2000 to 2017. A total of 53 papers met the inclusion criteria and were reviewed. Some of the barriers reported were specific to the RCT methodology and others specific to people with disabilities. Notable barriers included; difficulties recruiting; obtaining consent; resistance to the use of control groups; engaging with carers, staff and stakeholders; the need to adapt interventions and resources to be disability-accessible; and staff turnover. Conducting RCTs with people with cognitive disabilities can be challenging, however with reasonable adjustments, many of these barriers can be overcome. Researchers are not maximising the sharing of their experience-base. As a result, the development of evidence-bases remains slow and the health inequities of people with disabilities will continue to grow. The importance of the MRC guidelines on process evaluations, together with implications for the dissemination of 'evidence-base' and 'experience-base' are discussed.

A quantitative study of attitudes toward the research participation of adults with intellectual disability: Do stakeholders agree?

BACKGROUND

Attitudes toward the research participation of adults with intellectual disability inform research policy and practice, impact interest in and support for research participation, and promote or discourage the generation of new knowledge to promote health among adults with intellectual disability. Yet we know little about these beliefs among the public and the scientific community.

OBJECTIVE/HYPOTHESIS

We quantitatively studied attitudes among adults with intellectual disability, family and friends, disability service providers, researchers, and Institutional Review Board (IRB) members. We predicted that adults with intellectual disability, and researchers would espouse views most consistent with disability rights, whereas IRB members, and to a lesser degree family, friends, and service providers, would espouse more protective views.

METHODS

We surveyed five hundred and twelve members of the five participant stakeholder groups on their attitudes toward the research participation of adults with intellectual disability.

RESULTS

We found broad support for research about people with intellectual disability, though slightly more tempered support for their direct participation therein. In general, IRB members and to some extent adults with intellectual disability endorsed direct participation less than others. We also found that adults with intellectual disability strongly believed in their consent capacity.

CONCLUSIONS

Resources should be directed toward health-related research with adults with intellectual disability, and interventions should be pursued to address ethical challenges and promote beliefs consistent with human rights.

What's the Harm? Harms in Research With Adults With Intellectual Disability

Scientific advances can improve the lives of adults with intellectual disability, yet concerns that research participation may impose harm impede scientific progress. What counts as harmful can be subjective and perceptions of harm may vary among stakeholders. We studied perspectives on the harmfulness of research events among adults with intellectual disability, family members and friends, disability service providers, researchers, and Institutional Review Board members. We found considerable variance. For example, adults with intellectual disability see exclusion from research as more harmful, but most psychosocial harms as less significant than others. All stakeholders agree that having someone else make the participation decision is harmful. Findings provide insights into the concept of harm and ethical research with adults with intellectual disability.

Is It Worth It? Benefits in Research With Adults With Intellectual Disability

Including adults with intellectual disability in research promotes direct benefits to participants and larger societal benefits. Stakeholders may have different views of what count as benefits and their importance. We compared views on benefits in research with adults with intellectual disability among adults with intellectual disability, family and friends, service providers, researchers, and institutional review board members. We found that adults with intellectual disability value direct and indirect research benefits, and want to participate in research that offers them. Other stakeholders generally see less value in direct benefits and predict more tempered interest in research participation as compared to adults with intellectual disability. To promote respectful research participation, research policy and practice should incorporate the views of adults with intellectual disability.

Complexity in programme evaluations and integration studies: what can it tell us?

Purpose

Complexity received increasing attention from researchers in integration and evaluation studies. Complex adaptive systems are the most prominent formulation of complexity used in programme evaluations. However, there remain significant theoretical and conceptual barriers to using complexity as an explanatory model in social sciences, and thus in applying it successfully in integration and evaluation studies. The paper aims to discuss these issues.

Design/methodology/approach

Discussion paper outlining the potential uses and risks of complexity theory for studying integration programmes in health and social care and programme evaluations in general. The paper proceeds by synthesising the work of various critics and proponents of complexity theory in the social sciences and evaluation theory.

Findings

Complexity offers opportunities and risks to social scientists working in programme evaluations and integration studies. The opportunities are defined by additional modelling and verification/falsification of possible cause and effect links in programme settings. The risks, on the other hand, are twofold. Social scientists may use complexity as a shorthand for as yet insufficient understanding of the contexts under examination, or they mistake it for an explanatory device without testing its potential to explain. The second risk emerges as a result of the nature of complexity and its role in natural sciences. Assigning complexity an explanatory role may prevent further investigation of a given setting that may reveal that complexity is insufficient to understand what is going on.

Originality/value

Researchers should make clear how they have operationalised and measured the various features of the complexity model to allow robust verification of the evidence. Scholars should also assume that complexity as defined by the natural sciences is philosophically and epistemologically problematic when transferred into the realm of social sciences that largely operate with concepts informed by the paradigm of understanding social behaviour.

Is Safety in the Eye of the Beholder? Safeguards in Research With Adults With Intellectual Disability

Human subjects research has a core commitment to participant well-being. This obligation is accentuated for once exploited populations such as adults with intellectual disability. Yet we know little about the public's views on appropriate safeguards for this population. We surveyed adults with intellectual disability, family members and friends, disability service providers, researchers, and Institutional Review Board (IRB) members to compare views on safeguards. We found many points of convergence of views, particularly for decision-making and participation. One trend is that adults with intellectual disability perceive greater safety in being engaged directly in recruitment, and recruitment by specific individuals. Researchers and IRB members need to consider community views to facilitate the safe and respectful inclusion of adults with intellectual disability.

Mental health inpatient experiences of adults with intellectual disability

This paper presents findings from a study exploring the mental health inpatient care of people with a dual disability of intellectual disability and mental health issues from the perspective of those people with the dual disability. A mixture of semi-structured interviews and focus group interviews were carried out with nine participants who had been admitted to an inpatient unit for mental health care exploring their experience of care. Interviews were transcribed and analyzed using open coding and Leximancer (an online data mining tool) analysis to identify dominant themes in the discourse. Analysis revealed themes around 'Therapeutic and Meaningful Activity', 'Emotion Focussed Care', and 'Feeling Safe?' Participants were able to identify the aspects of inpatient care that worked for them in terms of coping with time in hospital. This research suggests that there are several factors that should be considered in providing effective mental health inpatient care for people with dual disability. A number of strategies and recommendations for responding to their needs are identified and discussed.

"You can't be cold and scientific": community views on ethical issues in intellectual disability research

Perceptions, attitudes, and ethical concerns related to conducting research with adults with intellectual disability hinder scientific innovation to promote health. Yet we lack an understanding of community views on effective research policy and practice. To address this knowledge void, we qualitatively studied the views of adults with intellectual disability and those who provide them support regarding research participation of adults with intellectual disability. We found substantial support for their inclusion, particularly given the possibility of benefits to adults with intellectual disability, researchers, and society. We also found concerns for potential harm and differing ideas on how to promote safety. Our findings emphasize the importance of their inclusion in research, and the need for policies and practices that promote respect and safety.

Research participation by people with intellectual disability and mental health issues: an examination of the processes of consent

Balancing the demands of research and ethics is always challenging, and even more so when recruiting vulnerable groups. Within the context of current legislation and international human rights declarations, it is strongly advocated that research can and must be undertaken with all recipients of health-care services. Research in the field of intellectual disability presents particular challenges in regards to consenting processes. This paper is a reflective overview and analysis of the complex processes undertaken, and events that occurred in gaining informed consent from people with intellectual disability to participate in a study exploring their experiences of being an inpatient in mental health hospitals within Aotearoa/New Zealand. A framework based on capacity, information, and voluntariness is presented, with excerpts from the field provided to explore consenting processes. The practical implications of the processes utilized are then discussed in order to stimulate debate regarding clearer and enhanced methods of gaining informed consent from people with intellectual disability.

Participatory research, people with intellectual disabilities and ethical approval: making reasonable adjustments to enable participation

AIMS AND OBJECTIVES

The aim of this paper is to explore how making reasonable adjustments to the process of securing ethical approval for research can facilitate the meaningful involvement of people with intellectual disabilities as members of a research team. This is achieved through critical reflection upon the approach taken within one participatory research study whose objective was to explore how people with intellectual disabilities understand abuse.

BACKGROUND

Internationally participatory research studies (in which active involvement of community members in all stages of the research process is sought) are becoming increasingly common in the context of health care and, more specifically, within research involving people with intellectual disabilities. However, whilst it is acknowledged that participatory research gives rise to specific ethical challenges, how (or if) involvement in securing ethical approval is facilitated, is not discussed in most research reports. The significance of this paper is that it seeks to address this gap by exploring how meaningful participation can be promoted by making reasonable adjustments.

METHODS

Within the study, the research team worked in collaboration with the ethics committee to identify potential barriers that could prevent the participation of members of the research team who had intellectual disabilities. Reasonable adjustments (such as redesigning forms) were made to the processes involved in securing ethical approval.

CONCLUSIONS

This study demonstrated that it is possible to ensure that ethical standards are upheld and the requirements of ethics committees met whilst also facilitating the meaningful involvement of people with intellectual disabilities.

RELEVANCE TO CLINICAL PRACTICE

The reasonable adjustments approach explored within this paper can be translated into the context of clinical practice: making changes to the way that services are delivered can promote greater involvement of people with intellectual disabilities in their own health care.

Where are persons with intellectual disabilities in medical research? A survey of published clinical trials

BACKGROUND

Persons with intellectual disabilities (ID) are exposed to the same medical interventions as everyone else. Given the unique health profiles of many persons with ID, it cannot be assumed that they will react to medical treatments the same as persons without ID. It is not clear if medical clinical trials routinely include persons with ID. The purpose of this research survey was to examine the inclusion of persons with ID in medical research trials, and to determine whether accommodations and/or study modifications could have been made to promote greater inclusion in medical research.

METHOD

Three hundred randomised control and clinical trials published between 2007 and 2011 in the six highest impact medical journals were randomly selected. Each study was reviewed for inclusion of persons with ID, and possible accommodations that could have been put in place without compromising research integrity. Corresponding authors received a follow-up survey to determine whether persons with ID were included, but were not mentioned in the article.

RESULTS

Only 6 (2%) of 300 randomly chosen studies clearly included persons with ID. Over 90% of studies were designed in ways that would automatically exclude persons with ID from participating. The author survey revealed three additional studies including persons with ID. Most persons with ID could have participated in at least 70% of the studies with simple accommodations and/or minor procedural modifications.

DISCUSSION

The findings highlight the exclusion of persons with ID in medical research. Efforts are needed to increase inclusion through research policy initiatives and education.

Paradigm shifts in disability and health: toward more ethical public health research

Disability is often considered a health outcome disproportionately experienced by minority groups. It is also possible to view people with disabilities as a minority group that itself experiences health disparities. Calls to reduce these disparities necessitate the inclusion of people with developmental disabilities in research, although resulting ethical issues can thwart scientific progress. Using disability rights principles can help address ethical challenges and promote safe, respectful public health research. Examples include applying human rights frameworks, providing accommodations, attending to power, countering legacies of deficits-based models of disability, and transforming access to science more broadly. Collectively, these strategies can encourage broader engagement in safe, respectful, inclusive public health research aimed at promoting the health and well-being of people with developmental disabilities.

Assessing Understanding and Obtaining Consent from Adults with Intellectual Disabilities for a Health Promotion Study

People with intellectual disabilities are often excluded from research, in part because they may be perceived as lacking capacity to provide informed consent. A requirement of informed decision making about research participation is ability to understand the study description and disclosures presented during the consent process. The authors' aims were to determine the extent to which study participants with intellectual disabilities were able to answer questions about key aspects of study disclosures, identify ways in which people who provided appropriate answers for all of the questions differed from those who had difficulty with one or more of the questions, and examine patterns of responses to see if certain issues were more difficult to understand than others. The authors piloted a short set of questions to assess the extent to which adults with intellectual disabilities were able to answer questions about key aspects of a health promotion study. More than half of study participants correctly answered all of the questions. For those not able to answer all questions, identifying potential risks of being in the study proved the most challenging. The findings indicate that many people with intellectual disabilities likely can provide their own consent to participate in low risk studies.

'You need to let your voice be heard': research participants' views on research

BACKGROUND

Persons with intellectual and developmental disabilities have had regrettably few opportunities to voice their opinions on aspects of research with which they have had direct experience. Understanding and responding to these views can contribute to policies and practices that increasingly treat people as they desire to be treated.

METHODS

We conducted individual interviews and focus groups with 16 adults with intellectual and developmental disabilities to examine their perspectives on participating in research.

RESULTS

Our analysis indicates that adults with intellectual and developmental disabilities want to engage in research to improve their quality of life and to have greater access to a worthwhile activity through more active participation. Our results also highlight trust as a critical ingredient in the success of research with this group.

CONCLUSIONS

Our findings suggest that despite ethical challenges, researchers can and should pursue research that has the potential to improve the lives of persons with intellectual and developmental disabilities. Such research is more likely to be both ethical and successful if researchers pay attention to enhancing autonomy and person-centredness, while at the same time engendering participant trust.

"We want respect": adults with intellectual and developmental disabilities address respect in research

Respect is central to ethical guidelines for research. The scientific community has long debated, and at times disagreed on, how to demonstrate respect in research with adults with intellectual and developmental disabilities. To illuminate the voices of those most affected, the author studies the views of adults with intellectual and developmental disabilities on respect in research. Findings are consistent with disability rights' ideas and indicate that adults with intellectual and developmental disabilities have much to contribute to the discussion, that they value participating, and that they agree with calls to focus on human rights and dignity. Notably, participants spoke at lengths about the nature of interactions between researchers and participants. Implications are discussed, including how to infuse research standards with community-supported values and preferences.