Trauma‐informed care: A qualitative study exploring the views and experiences of professionals in specialist health services for adults with intellectual disabilities

Mental Health Services for Adults With Intellectual Disabilities: A Qualitative Study of Patient Characteristics, Associated Factors and Consequent Needs for Adaptation in Assessment and Treatment

BACKGROUND

Individuals with intellectual disabilities are at increased risk of mental health disorders, but may struggle to access appropriate services. While assessment/treatment may need to be adapted, knowledge is limited about what such adaptations may entail.

METHOD

During a service development project, the participants (33 professionals, 13 family members) were asked to identify the characteristics/associated factors of individuals with intellectual disabilities and co-occurring mental health disorders. Using thematic analysis, 1103 participant responses were analyzed to identify the needs for adaptation in assessment/treatment.

RESULTS

Three core themes were identified: (1) A broader assessment: Gaining an accurate and comprehensive understanding of the individual's history, abilities and difficulties, (2) Adjusting/modifying existing treatment strategies, (3) Ensuring that the individual's day-to-day needs are met.

CONCLUSIONS

According to the participants, assessment/treatment of mental health disorder in this population requires more time and broader assessments are necessary. Family/caregiver involvement and cross-service organisation/collaboration represent other important adaptations.

Trauma-informed counseling for individuals who have an intellectual developmental disorder: Considerations for mental health counselors

Individuals with an intellectual developmental disorder are four times more likely to have a co-occurring mental health diagnosis, as compared to the general population, and 60%-80% of individuals with IDDs have experienced at least one form of abuse. However, counselors receive little training to adequately help this population. In this article, counseling considerations related to individuals who have intellectual development disorder are discussed, with a particular focus on the presence of trauma in this population. Trauma-focused treatment, potential mental health issues, counseling considerations, general issues related to counseling this population, and common associated mental health experiences among this population are addressed. Specific evidence-based counseling approaches, modifications to counseling, and best practices that can be helpful when counseling this population are presented. Due to the unique challenges that individuals with IDDs face, it is essential that counselors address the counseling and mental health needs of this population.

A call for trauma-informed dental care for individuals with intellectual disabilities

People with intellectual disabilities are at increased risk of dental anxiety and poor oral health. In addition, people with intellectual disabilities are at increased risk of potentially traumatic experiences, such as violence and sexual abuse, and appear to be more vulnerable to developing trauma-related disorders following such experiences. While psychological trauma is associated with poor oral health and dental anxiety in the general population, the potential link between dental anxiety, poor oral health and psychological trauma is yet to be explored in people with intellectual disabilities. In this conceptual paper, we provide an overview of recent findings concerning the relationships between oral health and intellectual disabilities, psychological trauma and intellectual disabilities, as well as between psychological trauma and oral health, and discuss the relevance of these findings related to dental care for people with intellectual disabilities. We conclude that psychological trauma is likely to contribute to dental anxiety and poor oral health also in people with intellectual disabilities. Implications include an urgent need for research exploring how trauma affects oral health and experiences of dental care for people with intellectual disabilities, as well as the importance of individualized and trauma-informed dental care for these individuals.

Bias in assessment of co-occurring mental disorder in individuals with intellectual disabilities: Theoretical perspectives and implications for clinical practice

Influence from bias is unavoidable in clinical decision-making, and mental health assessment seems particularly vulnerable. Individuals with intellectual disabilities have increased risk of developing co-occurring mental disorder. Due to the inherent difficulties associated with intellectual disabilities, assessment of mental health in this population often relies on a different set of strategies, and it is unclear how these may affect risk of bias. In this theoretical paper, we apply recent conceptualisations of bias in clinical decision-making to the specific challenges and strategies in mental health assessment in intellectual disabilities. We suggest that clinical decision-making in these assessments is particularly vulnerable to bias, including sources of bias present in mental health assessment in the general population, as well as potential sources of bias which may be specific to assessments in this population. It follows that to manage potential bias, triangulating information from multi-informant, multi-method, interdisciplinary assessment strategies is likely to be necessary.

Post-traumatic stress disorder and experiences involving violence or sexual abuse in a clinical sample of autistic adults with intellectual disabilities: Prevalence and clinical correlates

LAY ABSTRACT

Post-traumatic stress disorder is a mental health disorder that may be triggered by the experience of events perceived as terrifying or overwhelming. Examples of such events include being the victim of violence or sexual abuse. Compared with other people, autistic people have increased risk of being exposed to violence or sexual abuse. In addition, autistic people may be more vulnerable to developing post-traumatic stress disorder following such exposure. However, knowledge is limited concerning the prevalence of experiences involving violence and sexual abuse, and post-traumatic stress disorder, in autistic people with co-occurring intellectual disabilities. Detection of these experiences, and identification of post-traumatic stress disorder, may be challenging in these individuals, and previous research indicates that post-traumatic stress disorder symptoms may be overlooked or misinterpreted. In this study, we examined prevalence of post-traumatic stress disorder, violence and sexual abuse in a clinical sample of 88 autistic adults with intellectual disabilities referred for mental health assessment. Only 3.4% were diagnosed with post-traumatic stress disorder, even if experiences involving violence (34.1%) or sexual abuse (17.0%) were common. Anxiety and affective disorders were common diagnoses among participants with these experiences. Controlling for autism characteristics, level of intellectual disability and communication skills, experiences of violence/sexual abuse were found to be associated with a measure of 'challenging' behaviours. These results indicate that potentially traumatic experiences are common in autistic adults with intellectual disabilities referred for mental health assessment, and that post-traumatic stress disorder may be under-recognised. The findings highlight the importance of trauma screening and post-traumatic stress disorder assessment, as well as the importance of trauma-informed care, in this population.

Clinicians' experiences of learning to use eye movement desensitisation and reprocessing therapy with people with intellectual disabilities: A qualitative study

BACKGROUND

Eye Movement Desensitisation and Reprocessing therapy (EMDR) is a NICE recommended treatment for post-traumatic stress disorder within the general population. Ongoing research is now investigating the use of EMDR for individuals with intellectual disability. Alongside quantitative research efforts, it is beneficial to explore the qualitative experience of clinicians adopting EMDR in their practice. The current study interviewed newly trained EMDR therapists working in intellectual disability services.

METHOD

Participants (six Clinical Psychologists from an NHS learning disability service) had recently undertaken EMDR training as part of a wider randomised control trial (Trauma-AID). Interviews were qualitatively analysed using thematic analysis.

RESULTS

Three themes emerged; learning EMDR, conducting EMDR and external factors, with respect to clinicians' experiences.

CONCLUSIONS

Further research is needed to provide guidance and reassurance for clinicians currently using or hoping to use this therapy with people with intellectual disabilities.

"I am not a number!" Opinions and preferences of people with intellectual disability about genetic healthcare

There is limited research exploring the knowledge and experiences of genetic healthcare from the perspective of people with intellectual disability. This study, conducted in New South Wales (Australia), addresses this gap. Eighteen adults with intellectual disability and eight support people were interviewed in this inclusive research study. The transcribed interviews were analysed using inductive content analysis. The findings were discussed in a focus group with ten adults with intellectual disability and in three multi-stakeholder advisory workshops, contributing to the validity and trustworthiness of the findings. Five main themes emerged: (i) access to genetic healthcare services is inequitable, with several barriers to the informed consent process; (ii) the experiences and opinions of people with intellectual disability are variable, including frustration, exclusion and fear; (iii) genetic counselling and diagnoses can be profoundly impactful, but translating a genetic diagnosis into tailored healthcare, appropriate support, peer connections and reproductive planning faces barriers; (iv) people with intellectual disability have a high incidence of exposure to trauma and some reported that their genetic healthcare experiences were associated with further trauma; (v) recommendations for a more respectful and inclusive model of genetic healthcare. Co-designed point-of-care educational and consent resources, accompanied by tailored professional education for healthcare providers, are required to improve the equity and appropriateness of genetic healthcare for people with intellectual disability.

Trauma, intellectual and/or developmental disability, and multiple, complex needs: A scoping review of the literature

BACKGROUND

Trauma is a significant underlying factor in the multimorbidity of people with Intellectual and/or Development Disabilities (IDD). This relationship is further complicated by a growing recognition of a subset of multiply stigmatized individuals with an IDD and complex, intersecting health and social needs.

AIM

The aim of this review was to examine what is known about trauma and people with an IDD and complex needs, as defined by Community Living British Columbia's (CLBC) Multiple, Complex Needs (MCN) framework, through a broad review of relevant literature.

METHOD AND PROCEDURES

We conducted a scoping review of the peer-reviewed (9 disability journals; 7 academic databases) and grey (2 grey literature databases) on IDD and trauma through an inclusive approach that used search criteria drawn from the defining features of CLBC's MCN Framework.

OUTCOMES AND RESULTS

Apart from there being a limited amount of research on trauma and IDD, two key findings emerged. Through differing approaches that get at issues of trauma in different ways (i.e., through adverse life events or experiences of abuse), the first finding is that the research related to trauma and IDD is not cleanly linked together. The second is the focus on treatment services or interventions and not on what's happening at the organizational or system level.

CONCLUSION AND IMPLICATIONS

There is limited research on trauma and IDD making it even more important to unify the evidence that exists. However, the literature is not integrated across different theoretical and disciplinary perspectives. In addition, the focus of trauma-related research that is occurring is interventions at the individual versus system level. Also needed are studies that explore trauma-informed practice from an organizational or top-down perspective.

Trauma experiences of people with an intellectual disability and their implications: A scoping review

BACKGROUND

People with an intellectual disability are more vulnerable to psychological trauma compared with the general population. The aim of this scoping review was to identify the current status of the literature on trauma that is specific to the experiences of adults with an intellectual disability, living in community settings.

METHODS

A scoping review was conducted using the Arksey and O'Malley (International Journal of Social Research Methodology, 2005, 8, 19) framework. Forty-one international papers were reviewed spanning 2000-2020, and their quality assessed using the MMAT.

FINDINGS

(1) Aggressive behaviours can be symptoms of trauma, (2) there are appropriate assessment tools for the impact of trauma, (3) evidence-based interventions for trauma may be effective, and (4) factors associated with disability can be experienced as traumatic.

CONCLUSION

There is a growing body of literature highlighting assessment needs and potential interventions for people with an intellectual disability who have experienced psychological trauma. Further research is needed to develop trauma-informed pathways.

The association between challenging behaviour and symptoms of post-traumatic stress disorder in people with intellectual disabilities: a Bayesian mediation analysis approach

BACKGROUND

A preponderance of behavioural symptoms is assumed to be the main difference in the manifestation of symptoms of post-traumatic stress disorder (PTSD) in people with intellectual disability (ID). However, no study so far has assessed the relationship between challenging behaviour (CB) and PTSD. The present study aims to explore this relationship by exploring whether CB is directly related to trauma exposure or whether this relationship is mediated through core symptoms of PTSD.

METHODS

Trauma exposure and current symptoms of PTSD were assessed in 43 adults with mild to moderate ID. Parallel versions were administered to 43 caregivers, including the Aberrant Behaviour Checklist to measure CB. Bayesian mediation analyses were conducted using self-rated and informant-rated data.

RESULTS

The self-report data showed no associations of CB with trauma exposure or PTSD symptoms. The association between informant-rated trauma exposure and irritability was mediated by severity and frequency of PTSD symptoms. The associations between informant-reported trauma exposure and the Aberrant Behaviour Checklist subscales hyperactivity and inappropriate speech were mediated by PTSD symptom severity.

CONCLUSIONS

The relationship between trauma exposure and CB was mediated by PTSD symptoms. PTSD core symptoms should be considered as underlying causes of CB, highlighting the necessity to explore trauma biography and symptoms of PTSD. The improvement of self-report assessment in people with ID is an important task for future studies.

"If we do not look for it, we do not see it": Clinicians' experiences and understanding of identifying post-traumatic stress disorder in adults with autism and intellectual disability

BACKGROUND

Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) are at increased risk of potentially traumatic events and may be at increased risk of post-traumatic stress disorder (PTSD). However, knowledge regarding identification of PTSD in this population is limited. The aim of this study was to investigate clinical experience regarding PTSD and trauma assessment in individuals with co-occurring ASD and ID.

METHOD

Interpretative phenomenological analysis was used to explore experiences of identifying PTSD in this population among 18 mental health clinicians working with ASD and ID.

RESULTS

Informants viewed PTSD in individuals with ASD and ID as equivalent to PTSD in the general population, but with causes and expressions potentially differing. Several factors were described to contribute to challenges in identification.

CONCLUSIONS

Trauma may have severe impact in individuals with ASD and ID. Multidimensional, individualized assessment strategies seem necessary to recognize PTSD or trauma-related symptoms in this population.