What's Good About Inclusion? An Ethical Analysis of the Ideal of Social Inclusion for People with Profound Intellectual and Multiple Disabilities

'Social inclusion' is the leading ideal in services and care for people with intellectual disabilities in most countries in the Global North. 'Social inclusion' can refer simply to full equal rights, but more often it is taken to mean something like 'community participation'. This narrow version of social inclusion has become so ingrained that it virtually goes unchallenged. The presumption appears to be that there is a clear moral consensus that this narrow understanding of social inclusion is good. However, that moral consensus is not clear in the case of people with profound intellectual and/or multiple disabilities (PIMD), who are not able to express their needs and preferences verbally. Moreover, social inclusion has proven to be difficult to conceptualize and implement for people with PIMD. Therefore, it becomes imperative to ask about the ethical rationale of the narrow understanding of social inclusion. For what reasons do we think social inclusion is good? And do those reasons also apply for people with PIMD? This article addresses these questions by providing an ethical analysis of the ideal of social inclusion for people with PIMD. It discusses four ethical arguments for social inclusion and probes their relevance for people with PIMD. The article argues that none of these arguments fully convince of the value of the narrow understanding of social inclusion for people with PIMD. It ends with advocating for an ethical space for imagining a good life for people with PIMD otherwise.

Community Living, Intellectual Disability and Extensive Support Needs: A Rights-Based Approach to Assessment and Intervention

People with intellectual disability (ID) and extensive support needs experience poorer quality of life than their peers whose disability is not as severe. Many of them live in residential settings that limit community participation and prevent them from exercising control over their lives. This work analyzes the extent to which professional practices are aimed at promoting the right to community living for people with ID and extensive support needs, as well as the rights that are particularly linked to it, such as the right to habilitation and rehabilitation and the right to privacy. A specific questionnaire was designed and administered to 729 adults with intellectual disability (M = 37.05; DT = 12.79) living in different settings (family home, residential facilities and group homes). Measurement and structural models were estimated using exploratory structural equation modeling. Results obtained reveal that people with extensive support needs receive less support in terms of guaranteeing their right to independent living and privacy, especially when they live in disability-related services. This study highlights the need to implement and monitor, using valid and reliable indicators, mesosystem strategies that guarantee the right to live and participate in the community, especially for individuals with ID and extensive support needs.

Meta-analysis of deinstitutionalization adaptive behaviour outcomes: research and clinical implications

BACKGROUND

A meta-analysis examined the effects of deinstitutionalisation on adaptive behaviour outcomes in persons with intellectual disability. The need for an updated review in this area is reflected by recent policy shifts in community care practices and the international status of deinstitutionalisation efforts.

METHOD

Twenty-three studies were compared using standardised mean effect sizes across 5 demographic, 4 methodological, and 1 outcome variable.

RESULTS

Moderate habilitative gains were found in 75% of adaptive behaviour domains. A weighted linear multiple regression revealed that larger effect sizes were significantly predicted by sample size and research design. Disability level also moderated the extent to which sample size affected the magnitude of effect sizes.

CONCLUSIONS

These results are discussed in relation to the implications they have for community services for persons with intellectual disability. The difficulties in accurately comparing studies with dissimilar procedures and contexts are also outlined.

Meta-analysis of deinstitutionalisation adaptive behaviour outcomes: Research and clinical implications

Background A meta-analysis examined the effects of deinstitutionalisation on adaptive behaviour outcomes in persons with intellectual disability. The need for an updated review in this area is reflected by recent policy shifts in community care practices and the international status of deinstitutionalisation efforts. Method Twenty-three studies were compared using standardised mean effect sizes across 5 demographic, 4 methodological, and 1 outcome variable. Results Moderate habilitative gains were found in 75% of adaptive behaviour domains. A weighted linear multiple regression revealed that larger effect sizes were significantly predicted by sample size and research design. Disability level also moderated the extent to which sample size affected the magnitude of effect sizes. Conclusions These results are discussed in relation to the implications they have for community services for persons with intellectual disability. The difficulties in accurately comparing studies with dissimilar procedures and contexts are also outlined.

Outcomes in different residential settings for people with intellectual disability: a systematic review

Large-scale reviews of research in deinstitutionalization and community living were last conducted about 10 years ago. Here we surveyed research from 1997 to 2007. Articles were included if the researchers based the study on original research, provided information on the participants and methodology, compared residential arrangements for adults with intellectual disability, and were published in English-language peer-reviewed journals. Sixty-eight articles were found. In 7 of 10 domains, the majority of studies show that community-based services are superior to congregate arrangements. These studies provide more evidence of the benefits of deinstitutionalization and community living and continue to indicate variability in results, suggesting that factors other than the basic model of care are important in determining outcomes.

Stress and burnout amongst professional carers of people with intellectual disability: another health inequity

PURPOSE OF REVIEW

This paper summarizes trends in the research literature about stress and burnout in the lives of people who are the professional carers of people with intellectual disability. The principal time period considered was from 2004 to 2006.

RECENT FINDINGS

Studies reviewed here focus on several themes including inequities affecting professional carers of people with intellectual disability and the possible effects of some models of care on inequities. Implications for people with intellectual disability are also considered.

SUMMARY

The diaspora of people with intellectual disability into the community and their accompanying services found a whole new set of unpredicted and unprecedented challenges. Life in the community has rendered professional carers of people with intellectual disability more clearly vulnerable to stress and burnout for a variety of complex reasons, some identified and others as yet unrecognized. Lack of support and lack of role definition are particular problems. Presence of physical and mental health inequities result in major disparities in community care for people with intellectual disability.

Community and cluster centre residential services for adults with intellectual disability: long-term results from an Australian-matched sample

BACKGROUND

Changes in residential accommodation models for adults with intellectual disability (ID) over the last 20 years in Australia, the United Kingdom and the United States have involved relocation from institutions primarily into dispersed homes in the community. But an evolving alternative service style is the cluster centre.

METHODS

This paper reports on the relocation of a matched group of 30 pairs of adults with moderate and severe IDs and challenging behaviour who were relocated from an institution into either dispersed housing in the community or cluster centres but under the same residential service philosophy. Adaptive and maladaptive behaviour, choice-making and objective life quality were assessed prior to leaving the institution and then after 12 and 24 months of living in the new residential model.

RESULTS

Adaptive behaviour, choice-making and life quality increased for both groups and there was no change in level of maladaptive behaviour compared with levels exhibited in the institution. However, there were some significant differences between the community and cluster centre group as the community group increased some adaptive skills, choice-making and objective life quality to a greater extent than the cluster centre group.

CONCLUSIONS

Both cluster centre and dispersed community living offer lifestyle and skill development advantages compared with opportunities available in large residential institutions. Dispersed community houses, however, offer increased opportunities for choice-making, acquisition of adaptive behaviours and improved life quality for long-term institutionalized adults with IDs.