"Sometimes I feel overwhelmed": educational needs of family physicians caring for people with intellectual disability

Providing Care to People With Intellectual and Developmental Disabilities in Medical Education

Medical professionals commonly report having inadequate training providing care for individuals with intellectual and developmental disabilities (IDD). This pilot study aimed to address this gap through a virtual Objective Structured Clinical Examinations (OSCE) with individuals with IDD as patient educators for 25 first- and second-year medical students (OSCE participants). Quantitative data through the Prediger competency scale and qualitative data through a semistructured interview were analyzed. OSCE participants reported a significant increase (p < 0.05) in self-perceived competency scores when comparing pre- and post-OSCE scores. Qualitative analysis yielded themes corresponding to improving skills, practice considerations, and perspectives and biases changes. These results suggested that this virtual OSCE promoted the development of self-perceived clinical competency and comfort providing care for individuals with IDD.

Health sciences training for disability inclusion: the need to engage with emotion

Material aspects of disability inequality, such as access to quality services, housing and employment, are an urgent, worldwide concern. Less recognised though, are psychological layers of prejudice and discrimination, which play a significant role in cementing marginality. Against this backdrop, health practitioners can fill influential roles in shaping the self-identity and citizenship entitlement of people with disabilities. Yet, these professionals are, like the balance of society, socialised in environments where ableism is intrinsic, invisible and unquestioned. Disability prejudice has both an emotional and unconscious basis, and overcoming its effects is argued to require a personal engagement with feelings relating to bodily frailty, universal dependency, mortality and other prickly aspects of the human condition with which it is associated. These aspects are all at play in the clinical encounter between a health professional and a patient with disability, but the layered and consequential nature of such interactions for the flourishing and empowerment of people with disabilities, as well as the disability movement as a whole, is poorly understood. Evidence suggests that mere tuition in social justice has limited effects on behaviour in relation to issues of inequality and exclusion. In this paper I reflect on how socialisation in an ableist world can shape how disability is positioned in the clinical encounter, potentially leading to interactions which embed inequality. Drawing on my own experience as disability studies scholar and disabled person, I then describe a teaching method for facilitating shifts in the personal relationships which health sciences students have to disability, in the context of broader attempts to create clinical spaces and relationships in which empathy and self-compassion are encouraged.

How are medical students learning to care for patients with intellectual disabilities? A scoping review

BACKGROUND

Individuals with intellectual disabilities experience barriers to quality healthcare. To reduce this disparity, equipping medical trainees with the knowledge and skills required for treating this patient population is critical. Our aim is to describe the breadth of instructional interventions and identify gaps in intellectual disability medical education curricula.

METHOD

Using scoping review methods, the intellectual disability programmes described in 27 articles were evaluated and their coverage of the six core competencies on disability for health care education was examined.

RESULTS

The most frequently represented core competencies were disability conceptual frameworks, professionalism and communication, and clinical assessment, which were, in most programmes, fulfilled by activities involving individuals with intellectual disabilities. Uneven competency coverage warrants consideration.

CONCLUSIONS

Considerable variabilities exist in medical school curricula on intellectual disabilities. Using core competencies on disability for health care education for curricular design and evaluation would provide a coherent training experience in this important area.

Development and implementation of a continuing care program for patients with intellectual and developmental disabilities in family medicine

In the United States, individuals with intellectual and developmental disabilities (IDD) consistently experience health disparities. One factor is limited access to quality healthcare services equipped to meet the needs of those with IDD, particularly as they transition to adulthood. The purpose of this work is to describe the development and implementation of Jefferson's Continuing Care Program (JCCP), which was designed to address this care gap. We share how the idea, logistics, and support for the clinic were developed; how JCCP was designed to be uniquely accessible both via physical space and clinic flow; and how those challenges encountered have been crucial for fine-tuning optimal patient care. Since its inception in 2019, JCCP has made large strides towards educating the next generation of medical providers to care for patients with IDD. Looking to the future, JCCP plans to broaden its impact by serving more patients, continuing our advocacy and education work, and continuing to adapt to the needs of our community.

Trainee advocacy for medical education on the care of people with intellectual and/or developmental disabilities: a sequential mixed methods analysis

BACKGROUND

Medical trainees (medical students, residents, and fellows) are playing an active role in the development of new curricular initiatives; however, examinations of their advocacy efforts are rarely reported. The purpose of this study was to understand the experiences of trainees advocating for improved medical education on the care of people with intellectual and/or developmental disabilities.

METHODS

In 2022-23, the authors conducted an explanatory, sequential, mixed methods study using a constructivist paradigm to analyze the experiences of trainee advocates. They used descriptive statistics to analyze quantitative data collected through surveys. Participant interviews then yielded qualitative data that they examined using team-based deductive and inductive thematic analysis. The authors applied Kern's six-step approach to curriculum development as a framework for analyzing and reporting results.

RESULTS

A total of 24 participants completed the surveys, of whom 12 volunteered to be interviewed. Most survey participants were medical students who reported successful advocacy efforts despite administrative challenges. Several themes were identified that mapped to Steps 2, 4, and 5 of the Kern framework: "Utilizing Trainee Feedback" related to Needs Assessment of Targeted Learners (Kern Step 2); "Inclusion" related to Educational Strategies (Kern Step 4); and "Obstacles", "Catalysts", and "Sustainability" related to Curriculum Implementation (Kern Step 5).

CONCLUSIONS

Trainee advocates are influencing the development and implementation of medical education related to the care of people with intellectual and/or developmental disabilities. Their successes are influenced by engaged mentors, patient partners, and receptive institutions and their experiences provide a novel insight into the process of trainee-driven curriculum advocacy.

Reporting Down syndrome on the death certificate for Alzheimer disease/unspecified dementia deaths

BACKGROUND

Death certificates are crucial for understanding population health trends including the burden of disease mortality. Accurate reporting of causes of death on these records is necessary in order to implement adequate public health policies and fund disease research. While there is evidence that Alzheimer disease and unspecified dementia are prevalent among people with Down syndrome, a 2014 Centers for Disease Control and Prevention (CDC) rule change instructing that Down syndrome should be reported as the underlying cause of death in instances when death occurred from Alzheimer disease or unspecified dementia threatens the accuracy and the utility of death certificates for this population.

METHODS

This study used 15 years (2005-2019) of US death certificate data for adults with and without Down syndrome. We compare the mortality burden due to Alzheimer disease and unspecified dementia prior to and after amending death certificates that report Down syndrome as the underlying cause of death.

RESULTS

When analyzing death certificates without addressing the reporting of Down syndrome as the underlying cause of death, rates of death due to Alzheimer disease and dementia ranked as the third leading cause of death for both adults with and without Down syndrome. After amending death certificates that reported Down syndrome as the underlying cause of death, Alzheimer disease and dementia were the leading cause of death among those with Down syndrome, occurring 2.7 times more in adults with compared to without Down syndrome.

CONCLUSION

The findings of this study highlight the importance of accurate mortality data for studying and addressing population health trends. The current practice of reporting Down syndrome as the underlying cause of death rather than the disease responsible for death needs to be reconsidered and modified. If not, people with Down syndrome may be further marginalized within dementia related support and research.

Survey results on training in developmental disabilities in Canadian psychiatry residency programs

Objective

Mental health problems in children, adolescents, and adults with developmental disabilities (DD) are an underserviced clinical area. Although the Royal College of Physicians and Surgeons of Canada requires that experiences with patients with DD must be included during psychiatry residency training, the type and extent of this experience is not specified. The purpose of this study was to examine the current educational opportunities regarding DD in Canadian psychiatry residency programs.

Methods

A survey asking about training in DD was sent to psychiatry residency directors at all 17 medical schools in Canada. The survey consisted of three sections focused on didactic teaching and clinical rotations (required and elective) in DD for residents.

Results

Program directors of all psychiatry residency programs noted that their program included didactic teaching specific to DD, although the time dedicated to this differed greatly, ranging from 2 to 20 hours. Although 13 programs offered electives in DD, only five programs required residents to complete a clinical rotation specific to DD. Two programs did not have required or elective rotations in DD.

Conclusion

These results suggest that training specific to DD is probably inadequate for most residents. This is likely to result in limitations in knowledge and skills required to assess and treat people with DD, decreased comfort working with them, and ultimately reduced quality and availability of psychiatric care for this underserved population. More specific and comprehensive training requirements and opportunities are needed to ensure that residents receive appropriate training in this area.

The Role of Information and Knowledge in COVID-19 Vaccination Among People With Intellectual and Developmental Disabilities and Their Families

People with intellectual and developmental disabilities (IDD) may be at an increased risk of severe illness and death from COVID-19. This article examines the role of information and knowledge in COVID-19 vaccine uptake for people with IDD and their families. We developed a survey about COVID-19 vaccine uptake, confidence, and knowledge for people with IDD and their families. COVID-19 vaccine uptake was associated with higher self-reported knowledge about the vaccine, learning about the vaccine from one's doctor, and social media use. Qualitative results reflected the importance of trusted relationships with medical providers in vaccination.

Healthcare workers' experiences of caring for patients diagnosed with intellectual disability co-occurrent with psychiatric disorders

WHAT IS KNOWN ON THE SUBJECT?: Intellectual disability (ID) involves problems with general mental abilities and affects intellectual functioning and adaptive functioning. People diagnosed with ID present higher levels of functional disability, which means they usually have difficulty or the inability to independently perform basic activities of daily living. Little to no attention has been paid to the issues of the mental health of people diagnosed with ID. Specifically, healthcare workers' experiences of caring for patients with IDPD have been neglected. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The findings increase our understanding and partially address the knowledge gap regarding the situations and circumstances faced by healthcare workers in caring for patients diagnosed with intellectual disability co-occurrent with psychiatric disorders (IDPD). In cases of insufficient staffing, healthcare workers may be forced to ignore the individualized needs of patients so as to facilitate management. Healthcare workers may also feel frustrated by not being able to anticipate or deal with patients' unexpected problem behaviours or accidents. They adapt by adjusting their expectations of their patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Healthcare administrators need to understand the difficulties faced by staff in caring for patients diagnosed with IDPD, arrange appropriate in-service education to increase the healthcare workers' knowledge and skills in caring for patients diagnosed with IDPD, and create warm and supportive environments for them. The government department responsible for the management of ID patient care institutions should be able to regularly monitor the overall staffing and quality of care in these institutions. ABSTRACT: Introduction When intellectual disability co-occurs diagnosed with psychiatric disorders (IDPD), the impact of the burden of illness on the affected individuals, their caregivers, their family and friends, and the services that provide for them is particularly high. The issues of the mental health of people diagnosed with ID have received little, if any, attention. One specific area of neglect is healthcare workers' experiences of caring for patients diagnosed with IDPD. Aim The aim of this study was to understand healthcare workers' experiences of caring for patients diagnosed with IDPD. Methods A qualitative descriptive research approach and semi-structured interviews were used in this study. We interviewed 15 participants who had experience in caring for patients diagnosed with a dual diagnosis of IDPD. Findings Four themes were found, as follows: (1) Negative impacts of insufficient staffing on the quality of care, (2) Constantly worrying about harmful incidents, (3) Discovering effective ways to provide individual patient care and (4) Adjusting expectations and attitudes towards patients. Participants' experiences revealed that they perceived the importance and effectiveness of providing individualized care for IDPD patients. However, when staffing is insufficient, they may be forced to ignore the individualized needs of patients so as to facilitate management. They may also feel frustrated by not being able to anticipate or deal with patients' unexpected problem behaviours or accidents. In addition, they adapt by adjusting their expectations of the patients. Discussion The findings from this research help to fill the knowledge gap in our understanding of healthcare workers' experiences of and their perspectives on caring for patients diagnosed with IDPD. Implications for Practice Healthcare administrators need to understand the difficulties faced by staff in caring for patients diagnosed with IDPD, arrange appropriate in-service education to increase the healthcare workers' knowledge and skills in caring for patients diagnosed with IDPD, and create warm and supportive environments for them. The government department overseeing the management of institutions providing ID patient care should be empowered to conduct regular monitoring of the overall staffing and quality of care in such institutions.

What do specialist mental health professionals think of the mental health services for people with intellectual disabilities in Singapore?

BACKGROUND

This research aimed to investigate the views and experiences of specialist mental health professionals working with adults with intellectual disabilities and mental health problems in Singapore in order to gain insight into the functioning of the local specialist intellectual disability mental health service and how it may be improved.

METHODS

Eight staff members from specialist service were interviewed. The transcriptions of the interviews were analysed using thematic analysis.

RESULTS

Analysis revealed four themes (1) Identifying their roles; (2) Ensuring continuity of care; (3) Disempowerment of service users and (4) Improving clinical practice.

CONCLUSIONS

Participants identified the challenges they faced working with this population. They highlighted the importance of building therapeutic relationships during the treatment process and discussed the stigma that people with intellectual disabilities face in the community. Recommendations and implications are discussed in relation to service provision, improving staff knowledge and recruiting more staff to work in this field.

Primary mental healthcare for adults with mild intellectual disabilities: a Dutch database study

BACKGROUND

General practitioners (GPs) are increasingly confronted with people with both mild intellectual disability (MID) and mental health (MH) problems. Little is known about the type of MH problems for which people with MID visit their GP and the care provided.

OBJECTIVES

To identify the type and prevalence of MH disorders and MH-related complaints in people with MID in primary care and care provided, compared to people without ID.

METHODS

By linking the Netherlands Institute for Health Services Research's primary care databases, comprising electronic health records, with Statistic Netherlands' social services and chronic care databases, we identified 11,887 people with MID. In this four-year retrospective study, MH-related International Classification of Primary Care (ICPC) codes and care characteristics were compared between people with MID and without ID.

RESULTS

Of the people with MID, 48.8% had MH problems recorded vs. 30.4% of the people without ID, with significant differences in substance abuse, suicide attempts, and psychosis. Of the MID group, 80.3% were not registered by their GP with the ICPC code mental retardation. GPs provided more care to people with MID and MH problems than people without ID but with MH-problems regarding consultations (median 6.4 vs. 4.0 per year) and variety of prescribed medications (median 2.7 vs. 2.0 per year).

CONCLUSION

In primary care, the prevalence of MH problems and care provided is high in people with MID. To improve primary mental healthcare for this group, it is essential to increase GPs' awareness and knowledge on the combination of MID and MH.

Student Confidence in Providing Healthcare to Adults With Intellectual Disability: Implications for Health Profession Curricula

Self-perceived confidence of health professions students at one university in caring for adults with intellectual disability (ID) was examined via an electronic survey using the Therapy Confidence Scale - Intellectual Disabilities (TCS-ID). A stepwise multiple regression of data collected from 232 completed surveys revealed that prior training and prior experience were predictors of TCS-ID total score. Adults with ID experience healthcare disparities due, in part, to poor provider communication and a lack of confidence. Results from this novel study suggest that opportunities for experiential learning and training with people with ID are important considerations for health professions curricula. Further research is needed for generalizability of results.

Top Ten Tips Palliative Care Clinicians Should Know About Navigating the Needs of Adults with Intellectual Disabilities

As many people with intellectual disabilities (ID) live longer, the need for access to quality palliative care (PC) rises. People with ID realize significant barriers and inequities in accessing health care and PC. The need for integrated disability and PC services with extensive collaboration is great. The following tips are for PC clinicians caring for people with ID, their families, caregivers, and the community. While patient-centered care is difficult to distill into "tips," this article, written by an interdisciplinary team of PC and ID specialists, offers resources and references to improve the care provided to people with ID and serious illnesses.

Striving Toward Equity in Health Care for People With Communication Disabilities

PURPOSE

Approximately 10% of the U.S. adult population has a speech, language, and/or voice disability, collectively referred to as communication disabilities. An increasing number of studies demonstrate that persons with communication disabilities have worse health and health care outcomes as compared to those without communication disabilities. Understanding the state of the science, including potential contributing factors is critical to begin to address the disparities.

METHOD

Applying a historical lens and integrating multiple models of disability provide a comprehensive perspective of the health and health care outcomes of persons with communication disabilities.

RESULTS

Three phases for addressing health care disparities exist: detecting, understanding, and reducing. Results from a 2012 National Health Interview Survey provide compelling population-level results of the health and health care disparities experienced by persons with communication disabilities. To understand the disparities, factors within the health care system, such as availability of communication aids and services, as well as provider and staff biases, assumptions, and lack of knowledge need to be considered. To date, few interventions exist to address disparities in care for persons with communication disabilities. Consequently, researchers need to engage with stakeholders in innovative study designs and methods to facilitate the rapid development, implementation, and dissemination of interventions that address the disparities.

CONCLUSION

To ensure equity for the large and growing population of persons with communication disabilities, researchers, policy makers, patients, and health care systems need to collaborate in identifying and addressing the factors contributing to health and health care disparities. Presentation Video: https://doi.org/10.23641/asha.21215804.

Qualitative Focus Groups with Professionals of Special Education and Parents of Young Females with Intellectual Disability Exploring Experiences with Menstrual Hygiene Management and the Trigger for the Non-Therapeutic Hysterectomy in Mexico

How primary carers, physicians, health education professionals, and others see or understand the subject of menstruation in women with intellectual disability (ID) is rooted in the socio-cultural context and in the socio-economic structures in which all of them live. The aim of this study was to explore how parents of young females with ID and special education professionals perceive and experience menstrual hygiene management, which coping strategies are applied; and what triggers the performance of a hysterectomy. A qualitative focus group study design was conducted with 69 parents and 11 special education professionals, in 14 schools and one Down syndrome clinic, in Mexico City. Data were analysed using the method of thematic analysis. The main concern of parents was how to cope with the underlying disease. They perceived menstrual bleeding positively. Their psychological distress had to do with the reproductive health of their daughters, with their wish to avoid pregnancy, and with their fear of death and leaving their daughters alone and helpless without them. None of them favoured hysterectomy. Medical indication of hysterectomy was identified as the trigger for its performance. There is an urgent need of policy development/review on best practices for hysterectomy in the females in question.

Experiences of mental health professionals providing services to adults with intellectual disabilities and mental health problems: A systematic review and meta-synthesis of qualitative research studies

BACKGROUND

Mental health professionals play an important role in providing care and treatment for adults with intellectual disabilities. A number of studies use qualitative methods to explore the experiences of these professionals and their perspectives regarding the mental health services for this population. A systematic review using meta-ethnographic approach was undertaken to summarise this research.

METHOD

A systematic search found 14 relevant studies which were critically appraised. Key themes from these studies were extracted and synthesised.

RESULTS

Three main themes were identified: 1) Understanding the person, 2) Relational interaction and 3) Organisational factors.

CONCLUSIONS

The findings of this review identified the issues mental health professionals raised in relation to their work. They described the complex presenting problems as intense yet fulfilling therapeutic relationships with their clients and their wish to improve their knowledge and skills. They identified organisational issues that need to be addressed to improve staff morale and efficiency.

Accessibility of Virtual Primary Care for Adults With Intellectual and Developmental Disabilities During the COVID-19 Pandemic: Qualitative Study

Background

The COVID-19 pandemic has led to an unprecedented increase in the delivery of virtual primary care. Adults with intellectual and developmental disabilities (IDDs) have complex health care needs, and little is known about the value and appropriateness of virtual care for this patient population.

Objective

The aim of this study was to explore the accessibility of virtual primary care for patients with IDDs during the pandemic.

Methods

We conducted semistructured interviews with 38 participants in Ontario, Canada between March and November 2021. A maximum variation sampling strategy was used to achieve a diverse sample including 11 adults with IDDs, 13 family caregivers, 5 IDD support staff members, and 9 primary care physicians. An iterative mixed inductive and deductive thematic analysis approach was used to code the data and synthesize higher-level themes. The analysis was informed by the Levesque Patient-Centered Access to Health Care Framework.

Results

We identified themes related to 4 of 5 access-to-care dimensions that highlighted both the benefits and challenges of virtual care for adults with IDDs. The benefits included saving time spent traveling and waiting; avoiding anxiety and challenging behavior for patients who struggle to attend in-person visits; allowing caregivers who live far away from their loved ones to participate; reducing illness transmission; and allowing health care providers to see patients in their home environments. The challenges included lack of access to necessary technology, lack of comfort or skill using technology, and lack of nonverbal communication; difficulty engaging and establishing rapport; patient exclusion from the health care encounter; and concerns about privacy and confidentiality. An overarching theme was that “one size does not fit all,” and the accessibility of virtual care was dependent on the interaction between the following 5 categories of factors: patient characteristics, patient context, caregiver characteristics, service context, and reason for a particular primary care visit. Though virtual care was not always appropriate, in some cases, it dramatically improved patients’ abilities to access necessary health care.

Conclusions

This study suggests that a flexible patient-centered system including multiple delivery modalities is needed to ensure all patients have access to primary care. Implementing this system will require improved virtual care platforms, access to technology for patients and caregivers, training for primary care providers, and appropriately aligned primary care funding models.

'I Have to Explain to him': How Companions Broker Mutual Understanding Between Patients with Intellectual Disabilities and Health Care Practitioners in Primary Care

People with intellectual disabilities (ID) experience marked health inequalities. This is attributable, at least in part, to suboptimal healthcare communication with health care practitioners (HCPs) whereby patients with ID and HCPs struggle to understand each other. Companions who attend healthcare appointments with patients with ID can support the communicative exchange between patient and HCP, but their involvement can have unintended consequences. This article uses Conversation Analysis (CA) to analyse video-recorded data from primary care health checks involving 24 patients with ID. This method shows that companions use their linguistic and experiential resources to intervene as 'brokers' to address real or potential threats to mutual understanding between patients with ID and HCPs. Their interventions can fill in the gaps in knowledge and understanding of the other parties, but also run the risk of deskilling the others in the interaction, by relieving them of the obligation to address communication breakdown directly themselves.

Care and management of adults with autism spectrum disorder in family practice: difficulties experienced by general practitioners

BACKGROUND AND OBJECTIVES

Few studies exist regarding the management and support of adults with autism spectrum disorder (ASD) in family practice. Most of them concern the management of children. As a primary care professional however, the general practitioner (GP) has a role to play at every step of the autistic adult's care pathway. With this study, we sought to identify GPs' experienced difficulties in caring for and managing their adult patients with ASD.

METHODS

We conducted a qualitative study of 11 French GPs caring for adults with ASD via semistructured interviews and a thematic content analysis. GPs were recruited from 5 counties of the Grand Est Region (Marne, Haute-Marne, Meurthe-et-Moselle, Meuse and Vosges).

RESULTS

All of the GPs described difficulties with the diagnostic process and the lack of initial training. Most of the respondents expressed difficulties with medical consultations of patients presenting an intellectual disability (ID) and with the lack of communication between GPs and mental health specialists during the patient care process. More than half of the GPs described difficulties with referral pathways for diagnosis due to lengthy delays and patient reluctance to seek psychiatric care. More than half of the respondents also experienced difficulties with providing proper social care, and with responding to patient distress due to their healthcare experiences.

CONCLUSION

Improving awareness and training about ASD in adults, as well as harmonizing the diagnostic process and referral pathways, might reduce GPs' experienced difficulties in caring for this population.

Medical student program to learn from families experiencing developmental disabilities

Patients and families experiencing developmental disabilities (DDs) may lack trust in physicians due to negative experiences in healthcare. DDs include conditions impairing physical, learning, language, or behavior areas, beginning during the developmental period and impacting daily functioning ('Developmental Disabilities'). Medical students generally do not receive standard training to effectively communicate with and diagnose patients with DDs. ARIE is a program for medical students to meet and learn from these patients and their families. Students learn about these families' experiences during home visits, guided by standardized interview questions and surveys about families' trust in physicians. Families did not appear to strongly trust physicians, with no significant changes after the program. Families shared they experienced physicians' lack of empathy and knowledge when caring for patients with DDs. Families wanted future physicians to be empathetic and informed when treating children with disabilities. Students reported increased comfort and confidence in interacting with patients with DDs as well as their families after completing the training program. Implementing a service-learning model focused on DDs at other medical schools, incorporating training with communication techniques and home visits, can increase students' confidence and experiences when engaging with patients with DDs and their families.

Mentorship for the Future Special Care Dentist

Mentorship and exposure to individuals with intellectual disabilities and special health care needs is typically limited in predoctoral dental training programs due to time restrictions created by the expansion of technology and scientific learning within the dental school curricula. In this article, the authors look at the benefits of creating mentorship programs; characteristics of good mentors and mentees; and examples of successful, unsuccessful, and future programs in order to create dental professionals who are equipped to address the oral health needs for these vulnerable populations.

Time trends in emergency department use among adults with intellectual and developmental disabilities

BACKGROUND

Emergency Department (ED) visits are common among adults with intellectual and developmental disabilities (IDD). However, little is known about how ED use has varied over time in this population, or how it has been affected by recent Medicaid policy changes.

OBJECTIVE

To examine temporal trends in ED use among adult Medicaid members with IDD in eight states that ranged in the extent to which they had implemented state-level Medicaid policy changes that might affect ED use.

METHODS

We conducted repeated cross-sectional analyses of 2010-2016 Medicaid claims data. Quarterly analyses included adults ages 18-64 years with IDD (identified by diagnosis codes) who were continuously enrolled in Medicaid for the past 12 months. We assessed change in number of ED visits per 1000 member months from 2010 to 2016 overall and interacted with state level policy changes such as Medicaid expansion.

RESULTS

States with no Medicaid expansion experienced an increase in ED visits (linear trend coefficient: 1.13, p < 0.01), while states operating expansion via waiver had a much smaller (non-significant) increase, and states with ACA-governed expansion had a decrease in ED visits (linear trend coefficient: 1.17, p < 0.01). Other policy changes had limited or no association with ED visits.

CONCLUSIONS

Medicaid expansion was associated with modest reduction or limited increase in ED visits compared to no expansion. We found no consistent decrease in ED visits in association with other Medicaid policy changes.

Roadmap for Creating Effective Communication Tools to Improve Health Equity for Persons With Intellectual and Developmental Disabilities

Persons with intellectual and developmental disabilities (IDD) live 20 fewer years than the average person and almost 40% of their deaths are from preventable causes. They suffer from well-documented disparities in health and healthcare, and much of this inequity is rooted in information transfer failures between patients, their caregivers, and their healthcare providers. Tools to improve communication between these stakeholders, such as health checks and hand-held health records, or health passports, have been implemented in Europe, Australia and Canada with mixed results, and there are no standard information tools currently in widespread use in the U.S. We review the evidence of the effectiveness of these tools, as well as their barriers to adoption, to inform proposed development of next-generation information transfer tools most useful to patients with IDD and their healthcare providers. The repair of health information transfer failures will be a major step toward achieving health equity for this population.

Training Healthcare Professionals to Work With People With Intellectual and Developmental Disabilities

This study assessed 155 healthcare providers, from nine disciplines, who work professionally with people with intellectual and developmental disabilities (IDD). Using a national, web-based survey, respondents rated their experience, comfort, and competence in treating individuals with different disability types and preferred methods of continuing education; respondents also provided suggestions for attracting others to work with the IDD population. Findings revealed that experiences, comfort, and competence were all higher concerning persons with autism spectrum disorder (ASD) and intellectual disability (ID), lower for those with deaf-blindness. Overall, levels of experience exceeded levels of comfort, which in turn exceeded levels of competence. The most helpful venues for continued training involved day-to-day contact with persons with IDD, which also characterized open-ended responses. Research and practical implications are discussed.

Empirically supported psychological treatments: The challenges of comorbid psychiatric and behavioral disorders in people with intellectual disability

This paper reviews the current state of knowledge on psychological interventions with empirical evidence of efficacy in treating common psychiatric and behavioral disorders in people with intellectual disability (ID) at all stages of their life. We begin with a brief presentation of what is meant by psychiatric and behavioral disorders in this population, along with an explanation of some of the factors that contribute to the increased psychosocial vulnerability of this group to present with these problems. We then conduct a review of empirically supported psychological therapies used to treat psychiatric and behavioral disorders in people with ID. The review is structured around the three generations of therapies: Applied behavior analysis (e.g., positive behavior support), cognitive behavioral therapies (e.g., mindfulness-based cognitive therapy), and contextual therapies (e.g., dialectical behavior therapy). We conclude with some recommendations for professional practice in the fields of ID and psychiatry.

State of the practice of health information systems: a survey study amongst health care professionals in intellectual disability care

BACKGROUND

Care for people with an Intellectual Disability (ID) is complex: multiple health care professionals are involved and use different Health Information Systems (HISs) to store medical and daily care information on the same individuals. The objective of this study is to identify the HISs needs of professionals in ID care by addressing the obstacles and challenges they meet in their current HISs.

METHODS

We distributed an online questionnaire amongst Dutch ID care professionals via different professional associations and care providers. 328 respondents answered questions on their HISs. An inventory was made of HIS usage purposes, problems, satisfaction and desired features, with and without stratification on type of HIS and care professional.

RESULTS

Typical in ID care, two types of HISs are being used that differ with respect to their features and users: Electronic Client Dossiers (ECDs) and Electronic Patient Dossiers (EPDs). In total, the respondents mentioned 52 unique HISs. Groups of care professionals differed in their satisfaction with ECDs only. Both HIS types present users with difficulties related to the specifics of care for people with an ID. Particularly the much needed communication between the many unique HISs was reported a major issue which implies major issues with inter-operability. Other problems seem design-related as well.

CONCLUSION

This study can be used to improve current HISs and design new HISs that take ID care professionals requirements into account.

Birth outcomes affecting infants of mothers with intellectual and developmental disabilities

BACKGROUND

Women with intellectual and developmental disabilities (IDD) face increased risk of adverse maternal pregnancy outcomes, yet less is known about infant outcomes.

OBJECTIVES

To examine birth outcomes of infants born to mothers with IDD and assess associations with demographics and IDD-type.

METHODS

We used data from the Big Data for Little Kids project, which links Wisconsin birth records to Medicaid claims for live births covered by Medicaid from 2007 to 2016. We identified IDD using maternal prepregnancy Medicaid claims and ran Poisson regression (with a log link function) with robust variance clustered by mother to compare prevalence of outcomes between singleton births with and without mothers with IDD. We adjusted the associations for demographic factors and estimated prevalence ratios (PR) as the effect measure. We assessed outcomes by IDD-type (intellectual disability, genetic conditions, cerebral palsy, and autism spectrum disorder) to explore differences by categories of IDD.

RESULTS

Of 267,395 infants, 1696 (0.6%) had mothers with IDD. A greater percentage of infants with mothers with IDD were born preterm (12.8% vs 7.8%; PR 1.64, 95% confidence interval [CI] 1.42, 1.89), small for gestational age (8.5% vs 5.4%; PR 1.42, 95% CI 1.25, 1.61), and died within 12 months of birth (3.2% vs 0.7%; PR 4.93, 95% CI 3.73, 6.43) compared to infants of mothers without IDD. Prevalence ratios were robust to adjustment for demographics factors. Estimates did not meaningfully differ when comparing different IDD-types.

CONCLUSIONS

A greater porportion of infants born to mothers with IDD who were covered by Medicaid had poor outcomes compared to other infants. Prevalence of poor infant outcomes was greater for mothers with IDD even after accounting for demographic differences. It is imperative to understand why infants of mothers with IDD are at greater risk so interventions and management can be developed.

Healthcare inequities among adults with developmental disability: An integrative review with implications for nursing education

AIM

This integrative review synthesized research on the healthcare inequities experienced by adults with developmental disability in the United States and discussed implications for nursing education.

BACKGROUND

Individuals with developmental disability are living longer with chronic comorbidities and experience healthcare inequities.

METHOD

Application of inclusion criteria to database and ancestry searches resulted in 26 articles that were assessed for quality and analyzed thematically.

RESULTS

Three categories of inequity were identified: knowledge deficits, communication challenges and poor quality of care. Knowledge deficits and communication challenges can lead to frustration, errors and unmet needs. Poor quality of care encompasses the decreased availability and access to services, limited health promotion participation and higher rates of hospitalizations and complications for adults with developmental disability.

CONCLUSION

Healthcare inequities may be reduced by targeting patient and provider knowledge. Inclusion of developmental disability content and clinical experiences in nursing education may improve care and reduce inequities for this underserved population.

Services for people with intellectual disabilities and mental health problems in Singapore: perspectives from mainstream mental health professionals

Background: Generic mental health staff often have contact with people with intellectual disabilities when they access mainstream mental health services. To date, there has not been any research conducted in non-western countries to explore their views. This paper investigates the views and experiences of mainstream mental health professionals regarding the mental health services for people with intellectual disabilities in Singapore. Methods: Eight staff members from generic mental health services were interviewed. Thematic analysis was used to identify main themes. Findings: The main themes are related to their work experiences, perceptions of people with intellectual disabilities, ideal staff characteristics and service recommendations. Conclusions: Participants identified a lack of experience and knowledge when working with this population. They highlighted the challenges they face promoting choice and autonomy for people with intellectual disabilities. The discussion includes recommendations for improving staff knowledge through training opportunities, consideration of non-pharmacological approaches and early collaboration with caregivers during the treatment process.

The creation of a specializedmedical-dental clinic for adults with developmental disabilities in Montreal, Canada

Purpose

There is inadequate health care for patients with developmental disabilities (DD), due to a number of systemic issues. This case study describes the establishment of a medical-dental clinic in Montréal, Québec for adults with DD. The purpose of this paper is to describe the model of interdisciplinary care based on best practices, as an example to encourage a growing community of trained health professionals to serve this population.

Design/methodology/approach

Interviews with all the clinic staff and leadership were conducted on-site at the clinic, followed by document review and discussions with an embedded researcher in the organization.

Findings

The clinic was established through a series of events that led to public and government interest to act, the timely emergence of major donors, and bringing together several dedicated individuals and organizations. The core team engaged in consultation with clinics, followed by extensive billing analyses and iterative process mapping as a learning organization. Prior to patient visits, the clinic conducted detailed intake processes to adequately plan for each patient interaction. Desensitization visits were undertaken to improve patient tolerance for examination and treatment. The continual collection of data fed into an evaluation framework to facilitate continuous improvement and articulate a model for replication.

Originality/value

To the best of the authors knowledge, there is not a clinic of this nature serving this population in Canada. This work can serve to inform the efforts of other care providers looking to create a medical – dental home for this population.

Disability-competence training influences health care providers' conceptualizations of disability: An evaluation study

BACKGROUND

Often, health care providers' approach to people with disabilities is grounded in a medical model perspective. This view highlights individual deficits and does not foster patient-centeredness. Learning about and adopting a more social model, focused on creating accessible and inclusive approaches and environments, could help providers to reshape their attitudes about disability, dismantling barriers to care.

OBJECTIVE

This study used innovative methods to evaluate a recorded, online disability-competence training for health care providers. It was hypothesized that the training would 1) shift providers' conceptualizations of disability away from a medical model view toward a social model view of disability and 2) equip providers with actionable strategies to improve access to care for people with disabilities.

METHODS

Quantitative and qualitative evaluation data were analyzed for n = 192 training participants. Measures included participants' pre- and post-training conceptualizations of disability, proposed actions steps to facilitate patient-centered care, and measures of satisfaction and self-assessed knowledge gain.

RESULTS

Both hypotheses were supported. After the training, participants' conceptualizations of disability were more reflective of the social model, and participants were better able to articulate specific action steps they could take to promote accessible, responsive care.

CONCLUSIONS

This study demonstrates that health care provider training can positively affect providers' knowledge, outlook, and approach to caring for people with disabilities. Its findings can inform broader efforts aimed at systematically changing the way health professionals are educated and trained to provide care in disability-competent ways.

Linking national public services data to estimate the prevalence of intellectual disabilities in The Netherlands: results from an explorative population-based study

OBJECTIVES

Individuals with intellectual disabilities (ID) depend on public services for daily support and medical care; however, this group of individuals can be difficult to identify within population data. This therefore limits the opportunities to accurately estimate the size of the population with ID, monitor trends and tailor public health interventions according to the needs and characteristics of this group. By linking relevant databases, this study sought to identify individuals with ID in national data, to estimate the prevalence of ID based on public service use and to explore how this method can be used to better monitor the population with ID.

STUDY DESIGN

Explorative data linkage study using the Dutch population register and databases from public services accessible with an ID diagnosis.

METHODS

The overall prevalence of ID in the Dutch adult population was estimated, specified by age group and sex, and the identified ID groups were also characterised by their support needs. Participants included the entire adult Dutch population who were alive on 1 January 2015.

RESULTS

After linking databases, 187,149 adults with ID were identified within a population of almost 12.7 million Dutch adults, giving an ID prevalence estimate of 1.45%. Prevalence of ID was higher among males (1.7%) than females (1.2%). Most individuals with ID were identified through the use of residential care services (n = 91,064; 0.7%). Non-residential ID-related care was used by 27,007 individuals (0.2%). Social, employment or income support due to a (mild) ID was received by 69,078 individuals (0.5%); the mean age in these ID groups was between 8 and 10 years which is younger than that in the general Dutch population. ID prevalence declined with increasing age across all ID subgroups.

CONCLUSIONS

The ID prevalence in The Netherlands, as determined by ID-related public service usage, aligns with international estimates. This suggests that national supportive services are accessible and used by individuals with ID. Moreover, this demonstrated that databases from national supportive services can be a useful resource to identify individuals with ID at the population level and can enable structural monitoring of the ID population through linking national databases.

Who is Asked and Who Gets to Answer the Health-Care Practitioner's Questions When Patients with Intellectual Disabilities Attend UK General Practice Health Checks with Their Companions?

When patients with intellectual disabilities (ID) attend a General Practice annual health check, current guidance directs health-care practitioners (HCPs) to involve them as much as possible as informants on their health. However, previous research based on interviews with participants suggests that during health consultations their communicative contributions of patients with ID may be sidelined in favor of information provided by caregivers perhaps because of HCPs' uncertainties about how to address the communication needs of these patients. The aim of this study was to establish, within naturally occurring health consultations, who HCPs select to answer their questions during health checks - patients with ID or their companions - and who actually answers. A nonconsecutive case series of primary care annual health checks involving patients with ID and their companions (n = 24) was conducted. Health checks were video-recorded and analyzed using tools of Conversation Analysis. We found that HCPs consistently selected patients with ID to answer their questions and patients then responded without significant gaps or dyfluencies in the immediate next turn at talk 70.1% of the instances. Companions were selected to respond in 9.3% of the total question-answer sequences recorded. Family members were more likely to be chosen as the addressee of HCP questions, compared to staff companions. They were also more likely to intervene to answer questions that had been directed at the patient. We conclude that health communication with patients with ID need not necessarily pose insurmountable challenges for HCPs, though the structure of the health check, with many questions requiring only a yes/no response may have reduced the communicative demand on patients. More research is needed to investigate how HCP involve patients with ID in more extensive health information exchange or health decision-making.

Paediatricians' Views on Pain in Children with Profound Intellectual and Multiple Disabilities

Pain is a frequent issue in children with profound intellectual and multiple disabilities (PIMD). Its identification and treatment can prove highly challenging for primary care physicians, mainly because of the children’s limited communication abilities. We used an online survey to explore paediatricians’ views regarding the experience and management of pain in children with PIMD and invited 480 professionals working in the canton of Vaud, Switzerland, to take part. We received 121 responses (participation rate 25.5%). A large majority of respondents provided care to children with PIMD. All paediatricians considered that these children feel pain at least as much as typically developing children. However, paediatricians had mixed views on their tolerance to pain. More than 90% held the view that their pain is under-assessed and undertreated. The principal barriers they reported to appropriate management were communication limitations with the child, difficulties in pain assessment, lack of knowledge about children with disabilities and lack of experience. Paediatricians have complex opinions regarding how children with PIMD experience pain and how to manage this problem. Professional education and training on the specificities of children with PIMD, including how to address their pain, seem necessary to foster paediatricians’ ability and confidence in approaching this complex issue.

Training Medical Professionals to Work with Patients with Neurodevelopmental Disorders: A Systematic Review

Background: Patients with neurodevelopmental disorders are not always provided the quality of medical care they deserve. Medical personnel report limited preparation and education in caring for patients with neurodevelopmental disorders.  Aim: The purpose of this systematic review is to summarize the research on medical personnel training programs, identify effective training methods, and provide directions for future application and research. Methods: Thirty-four studies met inclusion criteria. The studies were summarized in terms of training components, the medical personnel trained, and the effectiveness of the training in achieving target outcomes.  Results: Seventy-nine percent of studies demonstrated improvement in target outcomes. A variety of training components were used in combination throughout the studies, demonstrating a possibility of significant change to medical personnel's abilities for and attitudes about working with patients with neurodevelopmental disorders.  Conclusion: Further research is needed to determine specifically which types of training can affect which target outcomes.

Caring for children with mental health or developmental and behavioural disorders: Perspectives of family health teams on roles and barriers to care

OBJECTIVE

To inform a shared care model between developmental and behavioural (DB) and mental health specialists and primary care physicians by having members of primary care family health teams (FHTs) report on strengths of and barriers to providing care for children with DB disorders and mental health concerns.

DESIGN

Qualitative study using semistructured focus groups.

SETTING

Academic and community-based FHTs in Toronto, Ont.

PARTICIPANTS

Primary care physicians, nurses, allied health professionals, and family medicine trainees within the participating FHTs.

METHODS

Nine focus groups were conducted with FHT members, and transcripts were analyzed for key themes using an inductive thematic analysis approach.

MAIN FINDINGS

Eighty-four participants across 9 sites were interviewed. Six sites were academically affiliated and 3 were community based. Participants described their roles in the care of children with DB disorders as primarily "referral agent" but also as "long-term supporter" and "health care coordinator." Family health team members expressed the desire to "learn" and "do more" for these children but noted numerous barriers to providing care, captured in 4 overarching themes: limited training beyond how to screen, lack of service knowledge, limited time and communication, and cumbersome access to mental health and dual diagnosis services.

CONCLUSION

Primary care physicians are in the unique position of being able to provide longitudinal care for children with DB and mental health disorders. However, they perceive barriers to providing care that can affect access to services, service quality, and health outcomes for these children and their families. The health system might benefit from addressing these barriers by providing more training for primary care physicians in the longitudinal care of children with mental health and DB disorders, and by improving communication between FHTs and DB and mental health specialists regarding service navigation and emerging comorbidities. A shared care model integrating DB and mental health specialists into primary care might be one approach that warrants implementation and research.

Experiences With the Mental Health Service System of Family Caregivers of Individuals With an Intellectual/Developmental Disability Referred to START

People with intellectual and developmental disabilities (IDD) frequently have behavioral or mental health needs, but experience obstacles to treatment. Family caregivers are often responsible for coordinating the care of individuals with IDD. This study examined family caregiver experiences using intake data from a national tertiary crisis intervention model designed for people with IDD and mental health needs. Caregivers (n = 488) completed the Family Experiences Interview Schedule. Less than half of families reported satisfaction with the mental health services received. Notable gaps were in crisis, night and weekend services, choice of services and providers, communication and coordination between providers, and specialized training. Experiences were worse for caregiving fathers and individuals with IDD with co-occurring chronic medical conditions.

What difficulties do people with mild intellectual disabilities experience when seeking medical help from their GP? A qualitative study

BACKGROUND

People with intellectual disabilities often have low health literacy as a result of their limited language comprehension. The aim of this study was to explore the difficulties Dutch people with intellectual disabilities experience during the process of considering and seeking medical help from their GP. The study was intended as input for an online intervention supporting health literacy.

METHODS

A qualitative study, in which 12 semi-structured interviews were conducted with people with mild intellectual disabilities and 4 with relatives of people with mild intellectual disabilities. The interviews were analysed following the principles of thematic analysis.

RESULTS

Difficulties were experienced in the following activities: assessing and proactively reacting to health complaints, processing health information, communicating with a GP and retaining information from the consultation. Support workers and relatives play an important role in all these activities.

CONCLUSIONS

To increase the capacity of people with intellectual disabilities to manage their health and seek care from their GP, it is important to support them in the activities they find difficult. Recommendations resulting from the study have been incorporated in an online intervention.

Getting comfortable with disability: The short- and long-term effects of a clinical encounter

BACKGROUND

Physicians report discomfort when interacting with patients with disabilities, which can negatively impact the quality of healthcare they provide.

OBJECTIVE/HYPOTHESIS

An intervention structured around a formative clinical encounter was assessed for its effectiveness in changing comfort towards treating patients with disabilities. It was predicted that this encounter would have a positive short- and long-term impact on medical students.

METHOD

During the 2017-2018 academic year, 169 third-year medical students conducted a patient encounter with a person who had a disability. Students met individually with the "patient" and completed a brief social and medical history as if they were meeting a new patient to establish care. A measure of perceived comfort caring for patients with disabilities was administered to students before and after the encounter. One year after the patient encounter, 59 students were surveyed about their satisfaction and the impact of the patient encounter.

RESULTS

The impact of encountering people with disabilities in a clinical setting was positive, with statistically significant improvements across all items on the measure of perceived comfort. Students were highly satisfied with the experience and anticipated feeling more confident, more comfortable, less awkward, and more skilled and efficacious when encountering a person with a disability in their future practice. A thematic analysis of the one year follow-up data suggest that students valued the encounter and desired more content on disability throughout their education.

CONCLUSIONS

Medical education should include dedicated exposure to persons with disabilities and a simulated patient experience allowing for a safe environment to gain skills and confidence.

Creating Disability-Competent Medical Students Via Community Outreach

INTRODUCTION

Medical students often have limited exposure to providing care to physically and cognitively disabled patients. To address this gap, Involvement with Disability Education and Advancement (IDEA) was started in 2015 at Rutgers New Jersey Medical School (NJMS). The organization provides NJMS students the opportunity to visit a school dedicated to disabled students and lead educational sessions on health topics.

MATERIALS AND METHODS

We conducted a survey study in 2018 to compare comfort levels between IDEA members and non-members in eliciting information from and providing medical attention to nonverbal, cognitively impaired, and physically disabled patients. The survey-based study utilized yes/no questions, and a Likert scale questionnaire to determine IDEA member and non-member comfort levels in working with various disabilities. Statistical analysis was performed using SAS Enterprise Guide 7.1; p value < 0.05 was considered statistically significant.

RESULTS AND DISCUSSION

A total of 56 responses (19 members, 37 non-members) were analyzed. Regardless of IDEA membership, medical students of all years perceived themselves to have more comfort caring for physically disabled than cognitively impaired or nonverbal patients. IDEA members also recorded higher comfort levels with eliciting information from cognitively impaired patients and lower comfort levels with providing medical attention to physically disabled patients.

IMPLICATIONS

IDEA members may have increased comfort interacting with cognitively impaired individuals due to their regular experience and lower levels of comfort providing medical attention to physically disabled patients due to awareness of complex problems specific to the population. The current results warrant continued data collection and further evaluation.

HIV-related risk behaviors and HIV testing among people with sensory disabilities in the United States

People with disabilities are an important target population for HIV prevention and treatment programs. In this study, we examined the prevalence of HIV-related risk behaviors and HIV testing among people with visual and/or hearing impairments in the United States, and compared with people without any impairments. The study was a secondary data analysis of the 2016 Behavioral Risk Factor Surveillance System. We performed weighted descriptive statistics and logistic regression analyses to determine the association between ever testing for HIV and sociodemographic characteristics, healthcare access, and HIV-related risk behaviors. The prevalence of HIV-related risk behaviors was 7.1% (95%CI = 5.4-8.8), 3.9% (95%CI = 3.0-4.9), 3.5% (95%CI = 1.5-5.4), and 5.9% (95%CI = 5.7-6.1) among those with visual, hearing, both visual and hearing, and no impairments, respectively. HIV testing among those with visual impairment was 39.7% (95%CI = 37.0-42.3) and 28.9% (95%CI = 27.3-30.5) among those with hearing impairment. Approximately 26.8% (95%CI = 21.4-32.2) of the respondents with both impairments and 38.0% (95%CI = 37.6-38.3) of those with no impairments had ever tested for HIV. In the adjusted models, the factors associated with HIV testing varied across the subgroups, with only age, race/ethnicity, and HIV-related risk behaviors common to all the four subgroups. Compared with those without any impairments, the odds of ever testing for HIV was significantly higher among respondents with hearing impairment (aOR = 1.3, 95%CI = 1.14-1.38), after controlling for sociodemographic characteristics, healthcare access, and HIV-related risk behaviors. Targeted interventions that will meet the unique needs of people with visual and/or hearing impairments are required to reduce HIV-related risk behaviors and improve uptake of HIV testing.

Nurses' attitudes, beliefs, and emotions toward caring for adults with intellectual disabilities: An integrative review

BACKGROUND

Negative health-care provider attitudes are a contributing factor to the myriad health disparities faced by people with intellectual disabilities (ID). Nursing comprises the nation's largest health-care profession, yet no integrative review on this topic is found.

PURPOSE

To organize findings of studies exploring nurses' attitudes, beliefs, and emotions about caring for adults with ID, to identify areas for future research, and to discuss recommendations for nursing practice.

METHODS

Whittemore and Knafl's integrative review method guided this study.

RESULTS

Twenty studies were conducted across eight countries, dichotomized according to mainstream or ID nursing specialty, and were mostly setting-specific. Common themes included: "knowing the person," "paternalism/infantilization," "communication challenges," "organizational support," "time," and "ID-specific knowledge and experience." Mainstream nurses' emotions were primarily negative, whereas ID nurses experienced conflicting positive and negative emotions. Antecedents and effects of nurse attitudes and emotions on the quality of care of adults with ID were identified.

CONCLUSIONS/IMPLICATIONS

Despite recent increased research on this topic across multiple countries, further research is needed. The findings of this study will aid the development of strategies to address negative nurse attitudes toward caring for adults with ID and act as a foundation for future research beyond the descriptive stage.

Mediating the interface between voluntariness and coercion: A qualitative study of learning disability nurses' work in medical examinations of people with intellectual disability

AIMS AND OBJECTIVES

To gain knowledge of prevention and use of restraints in provision of medical care to people with intellectual disability. To this end, we explore how learning disability nurses in community services support the individual through medical examinations when facing resistance.

BACKGROUND

Despite increased focus on limiting restraints, there is a lack of knowledge of how restraints are prevented and used in the delivery of physical health care to people with intellectual disability.

DESIGN

We used an ethnographic comparative case design (n = 6).

METHODS

The study was carried out in Norway. The analysis is based on data from semi-structured interviews, participant observation and document studies, in addition to health sociological perspectives on how to support individuals to make their body available for medical examination and intervention. The SRQR checklist was used.

RESULTS

Learning disability nurses strove to ensure that examinations were carried out on the individual's terms, supporting the individual in three phases: preparing for the examination, facilitating the examination and, when facing resistance, intervening to ensure safe and compassionate completion of the examination.

CONCLUSIONS

Supporting the person was a precarious process where professionals had to balance considerations of voluntariness and coercion, progress and breakdown, safety and risk of injury, and dignity and violation. Through their support, learning disability nurses helped to constitute the "resistant" individual as "a cooperative patient," whose body could be examined within the knowledge and methods of medicine, but who could also be safeguarded as a human being through the strain of undergoing examination.

RELEVANCE TO CLINICAL PRACTICE

The article sheds light on how restraints are used in the medical examination and treatment of people with intellectual disabilities and demonstrates the significance of professional support workers' contributions, both in facilitating safe and efficient medical care and in ensuring the least restrictive and most compassionate care possible.

COVID-19 and the need for disability conscious medical education, training, and practice

The COVID-19 era exposes what was already a crisis in the medical profession: structural racism, ageism, sexism, classism, and ableism resulting in healthcare disparities for Persons with Disabilities (PWD). Early research highlights these disparities, but we do not yet know the full impact of this pandemic on PWD. Over the last 20 years, many medical schools have attempted to develop disability competency trainings, but discrimination and inequities remain, resulting in a pervasive distrust of medicine by the disability community at large. In this commentary, we suggest that disability competency is insufficient because the healthcare disparities experienced by PWD are not simply a matter of individual biases, but structural and systemic factors requiring a culture shift in the healthcare professions. Recognizing that disability is a form of diversity that is experienced alongside other systemic disadvantages like social class, race, age, sex, gender identity, and geographic location, we explore the transformative potential of disability conscious medical education, training, and practice that draws on insights from intersectional disability justice activism. Disability conscious medicine is a novel approach, which improves upon competency programs by utilizing disability studies and the principles of disability justice to guide us in the critique of norms, traditions, and institutions to more fully promote the respect, beneficence, and justice that patients deserve.

Parent and Professional Experiences Supporting African-American Children with Autism

While the identification of autism spectrum disorder (ASD) has stabilized at 1 in 59 children in the USA, and children can now be diagnosed reliably with ASD at 2 years old, African-American children are less likely to be diagnosed with ASD. Once African-American children with ASD are identified, there is a latency between diagnosis and access to services when compared to European American children. In an effort to investigate these disparities, this qualitative study explored the experiences and perceptions of African-American parents of children with ASD. This study also explored the experiences and perceptions of professionals who support African-American children with ASD and their families. Findings indicate that (a) participants identified few facilitators to service access, and (b) both parents and healthcare providers perceived similar barriers and facilitators to early diagnoses and service access. Implications for parents, healthcare providers, and educators are discussed.

Medical Students' Knowledge About Children With Disabilities, Special Education Laws, and Social Services: A Preliminary Scale Development and Pilot Study

Context

In order to design undergraduate medical education responsive to the American Academy of Pediatrics' recommendation that physicians learn about special education law and practices, it is important to understand medical students' baseline knowledge about children with disabilities, special education law, available services, and the sources of this information.

Objectives

To develop an instrument to measure what second-year medical students know about children with disabilities, special education law, and available services; to determine the most common sources of this information; and to establish a baseline on which to design curricula that address this topic.

Methods

This study adopted a survey design. The survey took place in 1 school of osteopathic medicine in a Northeastern state of the United States. One hundred fifty medical students in their second year of full-time enrollment were invited to complete the survey. The instrument designed by the authors consisted of 30 items organized into a demographics section and 3 domains: (1) perceived level of knowledge about children with disabilities, (2) sources of information about children with disabilities, and (3) actual knowledge about children with disabilities and special education.

Results

Ninety-eight students (65%) participated. Although students were accurate in self-assessment, their source of knowledge was limited. Medical students who identified personal experiences (t=1.64) and coursework as their source of knowledge had more correct responses (t=2.62).

Conclusion

This preliminary study demonstrated a lack of knowledge among second-year medical students with regard to children with disabilities, special education laws, and social services. Curricula emphasizing disabilities and special education along with longitudinal experiential training may be effective methods to deliver these topics.

Contraceptive Practices and Reproductive Health Considerations for Adolescent and Adult Women with Intellectual and Developmental Disabilities: A Review of the Literature

Whereas progress has been made on increasing access to comprehensive healthcare for individuals with intellectual and developmental disabilities (I/DD), disparities continue in health outcomes, including those related to the reproductive health of adolescent and adult women with I/DD. This review summarizes reproductive care considerations for adolescent and adult women with I/DD and current practices regarding the delivery of contraceptive services to these women. Forty-seven (47) articles based on research conducted in the US between 1999 and 2019 were selected for inclusion in the review. Primary themes discussed include (1) common reproductive health concerns for adolescent and adult women with I/DD, other than pregnancy prevention; (2) contraceptive methods and disability-related concerns; (3) informed consent and reproductive decision-making; and (4) provider knowledge and education. The management of menses and hormonal dysregulation were identified as concerns that providers encounter among patients with I/DD and their families. Disability-related concerns with regard to use of contraception in general and considerations regarding certain methods in particular include challenges with prescription adherence, physical effects of hormonal therapies, drug interactions for individuals with additional health conditions, and legal and ethical concerns involved with decision-making and consent. The results of this review also suggest that focused efforts in partnership with health care providers may be needed to address barriers that adolescent and adult women with I/DD face when trying to obtain quality reproductive health services and contraceptive guidance.