An observational investigation of unemployment, underemployment, and competitive integrated employment of people with intellectual and developmental disabilities in 2021-2022

BACKGROUND

Employment is an important component of community living, and a precursor to economic stability and independence. Despite this, research consistently demonstrates people with intellectual and developmental disabilities (IDD) have low rates of community-based employment. However, little research has been conducted to quantify competitive integrated employment, and which individuals have better employment outcomes as it relates to competitive integrated employment.

OBJECTIVE

This study aims to explore the ways in which key service-related and demographic characteristics of individuals with IDD are associated with participation in competitive integrated employment.

METHODS

We used the 2021-2022 National Core Indicators Intellectual and Developmental Disabilities In-Person Survey dataset. We conducted bivariate and multivariate analyses, using chi-square and generalized linear models, to examine the cross-sectional relationship between employment and demographic and service-related characteristics for 4629 individuals with IDD.

RESULTS

Overall, 42% of the sample was unemployed but wanted a job, while 39% were underemployed and just 21% have competitive integrated employment. Several demographic and service-related characteristics were significantly associated with employment. After controlling for demographic and service-related correlates of employment, having an employment-related goal in one's service plan was associated with 4.5 (95% CI: 3.6-5.5) times higher odds of competitive integrated employment relative to unemployment.

CONCLUSIONS

This study underscores the value of person-centered planning for improved employment outcomes. Further research is needed to fully understand potential inequities in employment and system-level factors that are associated with competitive, integrated employment, as well as solutions to improve access to customized individual employment supports for all people with IDD.

Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial

BACKGROUND

Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention.

METHODS

Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems.

RESULTS

Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040].

CONCLUSION

Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.

Quality monitoring of intellectual and developmental disabilities systems in the US: Assessing the utility and applicability of selected National Core Indicators to national and state priorities

This article provides historical context on the evolution of performance measures for system improvement, examines the perspectives and insights of state public managers on the use and utility of NQF-endorsed outcome measures from the NCI^®-IDD In-Person Survey (IPS) for quality improvement, and discusses the necessity of ensuring that outcome measures align with public policy goals.

COVID-19 IDD: Findings from a global survey exploring family members’ and paid staff’s perceptions of the impact of COVID-19 on individuals with intellectual and developmental disabilities (IDD) and their caregivers

Background: A growing body of evidence attests to the disproportionate impact of COVID-19 on persons with intellectual and developmental disabilities (IDD) during the pandemic. This study asked caregivers about their perceptions of how COVID-19 impacted them and the people they support.

Method: An online survey was conducted in 12 countries during August-September 2020 and sought information on demographics, support practices, information and training, experiences of COVID-19, social distancing, and wellbeing, as measured by the DASS12. This study reports on 3,754 family members, direct support professionals, and managers who participated in the survey.

Results: Caregivers observed increases in depression/anxiety, stereotyped behaviours, aggression towards others and weight gain in the person(s) they supported. They also reported difficulties supporting the person(s) to access healthcare.  Families reported reducing or ceasing employment and absorbed additional costs when supporting their family member. Direct support professionals experienced changes in staff shifts, staff absences, increased workload and hiring of casual staff. Caregivers’ wellbeing revealed high levels of stress, depression, and less so anxiety. The strongest predictor of wellbeing among families was observation of changes in mood in the person(s) they supported, while for direct support professionals, the strongest predictors of wellbeing were reorganisation of staff shifts and increases in new direct support staff. 

Discussion: Findings support the contention of this population experiencing a disproportionate burden during the COVID-19 pandemic, reflecting historical inequities in access to healthcare and other human rights violations which are now protected under the United Nations Convention on the Rights of Persons with Disabilities.

International advances in self-direction: themes from a disability leadership exchange

Purpose

Self-direction–also known as participant direction, personalization and self-directed care–is a service delivery model that enables people to manage their personal budget and purchase services and supports tailored to their needs based on a person-centered plan. This paper, the outcome of an international learning exchange on self-direction, describes approaches across four countries’ successful strategies, unresolved questions and recommendations to enhance self-direction globally.

Design/methodology/approach

The findings are a product of discussions at the 2019 International Initiative for Mental Health Leadership and International Initiative for Disability Leadership Exchange on Advances in Self-Direction. Participants included people who are self-directing, providers and caregivers who support people who are self-directing, advocates, fiscal agents and public managers who administer self-direction from the United States, England, Australia and New Zealand.

Findings

In all four countries, people who self-direct exercise high levels of choice and control and are able to individualize their services and supports to promote a good life in the community. The exchange also revealed challenges and possible solutions to improve and expand self-direction.

Practical implications

The results of the meeting provide guidance for public managers, providers and advocates for initiating and expanding self-direction.

Originality/value

This international meeting was a unique opportunity to compare self-direction across four different countries and across multiple perspectives, including people with disabilities, caregivers, providers and administrators.

Implementing a peer recovery coach model to reach low-income, minority individuals not engaged in substance use treatment

Background: Low-income, racial/ethnic minority individuals face significant barriers in access to substance use (SU) treatment. Peer recovery coaches (PRCs), individuals with lived experience with substance use disorder (SUD), may be uniquely well suited to assist those encountering barriers to treatment. PRCs can also help reach those not engaged in treatment to promote harm reduction and support linkage-to-care when embedded in community rather than clinical settings. This study evaluated a community-based program in which a PRC facilitated linkage to and supported retention in SU treatment. Methods: Guided by the RE-AIM framework, we evaluated implementation of the intervention in a community resource center (CRC) serving homeless and low-income residents of Baltimore City. We examined the reach, effectiveness, adoption, and implementation of this PRC model. Results: Of 199 clients approached by or referred to the PRC, 39 were interested in addressing their SU. Of those interested in addressing SU, the PRC linked 64.1% (n = 25) to treatment and was able to follow up with 59.0% (n = 23) at prespecified time points after linkage (24-48 hours, 2 weeks, and 1 month). Fifty-two percent (n = 13) of clients linked to SU treatment remained in treatment at 30 days post-linkage. Of clients who did not remain in treatment, 77% (n = 10) continued contact with the PRC. Conclusions: Results indicate the utility of the CRC's approach in linking people to treatment for SU and addressing barriers to care through work with a PRC. Findings also highlight important barriers and facilitators to implementation of this model, including the need for adaptation based on individual goals and fluctuations in readiness for treatment.

COVID-19 IDD: A global survey exploring family members' and paid staff's perceptions of the impact of COVID-19 on individuals with intellectual and developmental disabilities and their caregivers

Background: This protocol outlines research to explore family members' and paid staff's perceptions of the impact of COVID-19 on individuals with intellectual and developmental disabilities and their caregivers. Evidence suggests that people with intellectual and developmental disabilities experience disparities in healthcare access and utilisation. This disparity was evident early in the pandemic when discussions arose regarding the potential exclusion of this population to critical care. Methods: An anonymous online survey will be conducted with caregivers, both family members and paid staff, to explore their perceptions of the impact of COVID-19 in terms of demographics, living arrangements, access to services, social distancing, and carer wellbeing. The survey will be developed by the research team, many of whom are experts in intellectual disability within their own jurisdictions. Using back-translation our team will translate the survey for distribution in 18 countries worldwide for international comparison. The survey team have extensive personal and professional networks and will promote the survey widely on social media with the support of local disability and advocacy agencies. Statistical descriptive and comparative analyses will be conducted. Ethical approval has been obtained for this study from University College Dublin's Human Research Ethics Committee (HS-20-28-Linehan). Dissemination: Study findings will be prepared in a number of formats in order to meet the needs of different audiences. Outputs will include academic papers, lessons learned paper, practice guidelines, reports, infographics and video content. These outputs will be directed to families, frontline and management delivering disability services, national-level policy makers, healthcare quality and delivery authorities, national pandemic organisations and international bodies.

COVID-19 IDD: A global survey exploring family members' and paid staff's perceptions of the impact of COVID-19 on individuals with intellectual and developmental disabilities and their caregivers

Background: This protocol outlines research to explore family members' and paid staff's perceptions of the impact of COVID-19 on individuals with intellectual and developmental disabilities and their caregivers. Evidence suggests that people with intellectual and developmental disabilities experience disparities in healthcare access and utilisation. This disparity was evident early in the pandemic when discussions arose regarding the potential exclusion of this population to critical care. Methods: An anonymous online survey will be conducted with caregivers, both family members and paid staff, to explore their perceptions of the impact of COVID-19 in terms of demographics, living arrangements, access to services, social distancing, and carer wellbeing. The survey will be developed by the research team, many of whom are experts in intellectual disability within their own jurisdictions. Using back-translation our team will translate the survey for distribution in 18 countries worldwide for international comparison. The survey team have extensive personal and professional networks and will promote the survey widely on social media with the support of local disability and advocacy agencies. Statistical descriptive and comparative analyses will be conducted. Ethical approval has been obtained for this study from University College Dublin's Human Research Ethics Committee (HS-20-28-Linehan). Dissemination: Study findings will be prepared in a number of formats in order to meet the needs of different audiences. Outputs will include academic papers, lessons learned paper, practice guidelines, reports, infographics and video content. These outputs will be directed to families, frontline and management delivering disability services, national-level policy makers, healthcare quality and delivery authorities, national pandemic organisations and international bodies.

Personal characteristics and outcomes of individuals with developmental disabilities who need support for self-injurious behaviour

BACKGROUND

For people with intellectual and developmental disabilities, self-injurious behaviour (SIB) can have serious negative effects on both health and quality of life. This descriptive analysis will provide information on the characteristics and outcomes of a subsample of individuals who are identified as needing some or extensive support for SIB in the National Core Indicators Adult Consumer Survey sample.

METHODS

The data for this analysis come from states that participated in the 2015-2016 data collection cycle of National Core Indicators Adult Consumer Survey which is a face-to-face survey of adults receiving services through state developmental disability agencies.

RESULTS

The characteristics and outcomes of individuals who need at least some support for SIB differ from those of individuals with intellectual and developmental disabilities who do not need support for SIB. Individuals with SIB support needs, for example, tend to live in more structured settings, have fewer relationships, less inclusion in their communities and poorer employment outcomes.

CONCLUSIONS

The exploratory descriptive analysis concludes with suggested recommendations for more standardised definitions of SIB in public systems, enhanced behaviour plan protocols and the need for additional research.

Place of residence and preventive health care for intellectual and developmental disabilities services recipients in 20 states

OBJECTIVE

We identified trends in the receipt of preventive health care by adults with intellectual and developmental disabilities by type of residential setting.

METHODS

We used data from the 2008-2009 collection round of the National Core Indicators (NCI) program. Participating states drew random samples of adults receiving developmental disabilities services. The study was observational, with both self-report and report by proxy. Once the random samples were drawn in each state, data were collected using the NCI Adult Consumer Survey. Trained interviewers administered the survey in person.

RESULTS

The likelihood of a person receiving preventive care procedures was related to age, level of intellectual disability, mobility, health status, and state. Type of living arrangement also affected whether a person received these health services, even after controlling for state, level of disability, and other personal characteristics. In general, people living with parents or relatives were consistently the least likely to receive preventive health exams and procedures.

CONCLUSION

With growing numbers of adults being served in the family home, educational and policy-based efforts to ensure access to preventive care are increasingly critical.

How to Involve Undergraduate Medical Students in Psychiatric Research

The poster will address the important issue of how we can use opportunities in teaching our medical students how to take a wider view of psychiatry and learn to ‘think outside the box’ thus broadening their vision, enabling them to challenge presently held concepts, while at the same time learning the basic tenets of our profession.

Clearly, this is done by involving our students in clinical research based and audit based activities. However not all schools or teachers are comfortable with doing this, while the medical curriculum is broad, and there is a risk that students ‘only study for exams’.

Research based activities, including simple things such as using basic it skills to do a literature search for a review article or carrying out a useful clinical audit, using a unit held database, are however things which students can easily do, and these can lead to publishable case reports, posters, or ever articles in peer reviewed journals.

The poster will illustrate how we developed research activities with students at Cambridge University Clinical School. It shall discuss the advantages, difficulties, and indeed enjoyment of carrying out such activities.

Management of rectal prolapse in children

PURPOSE

Rectal prolapse in children is not uncommon and usually is a self-limiting condition in infancy. Most cases respond to conservative management; however, surgery is occasionally required in cases that are intractable to conservative treatment. This study was designed to analyze the outcomes of rectal prolapse in children and to propose a pathway for the management of these cases in children.

METHODS

A retrospective analysis of all cases of rectal prolapse referred to our surgical unit during a period of five years was performed. End point was recurrence of prolapse requiring manual reduction under sedation or an anesthetic. Results are presented as median (range) and statistical analysis was performed using chi-squared test; P < 0.05 was considered significant.

RESULTS

A total of 49 children (25 males) presented with symptoms of rectal prolapse at a median age of 2.6 years (range, 4 months -10.6 years). All children received an initial period of conservative treatment with watchful expectancy and/or laxatives. Twenty-five patients were managed conservatively without any additional procedures (Group A), and 24 patients had one or more interventions, such as injection sclerotherapy, Thiersch procedure, anal stretch, banding of prolapse, and rectopexy (Group B). Management of rectal prolapse was successful with no recurrences in 24 patients (96 percent) in Group A vs. 15 patients (63 percent) in Group B at a median follow-up period of 14 (range, 2-96) months. An underlying condition was found in 84 percent of patients in Group A vs. 54 percent in Group B (P = 0.024). The age at presentation was younger than four years in 88 percent of patients in Group A vs. 58 percent in Group B (P = 0.019).

CONCLUSIONS

Rectal prolapse in children does respond to conservative management. A decision to operate is based on age of patient, duration of conservative management, and frequency of recurrent prolapse (>2 episodes requiring manual reduction) along with symptoms of pain, rectal bleeding, and perianal excoriation because of recurrent prolapse. Those cases presenting younger than four years of age and with an associated condition have a better prognosis. The authors propose an algorithm for the management of rectal prolapse in children.

Interaction of eicosanoids and nitric oxide in renal reperfusion injury

BACKGROUND

Both the eicosanoids and nitric oxide are known to play an important role in the pathogenesis of postischemic injury. Recent evidence has suggested that the generation of each may affect the other via a feedback loop. This was investigated in an experimental model of renal warm ischemia reperfusion injury.

METHODS

Rats underwent bilateral renal warm ischemia (15-60 min) then reperfusion (20 or 80 min) followed by a unilateral nephrectomy to measure renal nitric oxide (as nitroxides) and eicosanoids. Renal function was measured on days 2 and 7 prior to terminal nephrectomy for tissue analysis.

RESULTS

Vasodilator eicosanoids (6-KPGF1alpha and PGE2) fell on reperfusion in line with the duration of warm ischemia with a concomitant rise in the vasoconstrictor TxA2. The ratio of vasodilator to vasoconstrictor eicosanoids fell from 8.22 (2.3) in the control to 0.82 (0.1) in the 60-min warm ischemia group (P<0.01). Renal levels of nitroxides rose on reperfusion demonstrating an inverse correlation with the eicosanoid ratio (r2=0.86). Renal function was impaired at both day 2 and day 7 and showed a positive correlation with the eicosanoid ratio (r2=0.67 and 0.62, respectively).

CONCLUSIONS

Renal warm ischemic injury is associated with a progressive fall in the ratio of vasodilator-to-vasoconstrictor eicosanoids from early in reperfusion through to day seven although nitric oxide was elevated throughout the same period. There was no evidence of coinduction of nitric oxide synthase and cyclooxygenase in this model.

Data elements for emergency department systems, release 1.0 (DEEDS): a summary report. DEEDS Writing Committee

Variations in the way that data are entered in emergency department record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership's initial product, Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations.

Data elements for emergency department systems, release 1.0 (DEEDS): a summary report. DEEDS Writing Committee

Variations in the way that data are entered in ED record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention's (CDC) National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership's initial product. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations.

On-line charging = increased revenue

Although the new ED charge system is not perfect, it has resulted in improved charging for services delivered; this increase in correct charges has more than offset the resources to develop the entire tracking system project within 1 year. This is one example in which computerization paid for itself, which should help ED managers justify computerization of their departments. It is hoped that more effective charge systems will occur as a component of the computerized patient record in which the patient charge is calculated on the basis of preset formulas for the amount of resources utilized, thus eliminating subjectivity in charging. With the capture of all services rendered, evaluation of practice patterns and outcomes would allow the ED staff to identify effective treatment regimens. Hopefully, unnecessary tests or treatments can be eliminated to promote a decrease in resource utilization and costs without compromising quality patient care.

Computers: getting started

Because there is not much written about computer application in the emergency department you will frequently find yourself reading about applications in other areas. It is up to you to apply this information in the emergency setting. This makes you pioneers, in search of a new and better tomorrow. Our future is not yet written. It is waiting on you and your creative ideas to keep the wagon rolling. Don't let the new territory of informatics, hardware hardships, and foreign computer languages get you down. Accept informatics as just another challenge, like the many we have faced successfully in the past. Use these resources and your expertise in emergency nursing to create innovative informatic systems.

A luteinizing hormone-releasing hormone agonist decreases biological activity and modifies chromatographic behavior of luteinizing hormone in man

The effect of the luteinizing hormone-releasing hormone (LHRH) agonist, [D-Trp6,Pro9-NEth]LHRH (LHRHA), on luteinizing hormone (LH) bioactivity was assessed with a rat interstitial cell assay in four men during a 14-d treatment period. Biologic/immunologic (B/I) ratios were unchanged initially with treatment but by day 12 had fallen to levels lower than basal values. Frequent sampling on day 12 revealed blunted gonadotropin responsiveness to LHRHA and absence of spontaneous LH pulsations. Despite continued administration of LHRHA, human chorionic gonadotropin administration resulted in elevated B/I ratios and testosterone levels. Further characterization of the serum immunoreactive LH by Sephadex chromatography revealed a later elution profile during treatment with LHRHA. Thus, LHRHA appears to act, in part, by modification of the bioactivity of LH in man.