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Background Recently, the frequency of audit inspections of health services for people with intellectual disability (ID) in the UK has increased, from occasional inquiries to a systematic audit of all services. From 2008, a process of continuous audit ‘surveillance’ of specialist health services is to be introduced. Similar regimes of inspection are in place for social care services. Aim To explore the conceptual positions which inform audit, through detailed examination of the investigation into the learning disability service at Sutton and Merton. Findings Audit is distinct from evaluation because it neither provides opportunities for service staff to give an account of their work nor represents a search for knowledge. Audit investigates adherence to government policy. In ID, audits measure aspirations derived from normalisation, despite research showing that some of these aspirations have not been achieved by any service. As audit consumes significant public resource, it is questionable whether the dominant finding of the Healthcare Commission's investigation into Sutton and Merton, that the ID service was chronically under-funded, represents value for money. Discussion and conclusions While basic checks on minimum standards will always be necessary, service excellence requires not audit but research-driven evaluation. Audits inhibit rather than open-up debate about improving support to people with ID. They impose an ideology, squander resource, and demoralise carers and staff. Evaluations challenge the implicit management-versus-professional binary enacted by audit, and can inform new care systems which make effective use of all those engaged with people with ID.

Background Theoretical literature in the intellectual disability (ID) field identified a mismatch between professional codes of practice (which assume clients to be ‘autonomous’) and the reality of fostering autonomy for people with ID (who at times are completely dependent on others). This research aimed to understand how professionals bridged this disjunction and actually provided ethical services with this client group. Method Nine professionals from adult ID services who had consulted with local Ethical Advisory Groups were interviewed about their experience of addressing an ethical issue within their work. Accounts were subjected to narrative analysis. Results Professionals' narratives featured the following themes: differing sources of conflict, professional vulnerability and seeking validation around resolution, centrality of relationships, fragility of resolutions and maintaining moral integrity. Conclusions Findings revealed systemic pressure on professionals to find ‘definitive’ solutions to ethical dilemmas when the issues were not open to such resolution. Findings were reviewed in light of ethical literature that shows how professionals' work inevitably features close and enduring relationships with people with ID. We suggest professionals need to draw on ethical frameworks that can accommodate relational aspects of their practice.

Background Research using the concept of Post-Traumatic Stress Disorder (PTSD) with adults with intellectual disability (ID)assumes they perceive and react to traumatic events in a similar way to non-disabled adults. Reactions to trauma displayed by children may be relevant to adults with ID as well. Methods Two focus groups were held with professionals and practitioners to explore the relevance of criteria from child as well as adult literature to adults with ID who experience trauma. Descriptive thematic analysis was carried out. Results Abuse, parental bereavement, and having children removed were considered common sources of trauma. Similarities identified between disabled and non-disabled adults were flashbacks and nightmares; distressed by reminders; avoidance; hypervigilance and increased arousal. Differences were the frequent occurrence of multiple rather than single events, which were considered significant in generating chronic problems similar to those described as PTSD; also the occurrence of physical health problems and behavioural re-enactments. Discussion and conclusions Experienced professionals and practitioners considered most of the ideas from PTSD research with non-disabled adults to be relevant to adults with ID who experience trauma, but that some behaviour reported in research with children was also relevant. Topics and questions for use in clinical and research practice with individuals who have experienced trauma were proposed.

Background The present authors investigated a database about people with severe intellectual disability (ID) to explore whether secure/insecure attachment plays a role in challenging behaviour. Methods The study took the form of a survey of staff and carers involved with a cohort of 54 school-leavers with severe ID. Results Thirty-four per cent of students were rated by placement staff as ‘over-investing in one or a few relationships which become a source of jealousy’. Students without such problems were significantly less likely to show challenging behaviours, while those with them were significantly more likely to be living outside the family home. Conclusions These preliminary results justify more detailed and longitudinal research into the relationship between attachment status and challenging behaviour.

Although bullying has been shown to reduce quality of life in many spheres, anti-bullying strategies have yet to be incorporated into services for adults with severe intellectual disability (ID). The present study employed a survey of staff and parent concerns about 54 previously surveyed students who had left a school for pupils with severe ID. A content analysis of follow-up interviews was performed in 10 cases. Staff identified 19% of the survey sample as bullying others and 11% as being picked on. Neither gender nor communication ability had an impact. There was no significant change in bully or victim status over time, although some people did change. Parents or staff raised bully/victim problems in more than half of the interviews. There is sufficient evidence of bullying behaviour to warrant the adoption of anti-bullying strategies.