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The use of out-of-area placements to meet the needs of individuals with intellectual disabilities and challenging behaviour has been increasing in the UK. Such placements claim a large proportion of service budget expenditure; therefore, it is important to consider whether they offer the best-quality care. This paper reports on current evidence relating to such placements and uses a scoping review across five London boroughs to illustrate key issues on provider characteristics and aspects of good practice.We conducted a literature review to identify papers that describe out-of-area placements and carried out a postal survey of 54 service providers that delivered services to service users from five London boroughs.Individuals with intellectual disability and challenging behaviour are more likely to be placed out-of-area in services of variable quality and a minority may underperform. Our empirical data suggest that the private sector that is the main accommodation provider is most likely to underperform on meeting standards of care.Overall, the majority of out-of-area providers appear to supply a good standard of care but there are many factors that continue to hinder the local treatment of individuals who present with challenging behaviour. There is an imperative to identify poorly performing providers as well as exploring ways in which service users, out-of-area, can be supported effectively.

Recent studies in the development of professionalism suggest that western society witnesses a transformation of professional practices in human services that deeply affects how professionals experience their work. This paper describes key aspects of this development and presents an account of how it can be explained.The paper offers a review of the main features of neoliberal managerialism as it is found in the literature. The paper does not assume a meta-theoretical perspective on this literature but rather presents an account on the level of description of what the literature interprets as a transformation of professional practices. Its method is therefore to report the main features of what the literature describes as neoliberal changes in human services.The review results in an account of the transformation of professionalism in human services that shows two sides. One is that of opposing logics that present the tensions between professionalism and managerialism in terms of conflict. The other side is that of compliance of professionals who seek to find their way in the new realities of a neoliberal service economy.I conclude that neoliberal managerialism presents serious challenges to professionals in human services to remain faithful to the values of their profession, and that these challenges--on the level of neoliberal society--raise a serious issue about social (dis)trust.

Complicated grief has been identified as a phenomenon in the general population, and there is an increasing body of research investigating complicated grief in people with intellectual disability. The aim of this study is to synthesise this existing knowledge from research published between 1999 and 2022.A structured systematic review using PRISMA guidelines was conducted, which searched three commonly used databases (Medline, PsycINFO and CINAHL) for research on the topic of bereavement and intellectual disability. The articles identified in this search were screened to identify those that addressed the issue of 'complicated grief', with all abstracts and subsequent full texts reviewed by two researchers.In total, 179 abstracts were initially identified, with 34 articles eligible for full text screening and 18 papers reaching criteria for inclusion. Data relating to the studies' objectives were extracted under the headings of definition, defining principles, signs and symptoms, risk factors and treatments for complicated grief in intellectual disability. Thematic analysis of the extracted data was performed to identify key themes.This review highlights that people with intellectual disability are likely to experience complicated grief reactions and that complicated grief is both underestimated and a clinically significant condition for people with intellectual disability. Future research should work to clarify diagnostic criteria and identify appropriate interventions.

Background This paper seeks to understand and conceptualize the experience of mothers of adolescents with intellectual disabilities (IDs) at a time in their lives which others have characterized as ‘mid-life’ or the ‘middle years of parenting’. The concerns of the paper are the lifecourse concerns in mothers’ own lives and with biographical elements of becoming and being such a parent. Methods Qualitative interviews were conducted with mothers of adolescents with IDs. The average age of mothers was 48 years. Typically parents were interviewed on two to three occasions. Results The data suggest that despite the difficulties they faced, these parents had constructed a ‘life-as-ordinary’ in the early phase of their parental careers. They saw themselves as ‘ordinary mothers’. However, the social content and events of the middle years of parenting prompt a realization that their lives and, for some, their sense of ‘self’, are undergoing considerable change. Mothers are forced to look over their lives to find the meaning and significance of these events. For some, there is biographical reinforcement. For others, there is only disruption. Discussion The overall picture of these years is one of considerable changes and challenges, and underlines the need for a focus on the lifecourse concerns of parents as well as their children. The implications of the data for further research and service development are discussed in the context of identity theory.

In recent years, a growing volume of research evidence has been generated about the relative cost-effectiveness of various types of community-based residential supports for people with intellectual disability (ID) in the UK. However, few reliable data are available to inform planners, commissioners or service providers about the quality and costs of providing support within residential or village communities.The evaluation described in the present paper aimed to fill some of the gaps in knowledge by examining the comparative costs of supporting people in village community settings, in National Health Service (NHS) residential campuses and in dispersed, community-based housing schemes. The complete service package received by each study participant was described and costed, and a series of statistical analyses was undertaken to identify factors associated with variations in the cost of support. The analyses reported in the present paper were based on comparisons of 86 people living in village communities, 133 in residential campuses and 281 in dispersed housing schemes.Wide variations in cost were found, not only between models of accommodation, but between individual organizations, settings and service users. Multivariate analysis revealed that higher costs were associated with supports for people with higher levels of ID and more severe challenging behaviour. The cost of support was affected by the size of the residential setting, with smaller facilities likely to be more expensive. Associations were also found between increased costs, and services for younger users, male users and people who had not moved from a NHS hospital. Generally, more sophisticated service processes within the setting were associated with higher costs; although systematic arrangements for supervision and training of staff had a negative effect on cost.The cost findings should be considered alongside evidence on outcomes. A comparison of village communities and dispersed housing schemes suggests that both models of provision appear be associated with particular benefits, although different types of setting are appropriate for different individuals and therefore, the continued development of a range of residential models is important.

The purpose of this paper is to present an overview of current trends in the field of dual diagnosis in the United States. Policy, programme, diagnostic and treatment issues are reviewed. The paper will examine the effects of the social policy of deinstitutionalization on people who have a dual diagnosis and will offer policy ideas for ameliorating some of the significant obstacles facing this population. Exemplary programme models are briefly discussed to illustrate the development of effective services. The challenges of assessing psychopathology in people with mental retardation are addressed. Several therapy and treatment modalities that have proven to be effective with people who have a dual diagnosis are also discussed. Lastly, this paper mentions a new community ideology driven by the values of consumers choice and satisfaction.

The study of measurements of quality of life (QoL) is one of the great challenges of modern psychology and psychometric approaches. This issue has greater importance when examining QoL in populations that were historically treated on the basis of their deficiency, and recently, the focus has shifted to what each person values and desires in their life, as in cases of people with intellectual disability (ID). Many studies of QoL scales applied in this area have attempted to improve the validity and reliability of their components by incorporating various sources of information to achieve consistency in the data obtained. The adaptation of the Personal Outcomes Scale (POS) in Spanish has shown excellent psychometric attributes, and its administration has three sources of information: self-assessment, practitioner and family. The study of possible congruence or incongruence of observed distributions of each item between sources is therefore essential to ensure a correct interpretation of the measure. The aim of this paper was to analyse the observed distribution of items and dimensions from the three Spanish POS information sources cited earlier, using the item response theory.We studied a sample of 529 people with ID and their respective practitioners and family member, and in each case, we analysed items and factors using Samejima's model of polytomic ordinal scales.The results indicated an important number of items with differential effects regarding sources, and in some cases, they indicated significant differences in the distribution of items, factors and sources of information.As a result of this analysis, we must affirm that the administration of the POS, considering three sources of information, was adequate overall, but a correct interpretation of the results requires that it obtain much more information to consider, as well as some specific items in specific dimensions. The overall ratings, if these comments are considered, could result in bias.

Article 29 of the Convention on the Rights of Persons with Disabilities guarantees equality of political rights, including the right to vote and stand for election. The affirmation of these rights, first guaranteed by the Universal Declaration of Human Rights, raises an important question given the long-standing association between political rights and beliefs concerning the abilities of citizens to reason and act independently: how and to what degree can people identified as having intellectual disabilities participate in a defining act of the democratic process? Focused specifically on the right to vote, this paper addresses the question by (1) introducing the debates that have surrounded the voting rights of this population; and (2) reporting on recent attempts in Kenya, and in England and Wales, to promote voting by people with intellectual disabilities. It concludes by considering the effectiveness of the different approaches these countries have adopted.

People with intellectual disability (ID) experience health inequity compared with the general population, a key contributing factor being disparities in social determinants of health. The enactment of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) provides a platform for the progression and promotion of health and other interconnected rights to address barriers to the highest attainable standard of health for this populace. Rights can be brought to life through advocacy efforts. This paper explores the meaning, perceptions and experiences of advocacy by family members and paid support workers of adults with ID and locates the findings within a health and human rights discourse.As part of a larger randomised controlled trial, 113 parents and 84 support workers of adults with ID completed a telephone interview that included open-ended questions about their understanding and experiences of advocacy. Thematic analysis was used to identify relevant themes.Five key themes were identified. The first underscored how advocacy to 'speak up' for the person with ID is integral to both parent and support worker roles. The second and third themes considered the contexts for advocacy efforts. Access to quality health care was a core concern, along with advocacy across other areas and sectors to address the person's wider psychosocial needs. The remaining themes highlighted the many dimensions to advocacy, including differences between parent and support worker views, with parental advocacy being an expression of 'caring' and support workers motivated by a 'duty of care' to protect the individual's 'rights'.Parent and support worker advocacy provides one means to address the social determinants of health and fulfilment of health rights of and for people with ID. Policy and practice in the context of governmental obligation under the CRPD should support advocacy and make health rights the reality not rhetoric for this group of men and women.

Intellectual and developmental disability (IDD) researchers have been relatively slow to adopt the search for moderators and mediators, although these variables are key in understanding how and why relationships exist between variables. Although the traditional method of causal steps is useful for describing and understanding moderators and mediators, it is not sufficient for statistical analysis.The theoretical and statistical processes of evaluating moderators and mediators are explained in terms familiar to IDD psychologists, using examples from IDD literature. Moderator and mediator analyses in five leading IDD journals are assessed for patterns of usage.Although the number of publications in the past decade exceeds previous years, the field is still behind others in both the quantity and quality of the use of moderators and mediators.The field as a whole will advance if the recent theoretical and technical advances outlined in this paper are employed.

There is substantial literature investigating quality of life (QoL) of individuals with intellectual disability (ID). QoL of families of people with ID is emerging as an important field of research. Despite this, there is a lack of studies regarding their relationship.The present paper aimed to study the relationship between QoL scores of individuals with ID and members of their families.Twenty-seven parents or relatives of 27 adults with ID were recruited by four different research centres across Tuscany (Italy) to be interviewed through the Italian adaptation of the Family Quality of Life Survey - 2006 (FQoLS-2006), a tool developed for use in a multiple-country study on family QoL. The FQoLS-2006 was translated and adapted to Italian through three revisions. The last was submitted to the authors of the original version, who also maintain an electronic data file and data archive for statistical evaluations in various countries. QoL of persons with ID was assessed through the administration of the Quality of Life - Instrument Package. QoL scores were analysed to describe population characteristics and to examine the relationships among measures of individual and family QoL using correlations (Pearson and Spearman).Findings showed that family ratings of QoL were generally low. Families interviewed reported a low level of QoL in 'Support from Others' and 'Community Interaction', while 'Family Relationships' and 'Health of the Family' rated higher. For individual QoL, individuals had the lowest scores in the area of 'Spiritual being' and higher scores in the area of 'Physical being'. Correlations examining possible relationships among Importance, Satisfaction and Opportunities found some statistically significant correlation coefficients between some aspects of the three main areas of individual QoL (Being, Belonging and Becoming) and the nine family domains. Most of these correlations regarded family 'Financial Well-Being', 'Family Relationships, 'Support from Service' and 'Support from Others' areas.The results of this study suggest that QoL is perceived somewhat differently by individuals with ID and by members of their families. This difference could negatively impact QoL of people with ID, if their views are not taken into account when planning for family support. The relationships between individual and family QoL appear to be quite complex, and such complexity needs to be clarified in future research.

Social integration of people with intellectual disability (ID) moving into regular neighbourhoods tends to be studied and evaluated without detailed knowledge about the social psychological aspects of everyday interaction between neighbours with and without ID. The goal of the present paper is to show how the authors' social psychological research programme may contribute to this field of inquiry.The different ways in which societies respond to features and behaviours that may be perceived as deviant are theoretically analysed. Results of empirical studies are reported to clarify how social responses to people with ID are special in terms of perceptions, emotions and interaction desires of people with and without ID during a pre-contact and contact phase.On the basis of the theoretical analysis, it is concluded that regular neighbouring in modern Western society often takes the form of benevolent tolerance, rather than stigmatisation and prejudice. However, empirical studies reveal that, prior to getting people with ID as new neighbours, prospective neighbours without ID experience a specific pattern of emotions that are associated with specific desires (e.g. with respect to information supply or a caring relationship). These anticipatory reactions are dependent on the expected size of the group moving in and on the severity of ID. Furthermore, while actually engaging in neighbouring, neighbours with and without ID appear to have experiences related to behaviour of residents, staff and features of housing facilities that are perceived as (in)congruent with regular neighbouring.It is concluded that interpersonal relationships between neighbours with and without ID should not be simplified in terms of attitudes that would be primarily prejudiced/stigmatising versus entirely accepting. Rather, our studies paint a more complex picture of sometimes ambivalent thoughts, feelings and interaction needs that all should be taken into account to make social integration a success.

The Taiwanese government launched a new programme in November 2004 to support adults with intellectual disabilities living in smaller facilities. This paper aims to evaluate the service outcomes of this new residential scheme over 2 years including those residents who moved from an institution and those who moved from their family.A one-group repeated-measures analysis was conducted for five interviews after the adults with intellectual disabilities entered the new environment. Forty-nine adults were initially studied (T1) and 29 adults remained in the homes until the end of the study (T5).This study found significant improvements over the 2 years in the residents' quality of life and family contact. The results also highlight a decrease in maladaptive behaviour among the residents moving from institution and an increase in choice making and family contact among the residents moving from family. No significant changes in adaptive behaviour and community inclusion were found.Results revealed that further policy changes and financial support including service quality assurance are required in order to improve service outcomes for adults living in the new residential scheme.

The association between poverty and intellectual disability (ID) has been well documented. However, little is known about persons with ID who face circumstances of extreme poverty, such as homelessness. This paper describes the situation of persons with ID who were or are homeless in Montreal and are currently receiving services from a team dedicated to homeless persons.(1) To describe the characteristics, history and current situation of these persons; and (2) to report within-group differences as a function of gender and current residential status.The data were collected from files using an anonymous chart summary. Descriptive statistics on the whole sample (n = 68) and inferential statistics on cross-tabulations by gender and residential status were performed.Persons with ID exhibited several related problems. Some of these persons, primarily women, experienced relatively short periods of homelessness and their situations stabilised once they were identified and followed up. Other persons with ID experienced chronic homelessness that appeared to parallel the number and severity of their other problems. When compared with a previous epidemiological study of the homeless in Montreal, the population of homeless persons with ID differed from the overall homeless population in a number of respects.The results suggest prevention and intervention targets. The need for epidemiological research appears particularly clear in light of the fact that below-average intellectual functioning has been identified as a risk factor for homelessness and a predisposing factor for vulnerability among street people.

This paper describes the development of an Attitudes to Disability Scale for use with adults with physical or intellectual disabilities (ID). The aim of the research was to design a scale that could be used to assess the personal attitudes of individuals with either physical or ID.The measure was derived following standard WHOQOL methodology as part of an international trial. In the pilot phase of the study, 12 centres from around the world carried out focus groups with people with physical disabilities, people with ID, with their carers, and with relevant professionals in order to identify themes relevant for attitudes to disability. Items generated from the focus groups were then tested in a pilot study with 1400 respondents from 15 different centres worldwide, with items being tested and reduced using both classical and modern psychometric methods. A field trial study was then carried out with 3772 respondents, again with the use of both classical and modern psychometric methods.The outcome of the second round of data collection and analysis is a 16-item scale that can be used for assessment of attitudes to disability in physically or intellectually disabled people and in healthy respondents.The Attitudes to Disability Scale is a new psychometrically sound scale that can be used to assess attitudes in both physically and intellectually disabled groups. The scale is also available in both personal and general forms and in a number of different language versions.

Background Hospital closure programmes in England have generally sought to attain a fulfilling life for people with an intellectual disability by locating them in domestic-style housing in urban settings. Few have been placed in intentional or ‘village’ communities. Yet comparative studies of different housing types have found that intentional communities have better or similar outcomes for their residents than dispersed housing or residential clusters on former hospital sites. A possible explanation is the distinctive pattern of social relationships that exist in many intentional communities and the impact this has on the lives of their residents. This paper reports the results of research that explores the perceptions of people with an ID living in an intentional community and the meaning of their community to them. Methods The research used an ethnographic approach to interview a sample of 15 residents in a large intentional community (Botton Village), which is part of the Camphill Movement. Interviews used Makaton, pictures and symbols where required. Results Respondents included 10 men and 5 women aged between 38 and 78 years. Length of residence in Botton Village ranged from 5 to 50 years. All lived with the families of co-workers and valued these relationships. All but one (who had retired) worked in a diverse range of employment in the village. Almost all were positive about their work. Respondents reported that they took part in both individual and communal leisure activities and all but two had a network of friends. Opportunities for friendship were enhanced by proximity to other people with an ID and a sense of personal security in the village. As in many villages and communities in society in general, these advantages were balanced by some loss of privacy. Conclusions Results confirm those from earlier studies of intentional communities and suggest that positive outcomes derive from the absence of the overt subordination of residents to staff, the facilitation of friendship with other people with an ID, high levels of meaningful employment and a sense of community. These factors contrast with the experience of living in small homes funded on a contractual basis by public authorities, in which cost pressures reduce wage levels for staff resulting in difficulties in retaining suitable staff and a consequent high staff turnover.

Recent literature on professionalism describes the hybridisation of professional practices because of the pressures of neo-liberal managerialism. While the general opinion appears to be that this development was inevitable given the task of service organisations to operate on the market, this paper questions that blurring the distinction between professional and managerial responsibilities is sound business advice for market-orientated service providers.The method is philosophical analysis. A normative account of 'true' professionalism is discussed in order to determine the relation between professionalism and managerialism. By placing this account in the framework of Aristotelian moral philosophy, three distinctions are presented to argue that professional practices will most likely be successful in managerial terms when the internal values of professional practices are not mixed up with the external values of the service organisation.The analysis results in an argument about economic value as a contingent 'by-product' of professional expertise. The outcome is the prediction that professional activity will be most responsive to organisational goals implemented and monitored by management to the extent that professionals are enabled to serve the goals internal to their profession. Professional excellence will be most profitable when professionals do not have to mind about being profitable.Neo-liberal managerialism assumes that making professionals share managerial values of accountability and transparency will improve both the economic performance of service organisations and the quality of their services. The argument concerning the contribution to these values by professionals as a contingent by-product of professional excellence shows that this assumption is questionable.

The turn to neoliberalism in welfare policy suggests that human services need to be based on a market approach. The problem with this suggestion is that it presupposes marketing information such that service providers can market their services for identified client needs. In the field of intellectual disability (ID) services this type of information is not available.The method is a reflective analysis of the key presupposition of a market-orientated approach to disability services, namely that service providers know who needs what. Using insights from marketing theory the paper engages in a reflective thought experiment to lay out the intricacies of this presupposition.The analysis results in an argument regarding the validation of a market-based approach to disability services. First, this approach has its limits in view of the question of whether the specific and atypical needs of people with ID, as well as their financial position as potential consumers constitute a market. Second, the approach has limited validity both in view of the ability of people with ID to act as consumers, and of the restrictions imposed upon them by the eligibility criteria for welfare and support programmes.A market-based approach to disability services and supports can be helpful to spur innovation and further political and philosophical inquiry in human services, but the neoliberal optimism about the market as the only successful mechanism for service distribution is misplaced.

Background Research on the dental health of people with intellectual disability has consistently reported more untreated dental disease, more extractions and fewer fillings than in the general population. This paper describes the oral health of participants at the 2005 Glasgow Special Olympics (SO), relating this to the general population studied in the 1998 UK Adult Dental Health Survey (ADHS) and to participants' age and region of residence. Methods Consenting SO participants were offered oral examinations which followed the standardized SO protocol plus an innovative soft tissue examination. Urgency of any treatment required was noted and reported to participants and carers. Three measures of good dental health – having 21 or more natural teeth, absence of fillings and having no obvious untreated decay – were compared across age groups, regions and with the general population. Logistic regression was used to control for age differences between regions. Results In total, 1021 oral examinations were completed. Older SO participants were more likely to have fewer than 21 teeth and to have fillings, untreated decay, gum inflammation and heavy plaque levels. In all, 28% of SO participants had 21 or more teeth, no fillings and no obvious decay. Those from the north, midlands and south regions of England had significantly more chance of good dental health so defined compared with participants from Scotland [ORs 1.67 (1.09, 2.67), 1.69 (1.12, 2.54), 1.99 (1.26, 3.16), respectively]. Compared with the general population surveyed in the 1998 ADHS study, SO participants were more likely to be free from fillings and obvious untreated decay, but fewer had 21 or more natural teeth among older age groups. Nine per cent were found to have soft tissue problems, and one in four of these required follow-up. Gum inflammation was common. Overall, 5% of participants were judged to require urgent treatment for dental or soft tissue problems and 40% to require non-urgent treatment. This rose to 9% and 66% respectively among those aged 35 years and over. Discussion The low prevalence of untreated decay and fillings among SO participants compared with the general population may be due to their being well supported by family and carers. The study identifies the vulnerability of the older participants to dental problems, and this may indicate greater difficulty maintaining surveillance as individuals age or informal carers become less able or available. Regional variations are similar to those found in the general population. The implications for the organization of care for this group are discussed.

Changes in residential accommodation models for adults with intellectual disability (ID) over the last 20 years in Australia, the United Kingdom and the United States have involved relocation from institutions primarily into dispersed homes in the community. But an evolving alternative service style is the cluster centre. This paper reports on the relocation of a matched group of 30 pairs of adults with moderate and severe IDs and challenging behaviour who were relocated from an institution into either dispersed housing in the community or cluster centres but under the same residential service philosophy. Adaptive and maladaptive behaviour, choice-making and objective life quality were assessed prior to leaving the institution and then after 12 and 24 months of living in the new residential model. Adaptive behaviour, choice-making and life quality increased for both groups and there was no change in level of maladaptive behaviour compared with levels exhibited in the institution. However, there were some significant differences between the community and cluster centre group as the community group increased some adaptive skills, choice-making and objective life quality to a greater extent than the cluster centre group. Both cluster centre and dispersed community living offer lifestyle and skill development advantages compared with opportunities available in large residential institutions. Dispersed community houses, however, offer increased opportunities for choice-making, acquisition of adaptive behaviours and improved life quality for long-term institutionalized adults with IDs.

BACKGROUND This paper reports results from a total population of persons with intellectual disabilities (ID) in Western Australia arrested for the first time since 1 April 1984. It is part of a longitudinal study that 'tracked' offenders with ID through the criminal justice system over an 11-year period to compare their experiences at each stage of the justice process with a sample of the general offending population. The research draws on an analysis of the Western Australian Police Services Apprehension records and the Disability Services Commission database. METHOD The data collected provided the opportunity to calculate base rates of the probability of rearrest of offenders with ID in comparison to mainstream offenders. RESULTS The study found that people with ID had a significantly higher rate of rearrest than general population offenders and the study canvasses some possible reasons for this finding.

Background Social stigma and its impact on the life opportunities and emotional well-being of people with intellectual disabilities (IDs) are a subject of both practical and theoretical importance. The disability movement and evolving theories of self, now point to individuals’ ability to develop positive identities and to challenge stigmatizing views and social norms. Method This paper presents findings from a phenomenological study of 10 individuals making the transition from their family home to live more independently and 18 individuals moving from a long-stay hospital to live in community housing. It builds on an earlier data set obtained from people living at home with their families and examines: (1) people's awareness of stigma, and (2) their modes of adaptation to stigma. Results The participants all believed that they faced stigmatized treatment and were aware of the stigma associated with ID. They presented a range of views about self in relation to disability and stigma. These views included regarding themselves as part of a minority group who reject prejudice, and attempts to distance themselves from stigmatizing services and from other individuals with IDs. Conclusions The findings are discussed in relation to theories of self and the importance of considering psychosocial factors is stressed in clinical work with people who have IDs.

Background The present paper describes the results of an audit of referrals to a psychology service requesting specialist assistance in the investigation of allegations of abuse. Methods The referrals were over a 2-year period and case notes and records were reviewed to analyse the nature of the allegation, the characteristics of the victims or perpetrators, and the process of the investigation and its outcome. Results Twenty-six people were referred for investigation into allegations of sexual or physical abuse. The referrals were for assistance with an investigative interview (n = 12), capacity to give consent to a sexual relationship (n = 8) and competence to give evidence in court (n = 6). The referrals were all in relation to adults, covering a range of ages and degrees of intellectual disability. Conclusions The process of the investigations suggested that a number of barriers still exist which can make decision-making in relation to the alleged abuse extremely difficult. Resolution of the allegations through the criminal justice system was also problematic.

There has been a longstanding interest in the study of psychotic disorders in adults with intellectual disability. The DC-LD chapter for non-affective psychotic disorders provides operationalised criteria for use with this population.A detailed, structured review of the literature was carried out. Relevant papers were reviewed to provide a framework for a critique of the DC-LD criteria.Most of the research literature focuses on psychotic disorders in adults with mild intellectural disability and suggests that this group experience clinical symptoms similar to those experienced by adults with average abilities. Although the DC-LD criteria for non-affective psychotic disorders are derived from the ICD-10 equivalent categories they are broader than other classification systems, which may affect their reliability, validity and utility.At this stage, it is important that the DC-LD criteria are used alongside established systems to gather information about their use for clinical and research purposes.

Classification of psychopathology using operationalized diagnostic criteria is one component of psychiatric assessment. Previous literature has demonstrated that there are limitations in the International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual-IV (DSM-IV) when used with adults with intellectual disabilities.A literature search using Medline, PsychLIT and hand searching of key journals identified the existing literature, which was reviewed by the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) Development Working Group. Key findings are integrated into this paper. This, together with expert consensus led to the development of DC-LD, a new psychiatric classificatory system devised specifically for use with adults with intellectual disabilities. The new diagnostic criteria and classification within DC-LD were piloted with 52 field investigators drawing on 709 clinical cases. Validity of DC-LD classification was measured by comparison between the criteria providing DC-LD diagnosis and the gold standard of learning disabilities psychiatric assessment.In 96.3% of cases, the DC-LD diagnosis was fully concordant with that of clinical opinion. The few discrepancies related to level of detail.DC-LD accommodates the pathoplastic effect of intellectual disabilities on psychopathology. Its use will hopefully improve clinical practice and facilitate research, but further work to determine its usefulness and limitations is required.

Depressive episode is one of the most common types of psychiatric illness that occurs in adults with intellectual disabilities.A comprehensive literature search was undertaken using Medline, PsychLIT and hand-searching of key journals. This paper reviews the evidence and integrates findings, to report how evidence relates to the development of the new Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation[DC-LD] depressive episode criteria.This area is better researched than many others, providing evidence on clinical symptomatology and presentation. In view of the lack of utility of standard diagnostic criteria developed for use with the general population, and set within the historical context, there are clearly identified reasons for the introduction of DC-LD. The depressive episode category has been informed by the evidence, and field trials showed excellent validity compared with the gold standard of learning disabilities psychiatric assessment.The DC-LD depressive episode category may improve clinical diagnosis and facilitate research. Its usefulness and limitations are yet to be determined in detail.

Background Gender issues remain largely unaddressed in the dual diagnosis arena, even in the area of depression where there is a 2 : 1 female to male ratio in the general population. This paper argues that women with intellectual disability (ID) report higher levels of depressive symptoms than men with ID and that risk factors for depression identified for women in the general population are relevant to this group. Method Findings are based on structured interviews with 99 men and women with ID, with corroborative information provided from caregivers and casebook reviews. Results Overall, women reported higher levels of depression than men. Individuals with higher depression scores were more lonely and had higher stress levels than individuals with lower scores. Women with higher depression scores were more likely to report coming from abusive situations, to have poor social support from family and to be unemployed when compared to women with lower scores, but similar differences were not found when comparing men with higher and lower depression scores. Conclusion Men and women who report experiencing these psychosocial correlates of depression should be a target group for future prevention efforts, taking gender specific concerns into consideration.

People with autism experience profound and pervasive difficulties in the social domain. Attempts to teach social behaviours tend to adopt either a behavioural or a 'theory of mind' (ToM) approach. The beneficial aspects and limitations of both paradigms are summarized before an examination of how virtual reality technology may offer a way to combine the strengths from both approaches.This is not an exhaustive review of the literature; rather, the papers are chosen as representative of the current understanding within each broad topic. Web of Science ISI, EMBASE and PsycInfo were searched for relevant articles.Behavioural and ToM approaches to social skills training achieve some success in improving specific skills or understanding. However, the failure to generalize learned behaviours to novel environments, and the unwieldy nature of some behavioural methodologies, means that there is a need for a training package that is easy to administer and successful in promoting learning across contexts.Virtual reality technology may be an ideal tool for allowing participants to practise behaviours in role-play situations, whilst also providing a safe environment for rule learning and repetition of tasks. Role-play within virtual environments could promote the mental simulation of social events, potentially allowing a greater insight into minds. Practice of behaviours, both within and across contexts, could also encourage a more flexible approach to social problem solving. Virtual environments offer a new and exciting perspective on social skills training for people with autistic spectrum disorders.

Social support is an important determinant of well-being, including the stress experienced within the work setting. The present paper reports on the development of the Staff Support and Satisfaction Questionnaire (3SQ), from a previously published measure: the Staff Support Questionnaire. The 3SQ was piloted with 21 health professionals and examined for evidence of test-retest reliability with 24 staff. Data on internal reliability were collected on three occasions from a total sample of 177 staff. The validity of the 3SQ was examined in four studies with a total of 238 staff by testing it against validated measures of psychological well-being. The data showed that the total scale had a high level of test--retest reliability (rs=0.82, P < 0.001) and consistently high internal reliability. Three out of the four validity studies showed statistically significant inverse relationships between the total scale and measures of psychological well-being. The weakest link was the 'Supportive People' subscale. The reliability and validity studies suggest that the psychometric properties of the 3SQ are generally robust, except for the 'Supportive People' subscale, which should be interpreted with caution.

Mothers with learning difficulties1 are thought to be among the most socially isolated parents in the community. A great deal of attention has been directed to assessing their parenting abilities and teaching parenting skills, but less has been given to the support that mothers may (or may not) receive from family, friends and the service system. The present paper investigates mothers' views about the types of support which they receive and from whom they receive it. Data were derived from 70 mothers who participated in interviews using a support interview guide designed to accommodate the mothers' cognitive difficulties. The primary purpose of the interview was to explore the quantity and composition of the mothers' support networks, the frequency of contact and geographical proximity of support people, and the type of support provided. Key findings include: the central place that family members have in these mothers' lives; the importance of service providers as sources of information and advice; and the relative absence of friends and neighbours. Briefly, mothers living alone have service-centred networks, mothers living with a partner have family-centred networks with relatively dispersed family ties, and mothers living in a parent/parent-figure household have local, family-centred networks. The overall conclusion to be drawn from the present results is that these mothers do not live in a social vacuum, but many are socially isolated. The finding that so few mothers could identify supportive ties with friends and neighbours suggests that these mothers are isolated from their local communities and are potentially vulnerable if a breakdown occurs in the support provided by their families. The need for service providers to be more actively involved in linking mothers to their communities is discussed.

The present paper reviews studies on the prevalence of visual impairment (VI) in adults with intellectual disability (ID). Every publication describes an alarming prevalence of blindness and VI. Cataract and keratoconus were common. Many cases of poor distance vision were treatable by ordinary spherical or astigmatic glasses, but few people had had such prescriptions. Elderly residents in community and institutional care often did not receive glasses for near vision. Professional assessments disclosed higher prevalences of VI than questionnaires mailed to the care personnel. The prevalence of VI increased dramatically with the severity of ID and with age. Regular professional assessment of eye disorders, visual acuity and refraction are warranted in residents in both hospital and community care.

The deinstitutionalization movement is presently spreading in Europe. Studies evaluating the effects of deinstitutionalization on behaviour disturbances among people with intellectual disability (ID) have been inconclusive. The present paper focuses on people without self-injurious behaviour (SIB) who developed SIB after deinstitutionalization. The present authors studied individual and environmental characteristics before and after deinstitutionalization to look for factors associated with the development of SIB which could also be possible intervention points for preventive action. All those individuals in an institution for people with ID who did not have SIB before deinstitutionalization were included in the present study. The individuals who developed SIB after deinstitutionalization (n = 15) formed the study group (group A) and those who did not (n = 53) comprised the control group (group B). The population was examined both before and after deinstitutionalization. As far as possible, the same methods were used at both occasions. The covariates were both individual (e.g. mental health, behaviour disturbances and behaviour deficits) and environmental (e.g. caretaker education, caretaker:patient ratio, housing and leisure activities). Psychiatric disorders were identified in 1987 and 1995 with the Psychopathology Instrument for Mentally Retarded Adults, which was filled in by the caretakers. In 1987, the people in group A who acquired SIB had lower developmental quotients, used wheelchairs more often and had trouble with moving around without help. They also had a greater frequency of epileptic seizures, and hearing and communication impairment. In 1995, there were only minor environmental differences between groups A and B. There were significantly more individuals involved in the rotation period and more unskilled caretakers working with the people in group A than group B. The present authors found no differences between the two groups on variables such as global mental health and behaviour disturbances, or in the use of neuroleptics before or after deinstitutionalization. Groups A and B did not show differences in behaviour disturbances or psychiatric disorders in 1987. In both 1987 and 1995, there were no differences between groups A and B on variables such as accommodation, caretaker:patient ratio, the number of caretakers involved in direct care, the caretakers' education, or the time spent in structured activities before and after deinstitutionalization. The individual characteristics indicating that a person may acquire SIB are behaviour deficits which are suggestive of central nervous system dysfunction or damage, even if the results are inconclusive. The development of SIB may also be facilitated by communication deficits or by reinforcement of a incidentally occurring SIB if the staff includes many unskilled caretakers in the rotation period.