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Dedifferentiation describes a change that occurred in many developed countries during the 1990s: away from regarding people with intellectual disabilities as having particular needs resulting from ...

Intellectual disability scholarship tends to defend a fragile knowledge base by erecting barriers and refusing to look beyond them. This generates a sense of certainty that allows people in a diffi...

Treanor's (2017) wide-ranging article seeks to stimulate conversation about how service systems could become indelibly marked with integrity. It covers much ground. Frequent reference to “flourishi...

The Care Quality Commission's annual report described their purpose: “We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encou...

© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Dedifferentiation describes a shift away from regarding cognitive impairments as the origin of difficulties experienced by people with intellectual disabilities and, instead, regarding their difficulties as socially produced and common to all people with disabilities. This article reviews research evidence concerning the advantages and disadvantages of dedifferentiated policy and service systems for people with intellectual disabilities, the bulk of which addresses education and health service systems. Advantages of dedifferentiation include its avoidance of assumptions about homogeneity, and the stigma of being labelled intellectually disabled; and its support for strong collectives and advocacy that enable people with all types of disabilities to live in the presence of others. For young children, dedifferentiated school and mental health services have positive outcomes not found in similar services for older children and adults. Disadvantages of dedifferentiation include inaccurate or absent representations of unique needs arising from intellectual disability, failure to reduce marginalisation, poor-quality non-specialist mainstream secondary education and health services, and deteriorations in social care. Arguments that dichotomies such as dedifferentiation/differentiation encourage simplification and misconception are reviewed: instead, twenty-first-century thinking negotiates between diverse parties and perspectives. The article makes the case for treating people with intellectual disabilities as members of the broad disability group wherever possible, and for protecting and developing differentiated opportunities, services and research whenever necessary. This requires policymakers and practitioners to balance conflicting ideas more effectively, but it also requires reflection and debate that allow new conceptual tools to emerge. The article concludes by posing three questions intended to encourage reconceptualisation.

Article as accepted for publication in Philosophy, Psychiatry, and Psychology published by John Hopkins University Press

Successful critiques of health policies for people with impaired cognition identify a need for alternatives that go beyond individualism. ‘Choice’ policy was examined as young people with severe intellectual disabilities moved from special schools to adult services. We draw on three cases from a longitudinal cohort study to examine the way decisions with and for these young people were made and accounted for. It was not a simple matter of parents and transition workers hearing about these young people’s choices and facilitating what they wanted. The data raise questions about discourses of choice in ID when referring to people with severe intellectual disabilities: few ‘choices’ could be considered informed nor made by young people with capacity to make them and many decisions were informed by other ethics. Findings were interpreted through a Deleuzean ethical–relational lens. We identify implications for theory and practice to show how Deleuzean thinking can reinvigorate intellectual disability.

This article examines “imagined constructed thought”: speakers giving voice to the inner world of a non-present other. Drawing on 9 hours of video footage of health-care staff discussing patients with intellectual disabilities (ID) during Discovery Awareness sessions, we explored times when the staff presented a possible version of a patient’s thoughts. They used those versions to take a stance on the patient’s inner world, often as a bridge between description of objectively observable phenomena and subjective interpretation of its meaning. It also projected staff’s own stance on what the patient was thinking, both in first position descriptions and as a competitive resource in those given in second position. The findings suggest that presenting the patients’ thoughts from a first-person perspective can be a versatile way of enacting a variety of complex epistemic and empathic actions in this setting. Data are in British English.

Background. Psychomotor therapy enables people to reflect on the relationship between experiences and feelings by starting from awareness of bodily responses rather than from awareness of emotion. In this study we examine PsyMot (ID), an assessment that directs this psychological therapy. Method. Twelve suitable consecutive admissions were recruited from a specialist intellectual disability (ID) assessment and treatment unit for adults. Video-recordings of PsyMot (ID) allowed assessment of interrater reliability (IRR). Treatment goals indicated by PsyMot (ID) were addressed using psychomotor therapy as part of a comprehensive program of interventions. Results. Psychomotor therapy was both feasible and popular with patients who participated without any adverse effects. Nine patients completed PsyMot (ID). IRR of the treatment goals identified by all 3 raters was good to excellent in 81% cases, but there were discrepancies for individual items. Conclusions. PsyMot (ID) and psychomotor therapy is feasible within this context, and enriched the clinical team's formulation. Further studies of reliability and efficacy should be undertaken.

This final issue for 2019 elaborates existing ideas, introduces a discipline that is relatively new to intellectual disability, and interrogates existing approaches and beliefs to check whether the...

An ecological approach to understanding insecure attachments and social isolation among people with an intellectual disability is constructed using Gibson's (1979/1986) affordance-based theory. Although environmental affordances and individual limitations interact to limit the development of social competence, we believe that by focusing on the immediate environment, community-based approaches to helping people with an intellectual disability are often ignored, which increases the burden on individual caregivers. A more comprehensive strategy, which extends Gibson's theory of affordances, allows us to consider how higher level social systems influence the immediate environment and provides the context for understanding why successful change occurs when a multifaceted, holistic approach that works on several levels is adopted. Examining these systems within an ecological framework fundamentally redefines our thinking by shifting the focus from a person's disability to a more nuanced understanding of a pers...

In contrast to other forms of family caregiving, becoming the parent or carer of a child with an intellectual disability (ID) implies an ongoing responsibility beyond the attainment of chronological adulthood ( Meyers et al., 1985 ; Todd and Shearn, 1996 ). At the same time, a discourse of self-determination pervades policy around transition to adult services in ID in England ( Valuing People, 2001) . In this paper we present a subset of data from a project which aimed to examine how the process of transition from child to adult services in ID is managed. Using data from 8 tape-recorded meetings in which transitions were planned and discussed, we examine what happens when the views of the parent/carer and the young adult are in apparent conflict. Drawing on the growing body of interactional work in the field (eg Rapley, 2004 ; Finlay, Antaki and Walton, 2008 ), we use conversation analysis to examine how professionals manage and negotiate this conflict and how some points of view or courses of action ultimately prevail over others. While the discourse of self-determination may prevail in English policy terms, we show how the fact that parents or carers ultimately have a key role in enabling the choices of the young person has a significant impact on these interactions.

Background This study examines how those planning futures for young people with moderate-profound intellectual disabilities invoke, deploy and interpret contrasting definitions of adulthood and perceived capacity for autonomy and self-determination. Methods Twenty-eight young people were followed through transition from children’s to adult services. This paper incorporates data from interviews with young people, their carers and transition staff. Results Two discourses around adulthood were identified. One positioned the young people as adults entitled unequivocally to self-determination, invoking policy injunctions to do so. The second qualified the young people’s adult status and claims to self-determination, emphasising the obdurate reality of intellectual disability. Conclusions Transition to adult services for young people with intellectual disabilities raises difficult questions about the relationship between vulnerable young people, families, professionals and society. Reducing these to rigid moral polarities of ‘right’ and ‘wrong’ creates an unhelpful context for good decision making. A more constructive approach would include all stakeholders in discerning ‘the right thing to do’.

For young people with intellectual disabilities (ID), the transition from children's to adult services has long been recognised as a challenging move. One of the aims of the White Paper Valuing People (2001) was to address some of the problems associated with this transition. This paper reports on data from a project which examines the impact of these service changes, and the ways in which transition is negotiated by carers, professionals and users. It presents a conversation analysis of eight tape-recorded formal review meetings at which transition to adult services is discussed. It takes as its starting point the existing interactional work on ID and the way in which this demonstrates the effects of the local and contextual specifics of particular kinds of interaction on the eventual outcomes (e.g. Rapley 2004, Antaki 2001, Maynard and Marlaire 1992). We show that an attempt to allow self-determination in the context of transitions can paradoxically result in undermining user choice and control. We also argue that, while a rule-based approach to practice may offer moral clarity for professionals, it can result in interactional and practical difficulties which cannot be easily reconciled.

This paper explores the experiences of people with borderline and low intelligence when compared to the general population. The aim was to explore whether people with low intelligence, who are rarely considered apart from the general population, might have particular needs in relation to health or social care. The method was secondary analysis of the ONS survey of psychiatric morbidity, 2000. Variables associated with low intelligence were identified and entered into a logistic regression. We found that a person with low intelligence was significantly more likely to be a smoker, have problems with paperwork and be renting their home, and a significant subgroup was more likely to be friendless. The pursuit of social justice and social inclusion may require greater attention to be paid to the health and well‐being of people with below‐average intelligence.

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.

BackgroundPrevious research investigating post-traumatic stress disorder assumed that adults with intellectual disabilities would react to trauma in the same way as those in the non-disabled population. This study explored the personal experience of trauma in a small group of adults with intellectua

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.

Mourning exists at the nexus between individual experience, professional discourses, research, and culture, making it a complex issue for health services that has shown vibrant change in recent years. By contrast, bereavement discourse in intellectual disability is suffused by dogmatic assertions about correct intervention: we describe four vignettes to illustrate bereavement issues in intellectual disability. Suggestions concerning issues and management are made, but the article focuses primarily on the conceptual issues that underpin clinical intervention. The analysis shows how challenges to the meaning of the disabled life, and to the understandings carers and staff draw on, tend to be resisted. We hypothesize this is most likely to surround issues that evoke cultural uncertainty, such as bereavement. The thesis is that the field of intellectual disability tends to be isolationist because meaning is difficult to create and easily dissolved, especially when addressing culturally contested topics. Dialogue with other disciplines is necessary to stop the field from atrophying, but needs to be carried out in ways that enable carers and clinicians to continue providing the support that people with intellectual disability require.

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.

Ethical issues presented by people with intellectual disabilities (ID) and mental health problems are usually addressed by reference to rights, autonomy, choice, and inclusion. These liberal valuesprovide certainty in the face of uncertain and complex situations. However, Deleuze argues that ethical vision expands more effectively by sitting with repetition: the most obvious repetition in ID is scandals. Inquiries into the abuse of people in the community as well as hospital patients suggest that denial of difficulty associated with ID encourages denial of the difficulty experienced by staff and parents. They also show how an essentially-contested dichotomy between medical and social models is played out, obscuring the significant emotional impact of ID on all parties not least on the individual’s own sense of personhood. We argue for a triple shift in ethical thinking: from individual achievements to enduring relationships; from negative judgment to affirmative living; and from moral rules to practical action.

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.

A shift in accepted practice regarding sharing research led one editor to discuss adopting a legal rather than a moral stance to enforce ethical standards. Familiar ethical concerns regarding consent and balancing individual rights against those of others are considered, alongside lacunae in the field, by drawing on virtue ethics. Reappraisals of quality of life, person-centered planning and normalization are discussed, concluding that developing ethical relationships with people who have intellectual disability takes precedence over client competency.

Staff from four units for adults with profound learning disabilities described their relationship with a particular client during individual discussions. Issues arising from discussion were elaborated in subsequent individual and group meetings, evolving into an account of interactional aspects of professional care based on a core typology of relationships (Provider, Meaning-maker, Mutual and Companion). The process of this grounded theory analysis is exemplified. The analysis concludes with four propositions about staff-client relationships, and discussion of their implications for clinical services.

Vulnerability and protection are key concepts within the literature relating to systemic therapy for people with an intellectual disability (ID). This paper explores the processes by which these concepts were discussed in systemic therapy sessions.Four videotapes of systemic therapy sessions were evaluated using a qualitative design, incorporating thematic and conversation analysis. The videotapes were drawn from systemic therapy sessions with 3 families with an adult with ID.Vulnerability and protection themes were identified within the content of therapeutic conversations, including protection from the disability and its consequences; protection from peers, siblings, and the world at large; and protection from emotionally sensitive topics. Protective strategies were also used by all system members through the process of therapy. Key strategies were topic switch and reversals.Protection is a key issue. Clinical practice could be enhanced if therapists reflect on the strategies they employ in addressing protection effectively.

This paper argues that we are at a point of change in ID services, that new ideas and different frames of reference are required to take services forward in the 21st century. We describe how contemporary thinking in architecture, philosophy and organisational theory can assist in generating service principles for specialist services that allow us to better address the continuing isolation that is the experience of many people with ID, and the moral judgements that can limit service possibilities. We do not seek to offer a rigid blueprint for any particular service but one that allows for agency from its participants and relationships between them.

For young people with intellectual disabilities (ID), the transition from children's to adult services has long been recognised as a challenging move. One of the aims of the White Paper Valuing People (2001) was to address some of the problems associated with this transition. This paper reports on data from a project which examines the impact of these service changes, and the ways in which transition is negotiated by carers, professionals and users. It presents a conversation analysis of eight tape-recorded formal review meetings at which transition to adult services is discussed. It takes as its starting point the existing interactional work on ID and the way in which this demonstrates the effects of the local and contextual specifics of particular kinds of interaction on the eventual outcomes (e.g. Rapley 2004, Antaki 2001, Maynard and Marlaire 1992). We show that an attempt to allow self-determination in the context of transitions can paradoxically result in undermining user choice and control. We also argue that, while a rule-based approach to practice may offer moral clarity for professionals, it can result in interactional and practical difficulties which cannot be easily reconciled.

Two main studies of interaction between adults with intellectual disability and staff are reported. The first varied five interactive strategies with nine clients. Results showed that increased positive behaviour from clients was associated with staff talking with them and using social routines. No such increase was observed when staff made their responses contingent on clients, a finding which was supported by the second study carried out with 16 staff-client pairs. In this second study no correlations were found between behaviour during interaction and developmental age.

The interactions between adults with profound intellectual disability and staff are described, during sessions when the client's staff member talks with them. Information about 20 staff-client pairs from three different settings is reported. Results showed that, in relatively ideal conditions, clients responded positively during approximately one third of session time; that staff were very responsive to changes in client behaviour; and that clients were most likely to respond negatively to changes in staff behaviour, if they responded at all. No evidence of turn-taking between the interactors was found.

Institutional and psychological aspects of transition were explored with parents and staff involved with five young adults with severe intellectual disability whose challenging behaviour diminished after they made the transition, and five whose challenging behaviour remained high. They were selected from a previously surveyed cohort. Grounded theory analysis of interviews suggested little connection between the perspectives of parents and staff. The impact these differences have on communication about challenging behaviour was explored, and recommendations for service changes are made.

Contemporary ethical debate about clinical practice centres primarily on the individual resolution of dilemmas, an approach which is incompatible with the social constructionist focus on human interdependence. Many constructionists argue that virtue ethics (VE) offers a more useful perspective on ethics than either consequentialism or deontology. From this perspective, the purpose of ethics is not to specify the right act in a particular situation, but to understand ethical and unethical practices conceptually, i.e. how these are learned, and how these contribute to and develop the ethical life in an ethical environment. Criticisms of VE are considered alongside discussion of its implications for clinical practice with people who have intellectual disability.

Attachment theory makes sense of two phenomena observed in some people with learning disabilities: it provides a reason for their limited exploration of the world, and it explains discontinuities in the pattern and intensity of their expressions of anger. Applying this framework to three enmeshed relationships occurring between an adult with learning disabilities and a member of care staff achieved at least partial resolution of their problems. Attachment theory's critics have set a number of challenges for its proponents, including emphasizing an interactional rather than a unidirectional approach to relationships; prioritizing social context; and understanding the attachment dynamic dimensionally rather than as a set of categories. The latter issue is pertinent for residential services: facilitating secure attachment relationships for distressed clients may be difficult for professionals, but partial assuagement of their attachment needs is a realistic clinical goal.

Moving from an individual to a social focus will allow clinical psychologists working with people who have learning disabilities to address a wider range of difficulties experienced by this client group. Social constructionist theory may be a useful framework to facilitate such an approach, and is intellectually compatible with changes occurring in other related disciplines. Research relevant to this perspective is reviewed under four subheadings proposed by Doise. Implications for clinical practice are discussed by reference to two case studies.

Background Inclusion is one of four policies for people with disabilities in the UK. Criticisms of its three key attributes – mainstreaming, independent living and employment – are reviewed. Methods This study of 28 young people, most with severe intellectual disabilities, investigated engagement with inclusion at their transition to adult services. Data were collected from the young people where possible; from their carers, mostly parents; and from professionals responsible for brokering transition. Narrative analysis of this material investigated ways in which respondents did or did not engage with the goals of inclusion as defined in various policy documents. Results Both mainstreaming and independent living were experienced as moral imperatives which generated tension for many respondents. Employment was associated with less tension, probably because only a minority of respondents considered it salient. Possible alternative goals invoked by parents/carers and professionals were meaningful activity and same-age social relationships. Conclusions There is a need to acknowledge the moral pressures and judgements arising from inclusion policy that complicate decision-making at transition and to shift the moral horizon away from individual attainments and towards the activities and relationships that take people beyond themselves.