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Aim To present the cross‐case comparison component of a qualitative study exploring and describing the experiences of adults with an intellectual disability who have received trauma and orthopaedic hospital care for musculoskeletal conditions or injuries in the United Kingdom. Design A qualitative, exploratory study was conducted using 1:1 semi‐structured interviews to describe the lived experiences of trauma and orthopaedic hospital care from the perspectives of people with intellectual disabilities and a carer of a person with profound and multiple intellectual disabilities. The data were analysed using interpretative phenomenological analysis. The Standards for Reporting Qualitative Research guidelines were applied. Results There were common and interconnected experiences across the five participants: communication challenges; lack of person‐centred care; issues related to pain management; lack of confidence in hospital care; the valuable support and expertise of carers; and incompetence of hospital staff and isolation and loneliness.

Purpose The purpose of this paper is to summarise the current state of empirical knowledge pertaining to online risk and cybercrime relating to people with intellectual disabilities (ID). Design/methodology/approach This narrative review summarises, synthesises and critically evaluates the current literature and state of knowledge and offers suggestions for extending current knowledge and practice. Findings Evidence regarding risk for people with ID is limited but growing. Existing findings highlight that: risk may increase contingent upon higher levels of sociability, loneliness, anxiety and depression, poorer insight, judgement, discrimination and ability to detect deception online and reduced experience and life opportunities; people without ID perceive high online risk for people with ID, which may lead to gatekeeping restrictions and controlling digital access; restriction may potentially impede online self-determination, participation and development by people with ID; and experience of risk may enhance awareness, independence and resilience in managing future online risk amongst people with ID. Further research work is needed in this area to enhance understanding of risk experience and effective support strategies. Originality/value This review of current knowledge has highlighted the necessity for more research to better understand the propensity for engagement in different risky online behaviours and to better inform support practices to help people with ID to manage risk whilst maintaining digital inclusion.

Background Adults with intellectual disabilities are not often asked to participate in health research. This may be because researchers perceive them as unable to participate meaningfully with or without significant support and anticipate difficulty in obtaining ethical approval because of issues concerning consent and mental capacity. This means that the voices of adults with intellectual disabilities are often missing from health research and their experiences and views are unexplored. Aim To share successful strategies for accessing, recruiting and collecting data from a purposive sample of adults with intellectual disabilities from a study that used interpretative phenomenological analysis (IPA). Discussion IPA is a person-centred, flexible and creative approach to research. Meaningful collaboration with people with intellectual disabilities, their families, carers, advocacy group managers, specialists in intellectual disability services and research supervisors was vital to the success of the study. The authors share practical strategies for including people with intellectual disabilities, from the perspective of a novice researcher who is an outsider to the field of intellectual disability. Conclusion It is important to include people with intellectual disabilities in healthcare research. This article presents a framework to support researchers outside the specialist field of intellectual disabilities in achieving this. Implications for practice Personal views and perceptions of healthcare are important if health services are to meet individual needs. Adults with intellectual disabilities often receive poor healthcare and have poorer outcomes. This will be perpetuated without their input into research. People with intellectual disabilities can make valuable contributions to the evidence base.

Research focusing on online identity and the personal experiences of adults with intellectual disabilities (ID) is currently limited. Eleven adults with ID were interviewed regarding personal experiences of being online and using social media. Data were analyzed qualitatively using thematic network analysis. Two global themes, online relatedness and sharing and online agency and support, highlighted the positive potential of social media in enabling the development and maintenance of social bonds, valued social roles, and feelings of enjoyment, competence, autonomy, and self-worth. Participants reported sharing various expressed online identities that did not focus on or hide impairment, challenging notions of dependency, with participants both providing support and being supported online.

Background/Purpose Accessing oral health care can be more difficult for adults with intellectual disabilities with reports of poorer levels of oral health. This investigation identifies factors influencing engagement in day‐to‐day oral and dental health care for adults with intellectual disabilities. Method A survey, containing questions about facilitators and barriers to maintaining oral health and hygiene, was completed with adults with intellectual disabilities and their caregivers (N = 372). Results Data were analysed using thematic network analysis. Two global themes were identified; “Personal and lifestyle influences,” mentioned more often as barriers to oral care, included physical, sensory, cognitive, behavioural and affective factors and “social and environmental factors,” mentioned more as facilitators, included caregiver support, equipment and adaptations used and oral hygiene routine. Conclusions Numerous individual, social and environmental factors influence oral care. A coordinated organisational response is advocated involving collaboration between dental and intellectual disability services and training for caregivers and people with intellectual disabilities.

Services available for people with disabilities in Bolivia tend to be fragmented and costly. Children and adults with intellectual disabilities are more likely to have a related communication disability and are thus both literally and metaphorically excluded from having a voice. The following research aimed to explore the experiences of accessing services by people with communication disabilities in Bolivia through semi-structured interviews and one focus group carried out with family members, professionals, service providers, educators and policymakers. It aimed to establish the nature of current services in Bolivia where knowledge, information and resources are scarce. Findings indicated the need to consider an alternative to a medical model approach through a focus on empowering other stakeholders to participate more fully in meeting communication support needs. Conclusions plot ideas for future service delivery and emphasize the central power of sharing practical and expert knowledge.

Purpose: Dysphagia (difficulties in eating, drinking or swallowing) is associated with serious health complications and psychosocial sequelae. This review aims to summarise the state of the evidence regarding dysphagia in people with intellectual disabilities (excluding prevalence), identify gaps in the evidence base and highlight future research priorities. Method: Studies published from 1 January 1990 to 19 July 2016 were identified using Medline, Cinahl, PsycINFO, Web of Science, email requests and cross citations. Studies were reviewed narratively in relation to identified themes. Results: A total of 35 studies were included in the review. Themes identified were as follows: health conditions associated with dysphagia; mortality; health service use; practice and knowledge in supporting people with intellectual disabilities and dysphagia; intervention effectiveness and quality of life. Dysphagia is associated with respiratory infections and choking and may be under-recognised. Silent aspiration is common and may go unnoticed. Management practices exist, but there are few intervention studies and no randomised controlled trials (RCTs), and hence, the effectiveness of these is currently unclear. Conclusion: Dysphagia is a key concern in relation to people with intellectual disabilities. There is urgent need for research on the management of dysphagia in people with intellectual disabilities, including mealtime support offered, positioning, dietary modification and impact on wellbeing. Implications for Rehabilitation Dysphagia is common in people with intellectual disabilities, associated with serious health risks and may be under-recognised. Caregivers of people with intellectual disabilities should be educated about dysphagia. There is an urgent need for research on improving the management of dysphagia in people with intellectual disabilities. Improved recognition and management of dysphagia may reduce the occurrence of associated health conditions and reduce hospital admissions and premature death in people with intellectual disabilities.

Aims To review the empirical literature relating to the orthopaedic and trauma hospital experiences of people with intellectual disabilities (PWID). Design An integrative review was conducted following the steps advocated by Whittemore and Knafl (2005). Primary research studies from 2007 to 2020 which included the hospital experiences of adults with intellectual disabilities were reviewed. Data sources The literature searches were undertaken in 2014, 2015, 2018 and May 2020. Review methods The following electronic databases were searched: Academic Search Complete, Nursing and Allied Health, British Nursing Index and RCN Library archive, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE) Psychological Information Database (PsychINFO), the Cochrane Collaboration Database and Google Scholar. Results Despite the high prevalence of musculoskeletal problems for adults with intellectual disabilities, the review found no specific literature related to orthopaedic or trauma hospital experiences. Nine studies related to PWIDs’ experiences of general hospital care were included. Conclusion There is a gap in the empirical literature relating to orthopaedic or trauma hospital experiences of PWID. General hospital experiences of adults with an intellectual disability were poor overall.

Introduction People with intellectual disabilities have a greater prevalence of musculoskeletal conditions and injuries than the general population. Orthopaedic and trauma hospital care has not been investigated with this group who seldom have their voices heard or their experiences valued and interpreted. Aim To understand the orthopaedic and trauma hospital experiences from the perspective of people with intellectual disabilities. Methods A qualitative approach, focusing on peoples’ lived experiences was utilised. A purposive sample of five participants was recruited and one-to-one, semi-structured interviews were undertaken. Analysis of the interviews employed an interpretative phenomenological analytical framework. Findings There were communication challenges, a lack of person-centred care, issues with pain management, a lack of confidence in hospital care, valuable support and expertise of carers, incompetence of hospital staff and isolation and loneliness. Discussion and conclusions There were significant short comings as people with intellectual disabilities and a carer perceived they were unsupported and received poor care. Recommendations for practice: Person-centred care is needed along with specific education and training, including close liaison with the experts by experience – people with intellectual disabilities, their carers as well as the specialists in intellectual disability.

Accessible summary Both good and bad things can happen when people use the Internet, and people with learning disabilities are not using the Internet as much as other people. Worry about the bad things that can happen online might be one reason people with learning disabilities are not supported to access the Internet as much as other people. We wanted to find out what people without learning disabilities believe about these good and bad things for people with learning disabilities. We wanted to find this out because the way people without disabilities think about the good and bad things online might affect how people with learning disabilities are treated. We found out that people without learning disabilities think that both the good and bad things are more likely to happen to people with learning disabilities when they use the Internet. Abstract Background: Information and communication technologies, with the Internet at the forefront, have the potential to enhance the knowledge, service, employment, development and social interactional opportunities available to people with intellectual disabilities. Despite this, people with intellectual disabilities are not accessing the Internet to the same degree as people without intellectual disabilities. Issues of safety, risk and protection online for people with intellectual disabilities have yet to be adequately investigated, and these currently serve as reasons given for hindering people from gaining online access. Materials and Method: This survey aimed to gauge the views people without intellectual disabilities have of risks and benefits of using the Internet for themselves and for people with intellectual disabilities and to compare self-ratings of risk and benefits to ratings for people with intellectual disabilities. Results: The survey findings indicate that, with only a small number of exceptions, both the risks and benefits of being online were believed to be greater for people with intellectual disabilities compared with those without intellectual disabilities. Greater use of the Internet was associated with increased perception of benefits to being online for both people with intellectual disabilities and for participants. Conclusions: Perceptions of increased benefits suggest more needs to be performed to improve online access whilst a perception of increased risk may help to explain the reduced inclusion of people with intellectual disabilities in the online world.

People with intellectual disabilities face both societal and digital exclusion. This chapter focuses on the current state of evidence around the use of the Internet and Information Communication Technologies (ICT) by people with intellectual disabilities (ID). It considers the factors underpinning the digital exclusion of people with ID and the current levels and nature of Internet and ICT use by this group. It then discusses the benefits and barriers in relation to theoretical models and literature detailing the risks of being online and the role of support in facilitating and preventing digital inclusion. The chapter concludes by summarizing the current state of the research literature and highlighting areas where more research is required to increase the digital inclusion and self-determination of people with ID.

Background: Humor, both producing and appreciating, underpins positive social interactions acting as a facilitator of communication. There are clear links to wellbeing that go along with this form of social engagement. However, humor appears to be a seldom studied, cross-disciplinary area of investigation when applied to people with an intellectual disability, this review collates the current state of knowledge regarding the role of humor behavior in the social interactions of people with intellectual disabilities and their carers. Method: A systematic review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was completed which aimed to explore the current state of knowledge and quality of empirical evidence relating to humor in people with intellectual disabilities. Following this, articles were grouped thematically and summarized. A comprehensive search of four electronic databases (1954–2017) and additional search strategies yielded 32 articles which met the final inclusion criteria. Results: Humor played a significant positive and negative role in the social interactions of people with intellectual disabilities. Research had investigated humor in the classroom and humor expression in different groups including those with autism, Down syndrome, Angelman syndrome, Williams syndrome and Rett syndrome. Few investigations directly studied humor appreciation and comprehension hence themes did not focus solely on humor production/appreciation. Humor comprehension was reportedly supported by gestures. Some groups with intellectual disabilities found non-literal humor (e.g. sarcasm, irony) more difficult to understand which may affect social relationships. Various types of humor were found to be appreciated. The role of humor in relationship development, social facilitation, creativity and stigma had all received some limited attention. Humor also played a role for carer groups in coping with and enjoying the caring role. Research varied in quality with few experimental studies and mainly quasi-experimental and well-conducted qualitative studies. Conclusions: This review revealed the importance of humor behavior in many aspects of the social lives of people with intellectual disabilities. Limited disparate research exists pertaining to humor in this group, suggesting the need for further robust research in this area, including more high quality primary research in the areas of humor production, appreciation, comprehension and stigma.

Dysphagia (feeding and swallowing disorder) is associated with serious health complications and psychosocial sequelae. This review summarizes international research relating to the prevalence of dysphagia in people with intellectual disability. Studies published from 1990 to July 2016 were identified using Medline, Cinahl, PsycINFO, Web of Science, email requests, and cross-citations. Twenty studies were identified. Dysphagia in people with intellectual disability appears to be associated with more severe levels of intellectual disability, comorbid cerebral palsy, and motor impairments. However, further research with representative samples of people with intellectual disability using adequate methods of assessment are required in order to provide more precise prevalence estimates and clarify factors that may be associated with dysphagia in this population.

Background People with profound intellectual and multiple disabilities (PMLD) have communication impairments as one defining characteristic. Aims To explore speech and language therapists' (SLTs) decision making in communication interventions for people with PMLD, in terms of the intervention approaches used, the factors informing the decisions to use specific interventions and the extent to which the rationales underpinning these decisions related to the components of evidence based practice (EBP), namely empirical evidence, clinical experience and client/carer views and values. Methods & Procedures A questionnaire on communication assessment and intervention for people with PMLD was sent to SLTs in the UK to elicit information on: the communication intervention approaches they used; their rationales for their intervention choices; their use of published evidence to inform decision making. Outcomes & Results Intensive interaction and objects of reference were the communication interventions most often used with people with PMLD, with some differences between children and adults evident. Rationales provided conformed somewhat to the EBP framework though extension of the existing framework and addition of practical and organizational considerations led to a revised typology of rationale for decision making. Rationales most frequently related to the empowerment, development and behavioural preferences of the person with PMLD. Conclusions & Implications Empirical research evidence was seldom mentioned by SLTs as informing intervention decision making leading to very diverse practice. There is a need for further research on the effectiveness of commonly used but under-evaluated interventions. There is also a need to alert SLTs to the evidence base supporting other approaches, particularly switch-based, cause and effect approaches.

Background Modifying the consistency of food and drink is a strategy commonly used in the management of dysphagia for people with intellectual disabilities (ID). People with ID often depend on others for the preparation of food and drink and therefore depend on those caregivers achieving the correct consistency to keep them safe and avoid discomfort during mealtimes. Clinical experience and prior research have demonstrated that although training can improve modification, carers often find modification difficult and potentially stressful and recommend additional support for carers. Fluid consistency is often modified through the addition of powdered thickener. This study investigates the efficacy of typical training and use of consistency guides, the Thickness Indicator Model (TIM) tubes, in helping carers to modify fluids accurately. Method A 3 × 3 pre–post experimental design with a control group was employed to compare the observed accuracy of modification across three groups and at three time points (pre-intervention baseline, immediately post-training intervention and 3–10 months post-training). Sixty-two paid carers who supported people with ID were recruited to participate in the study and each was randomly allocated to one of the three groups: a control group given written guidance only, a group who received typical training and written guidance and a group who received training, written guidance and the TIM tubes. Results & Conclusions Typical training resulted in significantly greater carer accuracy in modifying fluid consistencies when compared with written guidance alone. Use of the TIM tubes also significantly improved accuracy in the modification of drinks compared with the group who modified with the aid of written guidance alone. At 3–10-month follow-up only the group who received typical training alongside the TIM tubes were significantly more accurate than the Written Guidance group. Further research is warranted to ascertain the effectiveness of the training and the utility of the TIM tubes in improving accuracy over a longer time scale and in individuals' usual living environments.

Accessible summary • We taught staff some useful signs to help them to communicate with people. • We asked staff if they liked the different ways of teaching we used. • We tested staff trained to see if they remembered the signs. We found out that: • Trained staff could do the signs better than untrained staff. • Staff who had been taught liked the different ways of teaching that we used. • Only a few staff used the signs a lot when they were communicating with people. Summary To contribute to increasing the quality and quantity of communication between staff and adults with intellectual disabilities, training was undertaken to enhance the awareness and knowledge of signing as a method of communication. Multidisciplinary team members, residential and day centre staff were trained to use 20 core signs. Training methods employed included: a training session; a training video; and a training card showing the 20 signs. Caregiver knowledge of the 20 signs was assessed between 6 and 12 months following implementation of the training. Information was also collected about the level of exposure to each of the training methods, and about staff perceptions of the usefulness and effectiveness of the different training types. Training was considered effective by staff, especially the formal training. Trained staff were significantly more accurate at signing, although this knowledge and capability did not often translate into everyday use of signs.

Background: There is scant research on the subject of dysphagia and people with intellectual disabilities. This study explores the barriers which caregivers believe make following Speech and Language Therapists' (SLTs) dysphagia management strategies more difficult. Method: Semi-structured open-ended interviews were conducted with 46 caregivers who supported 40 intellectually disabled adults with dysphagia. Results: Caregivers perceived particular difficulties in modifying food and drinks to safe consistencies, achieving the agreed positioning during mealtimes, and in using support and prompting strategies. Problematic support and prompting strategies included difficulties with pacing correctly; facilitating people to adequately relax and concentrate; observing and prompting people to pace suitably and take safe amounts of food and drink in each mouthful. Additional barriers identified included time pressures, staff turnover and insufficient reviewing of SLT management strategies by caregivers. Conclusions: Findings suggest that additional training and monitoring is required to ensure caregivers are aware of their role and responsibility in promoting safe oral intake for adults with dysphagia and intellectual disabilities. Ongoing support is suggested for people with intellectual disabilities and dysphagia to help them understand the reasoning behind management strategies.

This chapter provides insight into the nature of online engagement by people with intellectual disabilities, the extent and quality of this engagement in terms of the access that people have, and how people with intellectual disabilities present themselves in the online world. The authors of this chapter provide an overview of the extant literature on intellectual disability, identity, and the Internet. The chapter begins by outlining issues around Internet use and access by people with intellectual disabilities, including potential barriers. It then moves on to address online behaviour and the potential benefits of Internet use for people with intellectual disabilities. The chief focus of the chapter follows, describing the manner in which computer mediated communication affects how people with intellectual disabilities present themselves in the online world as well as considering the role that family members and supporters play in the development and management of people’s online identities. Finally, the chapter introduces future directions for research into intellectual disability, identity, and the Internet.

Background Families in Ireland remain the main providers of support for people with Intellectual disabilities, and the aim of this study was to map their life experiences whilst involving their family members as co-researchers.Materials and Method This qualitative, participatory study involved 10 focus groups attended by 70 parents and siblings of people with intellectual disabilities. Data were analysed using thematic analysis. Results Caring for a family member with intellectual disabilities was found to be a dynamic and adaptive process. The well-being of the family and the challenges they face throughout their lives was the central theme identified. This was affected by: the availability ofappropriate supports for families and having to advocate for them, communication and relationships with services and professionals, the availability of information and attitudes towards disability and governmental support.Conclusions Strategies are suggested as to how services can better support family carers in Ireland in their role. These include families being provided with flexible and timely support for families at critical times; being offered services, support, entitlements and information without having to fight for them; knowing that their family member with intellectual disabilities is well cared for, listened to and provided with opportunities todevelop and be part of the community; and carers being shown respect, listened to and involved in decisions.

People with intellectual disability (ID) are more likely to have health problems than people without disability. Little previous research has investigated health from the perspective of the people with ID themselves. We aimed to focus on what people with ID understand being healthy to mean and what their experiences are of healthy lifestyles.Semistructured interviews were conducted with 13 adults with ID to ask them about their health and healthy lifestyles. Data were analysed thematically.Participants demonstrated understanding of what it means to be healthy, have a healthy diet, the dangers of substance misuse, and the benefits of exercise. Participants demonstrated some knowledge about rationales for engaging in healthy behaviours. The idea of moderation was raised, along with barriers and facilitators to engaging in a healthy lifestyle.Findings suggest that people with ID demonstrate some understanding of what constitutes being healthy and are aware of healthy lifestyles, the consequences of unhealthy behaviours, and of the need for moderation.

This article presents findings on the long-term impact of health practitioner input to reduce obesity amongst adults with intellectual disabilities. Body mass index (BMI) was measured for an input group ( N = 33) and a comparison group ( N = 40) 6 years after the input group first received input. Data on BMI were collected at baseline, 6 months, 1 year and 6 years. Mean BMI for the input group reduced steadily over 6 years. Mean BMI in the non-input group rose initially, stabilized and then decreased (although remaining higher than at baseline). The input group demonstrated improvements in obesity levels and lost more weight than the non-input group. However, the differences between groups did not reach statistical significance. This and the improvements in BMI within the non-input group may be due to the relatively small sample size, effect size and the impact of other local initiatives.

Background Dysphagia has rarely been investigated in adults with intellectual disabilities (ID) despite being a serious condition affecting health and quality of life. Method This study collected information about 101 adults with ID, living in community settings, referred for an assessment of their eating and drinking. Ninety-nine people were classified as having dysphagia from clinical and videofluoroscopic assessments. This information was used to give an indication of the prevalence of dysphagia in adults with ID and identify the co-occurrence of physiological and anatomical indicators and associated negative health conditions. Results Details of the characteristics and conditions associated with dysphagia are provided. These include cerebral palsy, increased physical disability and cognitive impairment. A tentative indication of the current prevalence of dysphagia was found (8.15%). Conclusion Findings indicate that dysphagia is a significant issue for people with ID warranting further investigation. Practice implications detailed include increasing awareness of ‘at risk’ groups, changes in dysphagia with ageing, medication use and illness, and how findings can inform assessment and training.

Background: Adults with learning disabilities referred for assessment of their eating and drinking are frequently reported to cough and choke when eating and drinking. The research literature investigating dysphagia has often overlooked asphyxiation risk, highlighting coughing and choking as indicators of aspiration only. This is a notable oversight due to the prevalence of asphyxia as a cause of mortality in this population. Aim: This study aims to identify the physiological and environmental factors that predict asphyxiation risk in adults with intellectual disabilities and dysphagia. Method: Data were collected from dysphagia-trained speech and language therapists (SLTs) working with the participant adults with intellectual disabilities and dysphagia. The SLTs used case notes, clinical assessment and videofluoroscopic assessment reports to gather the data. Results: Speed of eating, cramming food and premature loss of the bolus into the pharynx were identified as significant predictors of asphyxiation risk in this population. Conclusions: The findings highlight the importance of maladaptive eating strategies in exacerbating the risk of asphyxiation and choking. These factors should be considered in the assessment of asphyxiation and choking risk and management. Finally, the need for joint assessment and management with other members of the multidisciplinary team is advocated.

People with learning disabilities are at high risk of obesity and consequent health risks. This study aimed to (1) describe levels of obesity for adults supported by learning disability services, and to (2) evaluate the effectiveness of health practitioner input with individuals with learning disabilities. Body mass index (BMI) was measured at 6 month intervals and change in BMI over time was compared between a non-input group and a group receiving practitioner input to improve healthy living. Initially 35 percent of the non-input sample was classified as clinically obese. Mean BMI increased over time for the non-input group at first, but decreased for the group that received practitioner input. The differences in weight change between the two groups reached statistical significance with a greater weight reduction in the input group. Implications for service provision are discussed.

The extent to which 40 individuals with intellectual disabilities and dysphagia and their caregivers adhered to speech and language pathology dysphagia guidelines was evaluated. These individuals were observed having a meal across four settings. In addition to monitoring overall adherence, guidelines were split into separate sections corresponding to consistency modification of food and drinks, physical positioning, use of equipment and utensils, and support and prompting recommendations. Adherence to speech and language pathology recommendations was generally high, particularly regarding consistency modification that can help reduce the risks of aspiration and asphyxiation. Significant differences in adherence were found across settings, across type of guidelines, and between people who were fed by caregivers and those who fed themselves.

Dysphagia can have many negative health consequences for people with learning disabilities, including dehydration, aspiration and asphyxiation. Few studies have investigated dysphagia management among adults with learning disabilities. This study aims to contribute to the existing knowledge by investigating carer knowledge of speech and language therapists' (SLTs) recommendations regarding dysphagia management, and by comparing carer knowledge with their behavioural adherence to SLT recommendations. An exploratory study was undertaken investigating carer knowledge of dysphagia management strategies, along with a within-participants' study comparing carer knowledge and adherence. Structured interviews were conducted with carers supporting adults with learning disabilities and dysphagia to explore and ascertain their knowledge of dysphagia management. These data were then compared with observational data gathered in naturalistic contexts, assessing the behavioural adherence of these same carers. Recommendations pertaining to altering consistency and using specialized equipment and utensils were recalled significantly more readily than those concerning support and prompting for the dysphagic persons. Moreover, carers adhered to management strategies to a significantly greater degree than they could recall the details of the written guidelines containing the dysphagia management strategies. The findings suggest that tangible and routinely used management strategies, e.g. food and drink consistency, and use of specialized utensils, are easier for carers to adhere to and remember than support-based strategies such as verbal prompting and pacing. The discrepancy between compliance and knowledge can be explained by calling upon cognitive theories of memory and skill acquisition. This has implications for the selection of relevant outcomes of dysphagia training of direct care staff. Knowledge does not necessarily predict actual behavioural adherence and, though desirable, does not appear to be an adequate outcome indicator if the goal is behavioural adherence. Practice implications for SLTs training carers in dysphagia management strategies include combating fossilization of incorrect knowledge; encouraging carers to refamiliarize themselves with management strategies and their rationales periodically following initial training; and providing more specific contingency information for support and prompting in the guideline documentation.