Social and community inclusion outcomes for adults with autism with and without intellectual disability in Australia

BACKGROUND

Research suggests that adults with autism tend to have poor outcomes. Outcomes have mostly been defined using summary outcome ratings, with less focus on specific outcomes such as employment, living situation, social satisfaction, loneliness, and friendships. This study aimed to explore social and community outcomes, including employment, education, living arrangements, friendships, and social satisfaction, for autistic adults with and without intellectual disability.

METHOD

Eighty-four adults with autism (mean age 34.2 years, SD = 4.5; 67% with co-occurring intellectual disability), recruited as children and adolescents, participated in the current study. Adult social and community inclusion outcomes were explored through interview and questionnaire, both parent/carer-report and self-report.

RESULTS

Participants predominantly lived with family or in supported accommodation, did not pursue higher education, and mostly participated in day activity programmes. Most had limited friendships as reported by parents/carers; however, self-report data (n = 28) indicated that adults were largely satisfied with their social relationships. Overall outcome was poor for 57%, and good/very good for 34%. Adults with intellectual disability generally had poorer outcomes.

CONCLUSION

Autistic adults encountered numerous difficulties in leading an independent life. Adults with co-occurring intellectual disability were most likely to experience difficulties; however, outcomes ranged from poor to very good for adults without intellectual disability. Discrepancies in parent/carer-report and self-reported experiences of friendships highlight the need to ensure individual experiences are captured in addition to parent/carer-report. Appropriate resources and programmes are crucial for adults with autism to support them to have the choice to live independently.

Mothers and fathers with intellectual and developmental disabilities who use US disability services: prevalence and living arrangements

BACKGROUND

Little information is available on the prevalence of mothers and fathers with intellectual and developmental disabilities among US disability-service users. Child removal is a key issue for these parents.

METHODS

We analysed 2018-19 National Core Indicators data from 35 states on US adults with intellectual and developmental disabilities being a parent. For parents of a child under 18, we examined whether the child lived with them.

RESULTS

Prevalence of parenthood was 3.7% (6.0% women, 2.1% men). Among parents of a child under 18, 44.0% had their child living with them. Being a mother, being married and living with family were positively associated with child co-residence. Parents with co-resident children mainly lived in their own home (59.7%) or their family's home (32.3%).

CONCLUSIONS

Our prevalence estimate suggests a national total of 33 794 US parents who use intellectual and developmental disabilities services. For parents living with their child, a critical task for disability services is to enable parents and children to live in a family setting.

Transition to retirement and participation in mainstream community groups using active mentoring: a feasibility and outcomes evaluation with a matched comparison group

BACKGROUND

This paper reports on the feasibility and outcomes of a transition to retirement programme for older adults with disability. Without activities and social inclusion, retirees with disability are likely to face inactivity, isolation and loneliness.

METHODS

Matched intervention and comparison groups each consisted of 29 older individuals with disability. There were 42 men and 16 women with a mean age of 55.6 years While attending their individual mainstream community group 1 day per week, intervention group participants received support from community group members trained as mentors. We assessed participants' loneliness, social satisfaction, depression, life events, quality of life, community participation, social contacts, and work hours before and 6 months after joining a community group.

RESULTS

Twenty-five (86%) of the intervention group attended their community group weekly for at least 6 months. They increased their community participation, made an average of four new social contacts and decreased their work hours. Intervention participants were more socially satisfied post-intervention than comparison group members.

CONCLUSIONS

The results demonstrate that participation in mainstream community groups with support from trained mentors is a viable option for developing a retirement lifestyle for older individuals with disability.

The impact of individual and organisational factors on engagement of individuals with intellectual disability living in community group homes: a multilevel model

BACKGROUND

Being engaged in daily activities is a strong indicator of quality of life for individuals with intellectual disability (ID) who live in small community group homes. This study aimed to identify individual and organisational factors that predict high levels of engagement.

METHOD

Individuals with ID (n = 78), direct support professionals (DSPs; n = 174) and supervisors (n = 21) from 21 US group homes participated in the study. For each individual with ID, we conducted 80 min of observation at the person's residence. Information was also gathered regarding demographic characteristics, DSP competence, supervisor years of experience and management practices. Data were analysed using multilevel modelling.

RESULTS

On average, individuals were engaged in social activities 12% of observed time and non-social activities 35% of the time. Individuals with greater adaptive skills who were supported by more competent staff showed significantly higher levels of social engagement. Individuals with less severe deficits in adaptive behaviours and less challenging behaviour showed higher levels of non-social engagement. Although none of the factors related to group homes were significant, 24% of the variance in non-social engagement existed among group homes.

CONCLUSION

These results suggested that engagement is a dynamic construct. The extent to which an individual with ID is engaged in daily life is a result of interplay between the individual's characteristics and the group home environment. Future research is needed to investigate the influence of variables specific to the group home on the engagement level of individuals with disabilities.

What is talked about? Community living staff experiences of talking with older people with intellectual disability about dying and death

BACKGROUND

The aim of this study was to explore what community living staff talked about and did with people with intellectual disability (ID) to assist them to understand dying and death.

METHOD

Guided by grounded theory methodology, focus groups and one-to-one interviews were conducted with 22 staff who had talked about any topic relating to dying and death with their clients.

RESULTS

There was little evidence that staff talked with, or did things with clients to assist understanding of the end of life, both prior to and after a death. Prior to death staff assisted clients in a limited way to understand about determining wishes in preparation for death, and what dying looks like by observance of its passage. Following a death staff offered limited assistance to clients to understand the immutability of death, and how the dead can be honoured with ritual, and remembered.

CONCLUSIONS

The findings have implications for why people with ID have only partial understanding of the end of life, the staff skills required to support clients' understanding, and when conversations about the end of life should occur.

Responsiveness to self-report questions about loneliness: a comparison of mainstream and intellectual disability-specific instruments

BACKGROUND

We compared responsiveness to two self-report assessments of loneliness: the UCLA Loneliness Scale (UCLALS) designed for the general community, and the Modified Worker Loneliness Questionnaire (MWLQ) designed for people with intellectual disability (ID).

METHODS

Participants were 56 older adults with disability - 40 individuals with ID and 16 without ID. They were individually assessed on the MWLQ and the UCLALS. The difficulty of the items in both scales was evaluated in relation to readability, features of question wording, question length and response format.

RESULTS

The UCLALS was more difficult than the MWLQ on each of the difficulty dimensions assessed. There was significantly greater responsiveness to the MWLQ than the UCLALS, especially among people with ID.

CONCLUSIONS

To enable as many people with ID as possible express their views on loneliness, the ID-specific MWLQ is a much better choice. However, this choice comes at the cost of ready comparison to loneliness data for the general community, which is available for widely used assessments such as the UCLALS.

Reconstructing the fall: individual, behavioural and contextual factors associated with falls in individuals with intellectual disability

BACKGROUND

Falls are a significant and recurrent problem for individuals with intellectual disability (ID). There has been little exploration of the fall event from the perspective of the individual who falls or their carers. Research has focused predominantly on personal risk factors, leaving the behavioural and contextual analysis of falls much less understood. This study aimed to identify these additional factors as well as briefly explore the fall experience for individuals and their carers.

METHOD

A qualitative design was used incorporating fall reconstructions and ethnographic-style interviews conducted in the home setting. Nine people with ID and their carers/family member participated: five pairs were living at home and four were in out-of-family-home settings. Interviews were recorded, transcribed verbatim and major themes identified via thematic analysis.

RESULTS

We identified 17 themes that contributed to falls and fell under the three headings of individual, behavioural or contextual factors. Themes include decreased physical capacity, unsafe behaviours, limited hazard awareness and the impact of others in the home on an individual's fall behaviours. Additionally, families and individuals identified a number of consequences and adaptations which they implemented to alleviate possible fall impact.

CONCLUSIONS

Qualitative interviews, observational methods and carer assistance are valuable in offering insight into understanding the individual, behavioural and contextual factors associated with falls in people with ID. The fall reconstruction technique may be a useful supplement when evaluating intrinsic risk in programmes designed to reduce falls.

Engagement in retirement: an evaluation of the effect of Active Mentoring on engagement of older adults with intellectual disability in mainstream community groups

BACKGROUND

As adults with intellectual disability age, retirement options need to be explored. One option is to attend a mainstream community group for retirees. Support within these groups could come from group members who are trained to act as mentors for the older adults with intellectual disability. This research evaluated a support training programme, Active Mentoring, which combines elements of Active Support and Co-worker Training.

METHOD

Three older women with intellectual disability participated in a non-concurrent multiple baseline design. Effect size analyses (Percentage of Non-overlapping Data) were used to evaluate observational data.

RESULTS

Active Mentoring was effective in increasing most types of engagement in activities, but there was no observed effect for social engagement. Mentor help also increased.

CONCLUSION

Active Mentoring was effective in eliciting support from mentors, and in increasing activity engagement of older adults with intellectual disability in mainstream community groups.

'If and when?': the beliefs and experiences of community living staff in supporting older people with intellectual disability to know about dying

BACKGROUND

The aim of this study was to explore the way in which community living staff engaged with people with intellectual disability (ID) about dying and death.

METHOD

Guided by grounded theory methodology, focus groups and individual interviews were conducted with staff who had either no experience with client death, experience of a client sudden death, or a client death experience which was pre-dated by a period of end-of-life care.

RESULTS

While in principle, staff unanimously supported the belief that people with ID should know about dying, there was limited in-practice engagement with clients about the topic. Engagement varied according to staff experience, client capacity to understand and the nature of the 'opportunity' to engage. Four 'opportunities' were identified: 'when family die', 'incidental opportunities', 'when clients live with someone who is dying' and 'when a client is dying'. Despite limited engagement by staff, people with ID are regularly exposed to dying and death.

CONCLUSIONS

People with ID have a fundamental right to know about dying and death. Sophisticated staff skills are required to ensure that people with ID can meaningfully engage with end-of-life issues as opportunities arise.

Experiencing rights within positive, person-centred support networks of people with intellectual disability in Australia

BACKGROUND

This research describes issues related to human rights as they arose within the everyday lives of people in nine personal support networks that included adult Australians with an intellectual disability (ID).

METHOD

The research was part of a wider 3-year ethnographic study of nine personal support networks. A major criterion for recruitment was that people in these networks were committed to actively developing the positive, meaningful future of an adult family member with an ID. Data were collected from November 2007 to March 2011 via interviews, participant observations and analysed within the framework of situational analysis. Findings were checked with network members.

RESULTS

The issue of rights was challenging to network members. Subtle rights violations could have a major impact on an individual with a disability. Network members worked to protect the rights of people with ID by building and maintaining an empathic and respectful support network, developing the person's self-confidence and autonomy and ensuring that the person with an ID was an active member of the personal support network.

CONCLUSION

The maintenance of rights within a supportive environment remains a difficult task. It can be facilitated by a deep knowledge and respect for the person being supported, the promotion of his or her active participation in the planning and provision of support, and an experimental and reflective approach.

Choice of living arrangements

BACKGROUND

The rights to choose where and with whom to live are widely endorsed but commonly denied to adults with intellectual disabilities (ID). The current study provides a contemporary benchmark on the degree of choice exercised by adult service users in the USA.

METHOD

Data came from the National Core Indicators programme. Participants were 6778 adult service users living in non-family-home service settings in 26 US states.

RESULTS

Most adults with ID did not participate in choosing where and with whom to live. Those with more support needs because of more severe ID and/or co-occurring conditions experienced less choice regarding living arrangements. Individuals living in their own home or an agency-operated apartment were more likely to choose where and with whom to live than individuals in nursing homes, institutions or group homes. However, few individuals with severe or profound ID chose where and with whom to live regardless of where they lived.

CONCLUSIONS

In 2008, despite community-living policies that emphasise choice, many adult service users with ID in the USA experienced little or no choice about where and with whom to live, especially those individuals with more severe ID. Our findings provide a clear endorsement of policies promoting more individualised living settings, such as one's own home or an agency apartment, because these settings do provide substantially more choice about living arrangements.

Incidence of and risk factors for falls among adults with an intellectual disability

BACKGROUND

Falls among people with intellectual disability (ID) occur at a younger age than the general population and are a significant cause of injury and hospitalisation. There is very limited research investigating risk factors for falls among people with ID and none with people living outside of formal care arrangements, either independently or with their family.We used a medical chart audit to identify the incidence and risk factors for falls among people with ID living in a variety of settings.

METHODS

We retrospectively identified 114 consecutive patients, aged 18 years and over who attended a clinic for people with developmental disabilities within a 15-month period. Fall information was measured by carer recall of falls in the past 12 months. Potential risk factors were extracted from medical reports and a patient information questionnaire. Potential predictors were identified using univariate analysis and entered into a multiple logistic regression.

RESULTS

Of 114 participants, 39 (34%) reported a fall in the previous 12 months.The number of reported falls was similar for formal care and non-formal care arrangements.The vast majority of fallers (84%) reported sustaining an injury from a fall and many potential risk factors were identified. Multivariate analysis revealed having seizures in the past 5 years, a history of fracture and increasing age were risk factors for falls.

CONCLUSIONS

Falls are a significant health concern for adults with ID of all ages as a result of their incidence and the resulting injuries. Falls appear to be equally an issue for people residing in formal and non-formal care accommodation. Further research is needed to develop screening tools and interventions for this population.

The role of informal networks in providing effective work opportunities for people with an intellectual disability

Being in paid employment is socially valued, and is linked to health, financial security and time use. Issues arising from a lack of occupational choice and control, and from diminished role partnerships are particularly problematic in the lives of people with an intellectual disability. Informal support networks are shown to influence work opportunities for people without disabilities, but their impact on the work experiences of people with disability has not been thoroughly explored. The experience of 'work' and preparation for work was explored with a group of four people with an intellectual disability (the participants) and the key members of their informal support networks (network members) in New South Wales, Australia. Network members and participants were interviewed and participant observations of work and other activities were undertaken. Data analysis included open, conceptual and thematic coding. Data analysis software assisted in managing the large datasets across multiple team members. The insight and actions of network members created and sustained the employment and support opportunities that effectively matched the needs and interests of the participants. Recommendations for future research are outlined.

Penile hygiene: puberty, paraphimosis and personal care for men and boys with an intellectual disability

BACKGROUND

Supporting men and boys with an intellectual disability (ID) to meet their penile hygiene needs is perhaps one of the least acknowledged but most confronting issues facing care staff. The delivery of intimate hygiene can be a challenging topic particularly as it has been drawn into the emerging sexuality discourse and the ongoing abuse narrative. Compounding this challenge is the lack of guidance in intimate care for support staff. In addition, whereas the male with an ID outnumber the female, female care staff greatly outnumber male staff. Whether this situation affects outcomes for men and boys with an ID is unknown but it is an issue which should be examined.

METHOD

This paper reports data from two separate studies, one quantitative the other qualitative, which sought to explore penile hygiene as a male health issue.

RESULTS

Results show the practice of care staff to be inconsistent, the views and values of care staff to be divergent. Some patterns and contextual differences were identified depending upon the gender of care staff. An emerging dialogue described some of the positive contributions that male staff make to men and boys with an ID.

CONCLUSIONS

The penile health needs of men and boys with an ID are being compromised by a lack of guidance, training, knowledge and limited gender-sensitive care.

Utility, economic rationalism and the circumscription of agency

BACKGROUND

Great strides have been achieved over the past few decades in service provision for people with intellectual disability (ID). However, there has also been a growth in the use of economic rationalism and a related rise in managerialism in forming service provision outcomes.

METHOD

An account of the focus on process and means of provision directed within the managerialist agenda to determine how individual authority has become subsumed within patterns of dependence.

RESULTS

An underlying influence of utilitarianism has led to a focus on servicing the average through service provision trajectories which in turn have weakened the pace for social change and perpetuated a vulnerable conception of people with ID.

CONCLUSIONS

There has been a qualification of the idealised intent of providing individualised support, choice and recognition of the moral worth of people with ID into relative features of equality. There remains an overriding static conception of the person with ID within funding frameworks and service provision which relies on economic and rationalist depictions of the individual.

Quality of life and its measurement: important principles and guidelines

BACKGROUND

The importance of the valid assessment of quality of life (QOL) is heightened with the increased use of the QOL construct as a basis for policies and practices in the field of intellectual disability (ID).

METHOD

This article discusses the principles that should guide the measurement process, the major interrogatories (i.e. who, what, when, where, why, and how) of QOL measurement, issues and procedures in the cross-cultural measurement of QOL, and the current uses of QOL data.

RESULTS

Based on the above methods, the article presents a number of important guidelines regarding QOL measurement.

CONCLUSION

From a measurement perspective the use of the QOL construct is changing. Initially it was used as a sensitizing notion, social construct, and unifying theme. Increasingly, it is being used as conceptual framework for assessing quality outcomes, a social construct that guides quality enhancement strategies, and a criterion for assessing the effectiveness of those strategies. This new role places additional emphasis on the valid assessment of one's QOL.

Living circumstances of children and adults with mental retardation or developmental disabilities in the United States, Canada, England and Wales, and Australia

The purpose of this article was to collate evidence to describe where people with mental retardation or developmental disabilities live in five developed countries: United States, Canada, England, Wales, and Australia. Family homes are important dwelling places for people with mental retardation. They are the home of the great majority of children with mental retardation and a considerable proportion of adults with mental retardation. The likelihood of placement outside the family home increases with adulthood and progressively as people age. Adults with mental retardation live in a wide variety of settings, with formal residential provision frequently dependent on the arrangements that the authorities responsible for providing service support have chosen to make. There has been a considerable move away from accommodating people in large segregated and geographically isolated institutions in the countries considered. However, the current range of accommodation includes much with a distinctively different character to the homes where other citizens live. Many people still live in larger groups than would be ordinarily found in typical homes and this may necessitate departure from the architectural norm. In all of the countries considered, there has been a recent trend towards small community settings, compatible with typical housing architecture. This appears furthest advanced in the U.S. but is discernible elsewhere. Availability of residential services at a national level varies between 100 and 155 places per 100,000 total population. Regional variation within countries is even greater. In no case is the national availability considered adequate to meet the demand arising from changing need or expectations. MRDD Research Reviews 7:115-121, 2001. (c) 2001 Wiley-Liss, Inc.

Living with support in the community: predictors of choice and self-determination

Ensuring that people with intellectual disability experience typical levels of choice and self-determination has become an essential objective for quality disability services. Three perspectives on self-determination were identified in the literature: psycho-educational, ecological, and socio-political. Personal characteristics, specific self-determination competencies, and environmental variables all were found to be associated with choice and self-determination. Living environments that were smaller and more individualized were linked to greater choice and self-determination. The theoretical perspective investigators applied to the issues influenced approaches to research and intervention, and differences in emphasis were evident regarding the relative importance of self-determination competencies and environmental factors. MRDD Research Reviews 7:91-98, 2001.

Personal control and the ecology of community living settings: beyond living-unit size and type

Personal control exercised by 74 adults from community living settings in Minnesota was evaluated. Comparisons between living-unit sizes or types controlled statistically for pre-existing differences in adaptive and challenging behavior. Individuals living semi-independently exercised more personal control than did residents of HCBS Waiver-funded settings, who had more personal control than persons from community ICFs/MR. Within the 1- to 5-person size range, size-related differences were detected in personal control. Using hierarchical regression, we found that personal characteristics, self-determination competencies, and environmental variables all made significant, unique contributions to predicting personal control. Path analysis also revealed that this range of variables was related to personal control. These findings strongly support an ecological approach to self-determination.

Substitute decision-making and personal control: implications for self-determination

Levels of personal control exercised by 76 adults with mental retardation were contrasted by substitute decision-making status. Individuals with no guardian or conservator exercised more personal control than did those with a conservator, who exerted more personal control than did participants with a guardian. Similar group differences in self-determination competencies were also observed. When self-determination competencies were controlled statistically, significant group differences in exercise of personal control remained. Restrictive substitute decision-making status, inappropriate to current competencies, may have constrained individuals' levels of personal control. Reviewing substitute decision-making status on a regular basis and limiting or removing guardianship/conservatorship when it is not appropriate, may enhance personal control.

Effectiveness of challenging behavior IHP objectives in residential settings: a longitudinal study

Effectiveness of challenging behavior Individualized Habilitation Plan (IHP) objectives in residential settings was examined. We evaluated three indicators of successful intervention: discontinuation of challenging behavior IHP objectives, change in challenging behavior over time, and frequency of one-to-one crisis intervention and found little evidence of effective intervention. Less than a fourth of participants had a challenging behavior objective discontinued within a year. There was no significant change in challenging behavior from one annual assessment to the next, although the decrease in asocial challenging behavior approached significance. Frequency of crisis intervention also did not change significantly over time. These findings suggest that most challenging behavior IHP objectives are ineffective in reducing challenging behavior.

Interventions for challenging behavior in residential settings

Predictors of interventions for challenging behavior by residential service providers were examined. Three forms of intervention investigated were (a) Individualized Habilitation Plan (IHP) objectives concerning challenging behavior, (b) one-to-one crisis intervention in the preceding 30 days, and (c) services from behavior management professionals in the preceding 6 months. Findings across these three interventions were largely consistent. Externalized challenging behavior (outwardly directed aggressive or disruptive behavior aimed at other people or objects) was consistently associated with all interventions. The implications of these findings for service providers and service users are discussed.

Proxy respondents and the reliability of the Quality of Life Questionnaire Empowerment factor

Previous studies have questioned the reliability of Quality of Life Questionnaire (QOL-Q) Empowerment scores, and reported marked disagreement between consumers' self-reports and proxy data from staff informants. The present study examined agreement between consumer self-reports and proxy responses from community living staff for 63 adults with intellectual disability. Substantial positive correlations between consumers and staff were evident No significant difference was found between total QOL-Q Empowerment scores for self- or staff reports. It was concluded that the QOL-Q Empowerment factor is sufficiently reliable for use both by self-report and proxy respondents. Even so, proxy data are not a substitute for consumer self-reports and the two data sources should not be treated as being interchangeable.

Effectiveness and quality of individual planning in residential settings: an analysis of outcomes

Individual Habilitation Plan objectives for adults with mental retardation living in institutional or community settings were evaluated for effectiveness and quality. Effectiveness was assessed by contrasting change in relevant outcomes over time for participants with and without individual plan objectives in specified content areas. No significant change in outcomes associated with having an objective was detected for any of the content areas. Except for functionality, ratings of individual plans on all quality domains were poor. Regression analyses mostly failed to show any significant relationship between quality domain ratings and outcomes, although there was weak but inconsistent evidence for validity of the technical adequacy and data-collection quality domains. Findings present a challenge to current expectations that presence and quality of IHP objectives are associated with improved outcomes.

Analysis of expenditures and outcomes of residential alternatives for persons with developmental disabilities

Expenditures, staffing, and outcomes were examined for 116 adults with severe or profound mental retardation who moved from state institutions in Minnesota to various community living settings and a comparison group of 71 persons who remained institutionalized. Outcome variables included community access, social activities, community inclusion, family relationships, and choice. Comparison of participants' personal characteristics revealed no differences between groups, but several differences emerged when the community sample was grouped by residence size or public versus private ownership. Where necessary, covariance analysis was used to adjust for these preexisting differences. Community residences were less costly and had more favorable staffing and uniformly better outcomes than did institutions. Few outcome differences were evident between community residents when compared by residence size or service ownership.

Longitudinal study of institutional downsizing: effects on individuals who remain in the institution

In a 4-year study we examined the longitudinal effects of deinstitutionalization programs on those who remain in institutions being downsized. Individual outcomes investigated were community access, social activities, community inclusion, family relationships, and choice. Effects of residential relocation on individual outcomes such as adaptive behavior were evaluated and total daily per-person expenditure on institutional services for participants was determined. Downsizing was associated with decreased community integration but no change in most other outcomes. Availability of therapy services fell over time, and individuals experienced many residential and day program moves within the institution. Per person expenditure on services increased substantially. Finally, no significant changes in adaptive behavior were associated with intrainstitutional moves.

Longitudinal study of deinstitutionalization and the exercise of choice

Day-to-day choices available to former institution residents with severe/profound developmental disabilities (movers) were assessed before and after deinstitutionalization and compared with peers who remained in the same institutions (stayers). Data were gathered annually for both groups for 3 years after baseline. Personal characteristics of the two groups did not differ significantly at baseline, except that stayers exhibited more challenging behavior. This was controlled by using baseline challenging behavior as a covariate in group comparisons. Overall, movers exercised significantly more choice, although groups did not differ at baseline. Effects of deinstitutionalization did not differ with level of disability. However, the absolute level of choice available to both movers and stayers was very low.

Community living-unit size, staff presence, and residents' choice-making

The impact of size of residence on residents' opportunities for choice was examined for Australian adults with mental retardation who lived in staff-supported community residences housing one to five residents. Significantly greater choice was exercised by individuals living in smaller settings, even when personal characteristics of individual residents were controlled statistically. Staff presence was confounded with living-unit size. Analyses including both staff presence and living-unit size revealed strong effects of staff presence, with more choice displayed in settings with longer periods when no staff members were present. Size effects were less evident once the variability associated with staff presence had been accounted for. Results suggest that both staff presence and living-unit size are important predictors of choice.

Assessing opportunities for choice-making: a comparison of self- and staff reports

Self-report responses by adults with mental retardation about the availability of choice were compared with staff responses. Self-reports and staff responses were in clear disagreement on 3 of 10 items. In each case subjects reported that they had significantly more choice than was perceived by staff members. These items involved issues of major life impact for which less choice was available than for other items. Intermingling self-report and third-party responses in research about choice seems unwise because their equivalence cannot be assumed. In contrast to some previous studies, high levels of choice were reported on most items.