Involuntary sterilization of persons with mental retardation: an ethical analysis

Legitimate concerns on the part of parents and guardians may lead to requests for sterilization of a mentally retarded person in their care. At the same time, mentally retarded persons must be protected from actions that do not serve their best interests. This paper will review the history of involuntary sterilization in the United States and evaluate the ethical arguments that are relevant to decisions about involuntary sterilization. While other, less permanent forms of contraception might be acceptable, involuntary sterilization ought not be performed on mentally retarded persons who retain the capacity for reproductive decision-making, the ability to raise a child, or the capacity to provide valid consent to marriage. Mentally retarded persons who lack capacity in those three areas should be considered for involuntary sterilization only when the procedure is necessary, sterilization would serve the best interests of the mentally retarded person, less intrusive and temporary methods of contraception or control of menstruation are not acceptable alternatives, and procedural safeguards have been implemented to assure a fair decision-making process.     

Cardiovascular disease prevalence and risk factors of persons with mental retardation

This paper reviews the recent literature on cardiovascular disease (CVD) prevalence, CVD-related mortality, physiological CVD risk factors, and behavioral CVD risk factors in adults with mental retardation (MR). The literature on the potential influences of modifiable behavioral CVD risk factors and the physiological CVD risk factors are also reviewed. Adults with mild to moderate MR residing in community settings appear to have an elevated disease prevalence, elevated CVD-related mortality, more adverse physiological CVD risk factors, and elevated behavioral risk compared to others with and without MR. Preliminary evidence supports the benefits of participating in the recommended physical activity levels and consuming the recommended diets to reduce the risk for CVD. The lack of large-scale longitudinal or experimental research indicates a gap in the research. The development of research-based, appropriate, primary prevention programs and intervention strategies aimed at lowering the risk for CVD is highly recommended. Programs should focus on educating individuals with MR along with direct care providers and family members on the importance of appropriate dietary concepts, physical activity habits, and regular health screenings by physicians. Programs should be individualized to regional and cultural issues.     

Abuse and neglect of adults with mental retardation in different residential settings

Eighty-two per cent of all cases of abuse or neglect of an adult with mental retardation substantiated by the Abuse Investigation Division of the Connecticut Office of Protection and Advocacy for Persons with Disabilities over a five-year period occurred in the victim's residence. Chi square analyses revealed that there was significantly more abuse in institutions and group homes and significantly less in the individual's own home. Furthermore, analyses revealed that there was significantly more personal neglect in group homes and community training homes and significantly less in own homes. The results were discussed and recommendations made regarding ways of reducing abuse and neglect.     

A review of substance use research among those with mental retardation

This article reviews research conducted on the cigarette, alcohol, and illicit drug use of adolescents and adults with mental retardation (MR). The majority of the research related to substance use conducted on this population has been limited to surveys. Overall, results of these studies suggest that, although substance use is slightly lower among those with MR than among nondisabled comparison groups, it is nonetheless a problem for many individuals. This research is reviewed and a discussion of both the general and specific flaws of these studies follows. Further, the examination of education, prevention, and treatment programs for this population has been overlooked, indicating that individuals with MR are likely not receiving the services most appropriate for them. The article concludes with a discussion of several topics that need to be addressed in future studies, including research on potential best practices in the overlooked areas of substance abuse interventions.     

History of mental retardation: an essay review

The history of mental retardation previously focused on residential institutions and the ideas of professionals. Given that the vast majority of people with mental retardation lived in their family homes or other locations in their communities, this emphasis has been misleading. Recent historical studies by James W. Trent Jr.; Philip M. Ferguson; Steven Noll; and the British scholars in David Wright and Anne Digby's collection, From Idiocy to Mental Deficiency, have opened up the field by describing the complicated relationships between families and the state, by outlining the development of lay concepts of mental disabilities, and by acknowledging the wide diversity of experiences of people with mental disabilities.     

Relation between self-paced and synchronized movement in persons with mental retardation

The relation between self-paced and synchronized tapping in 64 persons with mental retardation whose mental ages ranged from 2 to 11 years and chronological ages from 13 to 23 years was investigated. In a self-paced tapping task no stimulus was presented, and subjects' easy and spontaneous tapping was measured. In a synchronized tapping task their synchronous tapping with an auditory stimulus present at a quick or slow tempo was measured. Under both tempo conditions, the lower the subjects' mental age, the larger the errors in the intertap interval they made. The subjects of low mental age showed significantly larger errors in the intertap interval in the Slow than in the Quick Tempo condition and tended to tap at a rate near the self-paced tapping. These results may suggest that ability to adjust one's self pace is one of the key factors in the development of motor synchronization in persons with mental retardation.     

Pupillary responses in recognizing awareness in persons with profound mental retardation

Pupil-size changes have been shown to indicate positive or negative reactions to several sensory and psychologic stimuli in normal persons. Whether this could be extended to mentally retarded patients who lack ability for verbal or motor behavior was tested by pupillary responses to several visual, tactile, and auditory stimuli. 24 institutionalized severely and profoundly retarded patients were examined by video camera in their usual environments rather than in a controlled laboratory setting. The videotapes were later projected onto a screen for pupil-size measurements. Pupils dilated with pleasant stimuli, including visualizing a familiar person, soft touch to the arm, music, and soft compliments. There was constriction with presenting an unfamiliar person, rough grasp of the arm, and abrasive noise and harsh commands. The findings demonstrate the existence of pupil reactivity in profoundly retarded persons and suggest such testing as a means of determining which elements of their environment are pleasing or aversive to them.     

Brief report: Non-intrusive operant analysis of aggressive behavior in persons with mental retardation

A procedure for operant analysis of aggressive behavior was derived from multi-element assessment methods that have been previously applied to both self-injurious and stereotypic responding. Analog sessions included No Interaction Baseline, Social Disapproval, Demand, Social Reinforcement, and Discriminated Extinction conditions, repeatedly presented within a multi-element design. Three men with differing severity of mental retardation, communicative deficits and aggressive behavior were exposed to multiple brief analog sessions embedded within their normal meal-time routines in group home settings. Mean frequencies of aggressive behavior and concurrent eating indicate that, while aggressive behavior was negatively reinforced in all three participants, both social and non-social contingencies were also prominent. The same contingencies which have been demonstrated to maintain self-injury and stereotypic behavior can therefore also maintain aggression. Results suggest the feasibility of conducting relatively non-intrusive analog assessments in community residences, and support the-extension of functional analysis across differing classes of aberrant behavior.     

Making choice a routine part of mealtimes for persons with profound mental retardation

Despite increased recognition of the importance of providing routine choice opportunities for persons with severe handicaps, this population continues to experience a typical lack of such opportunities. We evaluated a program for increasing the amount of choices made during routine mealtimes by persons with profound mental retardation and minimal communication skills. The choice provision program, involving systematic presentation of alternative food and drink items in a step-wise fashion during the course of the meal, was implemented with three persons in a residential facility. Results indicated that after implementation of the choice program, all three participants made consistently more choices concerning the foods and beverages they consumed relative to baseline. The choice provision program was conducted without extending the amount of time typically allotted to mealtime within the residential setting. Results are discussed in regard to additional research needed to continue developing means of assisting persons with profound mental retardation to exert control over meaningful events in their lives.     

Adolescent sex offenders with mental retardation: Literature review and assessment considerations

Working with adolescent sex offenders can be a difficult challenge. When an offender also suffers from mental retardation, this challenge increases. Unfortunately, this has been a largely ignored population, and clinicians working with this group often find little empirical work to assist them. Yet, many theorists posit that addressing sexual offending behavior when the offender is an adolescent may help prevent that behavior from continuing into adulthood. This is important because adult sexual offenders are often very difficult to treat. The current paper begins by reviewing literature on social deficits of individuals who have mental retardation. These deficits may contribute to aberrant sexual behavior among adolescents. The focus of the paper is then a review of literature on adolescent sex offenders, including those with mental retardation. We conclude this review with suggestions for assessment of adolescent sex offenders and with recommendations for future directions.     

Reviews and critiques of school psychology materials Douglas T. Brown, Associate Editor : Assessing psychopathology in persons with mental retardation: A review of the Reiss Scales

This review addresses two instruments, the Reiss Scales for Children's Dual Diagnosis and the Reiss Screen for Maladaptive Behavior, that are commonly used with persons who are mentally retarded. An analysis of the psychometric properties of each instrument is provided. The circumstances under which each instrument could be appropriately used are discussed. It is concluded that both scales are useful as screening devices, especially given the lack of instrumentation for evaluation of social and emotional status in the mentally retarded. Concern is expressed in regard to the need for a more comprehensive set of items in each test and to the author's rationale for cut scores.     

Effects of reinforced directed rehearsal on expressive sign language learning by persons with mental retardation

This study used a multielement design to compare standard training (prompting and reinforcement) with and without reinforced directed rehearsal as a correction procedure in teaching expressive sign language to 10 nonverbal students with moderate to severe mental retardation. Standard training consisted of either sequential prompting or graduated guidance and 5 students were randomly assigned to each condition. Directed rehearsal involved 10 practices of the correct sign contingent on an error or no response; praise was given during directed rehearsal for cooperation and attempted signing. A stimulus control analysis revealed that only 6 of the 10 students (3 from each standard training condition) completely discriminated the trained signs within the maximum training period of 160 trials (3 of the 4 students who failed the stimulus control test were hearing impaired; the remaining 6 who showed stimulus control were not). Using only these six students' data, we found that directed rehearsal increased: (a) accuracy (percent correct), (b) speed of learning (required fewer trials to criterion), (c) efficiency (decreased total instruction time), and (d) generalization (across trainers, objects, and settings). There were no obvious interactions between directed rehearsal and the type of prompting strategy employed. Very little agitated behavior occurred in any of the sessions, and a treatment acceptability survey indicated that 10 of 14 direct-care staff and the trainers in this study preferred corrective directed rehearsal (as used in this study) over standard training alone. The results indicate that directed rehearsal may be a valuable adjunct to sign language training with nonverbal students with mental retardation.     

Brief report: Contact desensitization in the treatment of dog phobias in persons who have mental retardation

In comparison with the research done on phobias in non-retarded individuals, there is a paucity of research in the treatment of phobias in persons with mental retardation. In this study, contact desensitization was evaluated as a treatment for two individuals who have mental retardation and an intense fear of dogs. Following base-line assessment using a behavioral avoidance test (BAT) measuring actual approach behavior, treatment was implemented in a multiple base-line across subjects design. Contact desensitization resulted in the elimination of avoidance behavior in both subjects during the BAT. Measures of generalization in an outdoor setting, and maintenance during a two-month follow-up, showed that the clients continued to be free of avoidance behavior. The implications for further application and research are discussed.     

Brief report: Teaching persons with moderate mental retardation to use printed instructions and time cues in a work context

Printed instructions and programable watches were used for helping two adults with moderate mental retardation perform variable tasks and follow a time schedule for task execution. The subjects, who could not read, were to match the words appearing in instruction notes to identical words superimposed on illustrative pictures (and collected in a vocabulary form). The pictures identified through this matching explained the meaning of the words being matched (i.e., indicated to the subjects which responses/tasks to perform). Self-recording was also used. The results showed that both subjects learned to use the printed instructions and the watches successfully. The subjects' performance remained positive over time. Procedural aspects and practical implications of the study are discussed.     

The impact of environmental noise on mealtime social interactions in a residential facility for persons with mental retardation

Four levels of environmental noise were experimentally manipulated during lunch and dinner in a residential living unit for 10 behaviorally disordered persons with mental retardation. During the highest noise conditions, there appeared to be some suppression of social interaction between these people, while interaction rates were uniformly higher during softer noise conditions. This effect was evident at both lunch and dinner. Staff members were less affected by the fluctuation in noise levels, although lunchtime staff engaged in more interactions with clients when both the radio and TV were played softly.     

A survey of habit behaviors exhibited by individuals with mental retardation

The purpose of this study was to investigate the prevalence and characteristics of habit behaviors exhibited by individuals with mental retardation living in the community. Two hundred and fifty-nine direct care staff and parents from the upper mid-west and northeast regions of the country completed a survey measuring the prevalence of major habit disorders (bruxism, trichotillomania, motor/vocal tics, and stuttering) and habit behaviors exhibited by individuals with mental retardation being served by community residential agencies. Habit disorders were also subjectively evaluated according to the respondents' perception of the severity and noticeability of the behavior, and naturalness of appearance of the individual. In addition, respondents indicated their usual reaction to the habit disorder. Overall, stuttering was found to be the most prevalent habit disorder (32%), followed by tics (16·6%), bruxism (13·1%), and trichotillomania (5%) for the sample surveyed. Furthermore, differences were found in the prevalence of habit disorders and other habit behaviors by level of mental retardation and age (adults versus children/adolescents). The implications and limitations of the data, as well as suggestions for future investigations of habit disorders and habit behaviors exhibited by individuals with mental retardation, are discussed. © 1998 John Wiley & Sons, Ltd.