Author
BRUDER Corinna; KROESE Biza Stenfert;
The efficacy of interventions designed to prevent and protect people with intellectual disabilities from sexual abuse: a review of the literature.
Journal citation/publication details
Journal of Adult Protection, 7(2), August 2005, pp.13-27.Summary
This review is based on searches of only two databases, but employs systematic methods to identify and select literature. Nine studies, all employing small samples and a variety of research methods, met the inclusion criteria. They show that both children and adults with intellectual disabilities can be taught skills to help protect themselves from sexual abuse, but that questions remain about whether these skills can be reproduced in real life situations or over the long term. Further, better conducted studies are needed, but some general lessons for current practice are identified.
Context
It is generally accepted that people with intellectual disabilities are particularly vulnerable to sexual abuse, and exhibit the same range of symptoms and difficulties following such abuse as those in the general population. It has also been argued that developmental delay itself can be the outcome of sexual, as well as physical, abuse. A range of interventions to teach protection and prevention skills to people with intellectual disabilities has been developed, and this review explores their efficacy.
Methods
What sources were used?
PsycINFO and Medline were searched from 1 January 1993 to 1 April 2004. In addition, the references to 'key articles' were scanned.
What search terms/strategies were used?
The terms mental retardation, learning disability, learning difficulty and developmental disability were combined with the terms sexuality and sexual abuse.
What criteria were used to decide on which studies to include?
Eligible studies were published in peer reviewed journals, reported on their research methods and focused on evaluations of interventions targeted at children or adults with intellectual disabilities. Studies that addressed therapeutic issues once sexual abuse had taken place were specifically excluded.
Who decided on their relevance and quality?
The yield from the searches, and subsequent selection and quality assessment, are not discussed. However, the authors do discuss methodological aspects of their selected studies.
How many studies were included and where were they from?
Nine studies met the inclusion criteria. They are included in the references to the paper but are not tabulated. Nor are geographical origins specified, although at least one study is from the UK and one from Australia .
How were the study findings combined?
This is not discussed. The studies, using a variety of research approaches, are reviewed in turn and general lessons identified.
Findings of the review
The nine studies varied widely in design and methods, and all were characterised by small sample sizes (ranging from 4 to 49) so that results cannot safely be generalised to other populations or settings. The authors conclude, however, that they do demonstrate that it is possible to teach both adults and children some skills that could help protect them from sexual abuse. Although most studies evaluated participants with mild to moderate disabilities, one suggested that individuals were severe impairments were also capable of acquiring and maintaining a knowledge of behaviours that could help them in keeping safe.
However, where follow-up was carried out in the nine studies it did not exceed six weeks, making it difficult to reach conclusions on whether skills were retained. Moreover, 'it became clear that the acquisition of knowledge did not equal the ability to produce a desired behaviour skill in a real situation', while the ability to demonstrate certain behavioural responses during role play did not necessarily transfer to behaviour shown during in situ assessment.
Authors' conclusions
While the studies do demonstrate that teaching can successfully be carried out, there is a need for better designed studies of larger samples. Three elements of successful teaching require exploration in evaluations: information giving and instruction; modelling and rehearsing skills in role plays; and testing and rehearsing behaviours during in situ assessments.
The authors are also concerned about the ethical aspects of research with vulnerable subjects who are deliberately exposed to situations and behaviours that they are supposed to find threatening. While some researchers might argue that such research requires participants to be 'unsuspecting and uniformed', at the very least the potential impact on them needs to be carefully considered and measured. The de-briefing of participants about research objectives and methods in retrospect might help to address some of the ethical concerns.
Implications for policy or practice
None of the studies needed to screen out potential participants on the grounds that they did not need the intervention, suggesting that 'the majority of adults and children with intellectual disabilities did not appear to possess the appropriate knowledge or the necessary skills that would have enabled them to respond effectively to situations in which they were at risk of being sexually abused.' It thus 'seems paramount that protection and prevention skills are routinely taught to children with intellectual disabilities, so that during adulthood the maintenance of such skills would be the aim rather than acquisition.'
Such maintenance 'could place participants in state of great conflict' when they live in institutional settings 'where they are mainly expected to comply'. The authors found no studies of interventions for staff to help them address the potential tensions that might arise when people are taught (and encouraged) to be more self-assertive and to challenge authority. Most of the studies agree that the reporting of abusive situations to someone else is a crucial skill in preventing sexual abuse, and this requires staff who are trusted and who accept the right of individuals to assert and protect themselves appropriately.
Finally, the authors argue that the focus in the interventions reviewed on the dangers of exploitative sexual relationships 'should be matched by an equal effort in creating opportunities and helping people to acquire skills to experience their sexuality in a positive way.'