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Educating psychiatric residents in intellectual disability: does exposure during residency affect attitudes toward persons with intellectual disability?

We evaluated the attitudes of psychiatric resident graduates and current psychiatry residents, regarding community living for individuals with intellectual disability. Thirty-two graduates, and 17 current psychiatric residents, of a single residency program were surveyed regarding their attitudes toward community living for individuals with intellectual disability. All graduates had completed a three month, half-time residency rotation in intellectual disability. The Community Living Attitudes Scale-Mental Retardation version, Short Form (CLAS-MR) was administered by mail to the graduates, and in person to current residents. Twenty-one of 32 (66%) of graduates, and 16/17 (94%) of current residents completed surveys. On the CLAS-MR, 7/17 (41%) questions demonstrated statistically-significant differences between the two resident groups. For two of the four CLAS-MR subscales (Empowerment and Sheltering), there were statistically significant differences between resident graduates and current residents. It is important to expose psychiatric residents to persons with intellectual disability during residency training because it is associated with subsequent attitudes that favor the empowering, and oppose the sheltering, of these patients. Keywords: intellectual disability, psychiatry residency education, attitude scales, psychiatric, diagnosis, community inclusion


"We like to imagine ... that psychiatry will sometime in the future give mental deficiency the attention that she is so much in need of." (13) Eighty years later, the field still struggles to provide psychiatrists with knowledge and experience in working with individuals with intellectual disabilities. (17) A number of hypotheses have been offered to explain this relative lack of psychiatric expertise in intellectual disability, including avoidance, lack of education, (8 3,9,12) and little exposure to persons with intellectual disability. (10,15) As a result, there is consensus among both psychiatrists in practice, and many in academic settings, that the exposure and education of psychiatrists in the field of intellectual disability, and in the dual diagnosis of intellectual disability and psychiatric illness in particular, is inadequate. (1,2)

Many reports in the area of intellectual disability education for psychiatrists postulate that the lack of sufficient educational opportunity may lead psychiatric graduates to avoid the field following completion of residency. Similarly, it 8,14 may be that this inadequate exposure during residency produces not only a lack of confidence in this clinical area, but may also contribute to lasting attitudes about persons with intellectual disability and mental health problems.

In a pivotal study, Ouellette-Kuntz et al. (11) studied the attitudes of senior psychiatric residents across Canada, regarding their ideas about the inclusion and empowerment of persons with intellectual disabilities living in the community. The authors utilized the Community Living Attitude Scale (CLAS), a 17 item scale which characterizes community attitudes across four subscales (Empowerment, Similarity, Exclusion, and Sheltering). The authors noted 7 that, although most resident respondents endorsed the concept of Empowerment of individuals with intellectual disability, they also favored Sheltering, reflecting a possible ambivalent attitude toward the inclusion of persons with intellectual disability in community settings.

The Department of Psychiatry at the Case School of Medicine/MetroHealth program has provided a required rotation in Dual Diagnosis (intellectual disability and mental illness) Psychiatry for PGY-IV residents over the last 10 years. Two original goals of the dual diagnosis 16 rotation were to enhance the clinical competence of psychiatrists (resident graduates) in providing service to individuals with intellectual disability, and to hopefully increase the willingness, comfort, and perhaps number of psychiatrists providing such service at the local level. Briefly, the rotation is half-time, typically for 3-4 months, and consists of outpatient clinical contact with adults with intellectual disability and dual diagnoses, as well as community visits/consultation in a number of non-clinical settings for persons with intellectual disability (sheltered worksites, group homes, supported living, etc.).

In 2006, a project was undertaken to contact all graduates of the residency who had completed the intellectual disability rotation, seeking feedback about the rotation, post-residency work with persons with intellectual disability, and attitudes toward these persons. At the same time, current residents in the program who had not completed the intellectual disability rotation were also asked to complete an attitude survey.


Following approval of the project by the hospital Institutional Review Board, all resident graduates who had completed the intellectual disability rotation since its inception were invited to participate (N=32), by letter or email. Graduates were mailed the surveys, and asked to return them via U.S. mail. Initial non-responders were re-mailed a second request for participation. Current residents were also invited to participate. All surveys were anonymous, and only group results were examined.

The survey utilized was the Community Living Attitudes Scale, Mental Retardation version, short form (CLAS-MR). (7) It is a 17 item attitude scale, which asks respondents to address statements such as "Sheltered workshops for people with mental retardation are essential" or "People with mental retardation are a burden on society" on a 6 point Likert scale (1=disagree strongly, 6=agree strongly).

Scoring of the CLAS-MR produces a total score, and the short form has also been factor analyzed into four subscales, identifying attitudes regarding the Empowerment, Exclusion, Sheltering, and Similarity to oneself, of persons with intellectual disability.

Group means were calculated for overall CLAS-MR scores for all respondents. Mean CLAS-MR total scores for graduates were compared to means for current residents, employing t-tests for group means. Additionally, subscale scores were calculated and compared for the two groups utilizing analyses of variance.


Twenty-one of 32 (66%) of Case resident graduates completed and returned the survey. Sixteen of 17 (94%) of current residents completed the survey.

Total group mean CLAS-MR scores did not significantly differ between current and resident graduates. However, in examining individual items on the CLAS-MR, 7/17 (41%) questions demonstrated statistically-significant differences between the two resident groups. These means are compared in Table 1. Four of these seven statistically significant group differences were in the area of Empowerment, 2/7 in the area of Sheltering, and 1/7 in the area of Exclusion. For two of the four CLAS-MR subscales (Empowerment and Sheltering), analyses of variance revealed statistically significant differences between the group means. (Table 2)

On the CLAS-MR, on the Empowerment subscale, ex-residents endorsed positions fostering the empowerment of persons with intellectual disability to a statistically significant degree, compared to current residents. Resident graduates were more likely to answer questions such as "People with mental retardation can be trusted to handle money responsibly," or "People with mental retardation should not be allowed to marry and have children" in the direction favoring Empowerment. At the same time, current residents were more likely to endorse positions favoring Sheltering of persons with intellectual disability, such as, "People with mental retardation usually should live in sheltered facilities because of the dangers of life in the community," compared to resident graduates.


The CLAS-MR was introduced by Henry et al. (7) over 10 years ago. At the time, the CLAS-MR consisted of 40 items, which were designed to tap attitudes about individuals with intellectual disability and their inclusion into the community. In a follow-up study, Henry et al. (6) administered the CLAS-MR to a large sample of community staff caregivers, and reported that supervisory and managerial staffs were more likely to favor a community living philosophy for persons with intellectual disability, compared to a sample of persons from the community. Nearly a decade later, Henry et al. (5) compared U.S. and Israeli intellectual disability community agency staff with the CLAS-MR, and reported that U.S. staff demonstrated higher Empowerment scores, although Empowerment scores were associated with higher educational levels in both nations.

Following up this apparent association between higher educational levels and more enlightened attitudes, it would appear important to investigate whether similar relationships exist for other professionals. Unfortunately, there is little literature focusing on the attitudes of psychiatric or behavioral professionals toward community living by persons with intellectual disability. In fact, only two studies appeared to address this topic.

In the first, Ouellette-Kuntz et al. (11) utilized the CLAS-MR Short Form to survey attitudes of psychiatric residents across Canada, who were attending an elective preparatory course for certification in the Royal College of Psychiatry. Fifty-eight of 208 residents participated, representing 28% of the senior psychiatric residents in Canada. Although 24% reported that they had never met a person with intellectual disability outside of their medical training, 86% of respondents indicated that they had received specific teaching in intellectual disability during residency.

On the CLAS-MR subscales, Canadian residents' attitudes favored Empowerment and Similarity (perceived similarity of persons with intellectual disability to oneself) over Exclusion (from community living) and Sheltering. However, in an indirect comparison with previous CLAS-MR respondents, the residents had lower 6 Empowerment subscale scores, and higher Sheltering scores, than a sample of intellectual disability managers and professionals. The authors hypothesized that the recent exposure of the psychiatric residents to individuals with intellectual disability and behavioral or psychiatric disorders (in their residency training) may have led to higher Sheltering scores. They concluded that it may be useful (or necessary) to expose residents in training to individuals with intellectual disability who do not have co-occurring psychiatric disorders, and who might therefore seem less likely to require Sheltering.

The study by Ouellette-Kuntz et al. also 11 examined the possible effect of exposure to persons with intellectual disability during residency training on subsequent attitudes. On the CLAS-MR, only the Similarity subscale was affected. Canadian residents with intellectual disability training were more likely to view persons with intellectual disability as similar to themselves, compared to residents without such contact.

Comparing our resident graduates (N=21) and the senior Canadian residents (N=58) on the CLAS-MR produces some interesting contrasts (Table 3), although we did not have the opportunity to test the statistical significance of these results, and therefore chance cannot be eliminated as a possible explanation for the differences. Resident graduates in our study endorsed Empowerment and Similarity more than Canadian residents (Empowerment: 4.81 vs. 4.32; Similarity: 5.63 vs. 5.30). Canadian residents were more likely to favor Sheltering (3.63 vs. 3.26), and the two groups had similar Exclusion scores. Both groups had been exposed to training in intellectual disability psychiatry as part of their residency education (although 8/58 of the Canadian residents had not had a clinical experience in this area). Our resident graduates had been out of residency from 1-10 years, so that their attitudes regarding community living for persons with intellectual disability may have been additionally altered by post-residency experiences, both in the clinical area of intellectual disability, and in psychiatry in general. Additionally, unlike their U.S. counterparts, the intellectual disability experiences of the Canadian residents were not uniform. Nonetheless, the differences in attitudes between the groups, particularly in the areas of Empowerment and Sheltering, are worth noting.

In the second attitudes study, Graham et al. (4) utilized focus groups to examine the attitudes and emotions of four senior house officers working in intellectual disability psychiatry in the United Kingdom. The authors reported a number of negative themes and attitudes among the trainees, both toward themselves and toward patients with intellectual disability. Trainees felt themselves to be ill-equipped and unequal to the job of working with persons with intellectual disability, and cited feelings of dislocation from the patients with intellectual disability ("It doesn't feel that there are common aspects in our lives."). Although not directly comparable, it would seem that this sense of dislocation would be the opposite of the attitudes of Similarity expressed by the Canadian psychiatric residents.

The study had several limitations. Both groups (current and ex-residents) were small, and the survey sampled only a single residency program. Although the response rate (66% for the graduate group) was good for survey research, there may have been some bias in respondents who returned surveys. Finally, a three or four month training program alone may not be sufficiently powerful to account for all differences observed.

It appears that exposing psychiatric residents to persons with intellectual disability during residency training is associated with subsequent attitudes that favor the empowering, and oppose the sheltering, of individuals with intellectual disability living in the community. And, compared to Canadian senior residents, U.S. resident graduates are also more likely to favor empowerment and oppose sheltering of persons with intellectual disability. Subsequent studies of professional attitudes toward community living for persons with intellectual disability should attempt to further characterize those experiences (clinical and otherwise) which are associated with advancing the concepts of Empowerment and Similarity, and avoidance of Sheltering and Exclusion, for persons with intellectual disability.


(1.) American Psychiatric Association. Report of the Task Force on Psychiatric Services to Adult Mentally Retarded and Developmentally Disabled Persons. Szymanski L (Chair), 1991.

(2.) Antochi R. Training in developmental disabilities needed during psychiatric residency. Psychiatric Annals 2004;34:233-236.

(3.) Burge P, Ouellette-Kuntz H, McCreary B, et al. Senior residents in psychiatry: Views on training in developmental disabilities. Can J Psychiatry 2002;47:568-571.

(4.) Graham S, Herbert R, Price S, Williams S. Attitudes and emotions of trainees in learning disability psychiatry. Psychiatr Bull 2004;28:254-256.

(5.) Henry DB, Duvdevany I, Keys CB, Balcazar FE. Attitudes of American and Israeli staff toward people with intellectual disabilities. Ment Retard 2004;42:26-36.

(6.) Henry D, Keys C, Balcazar F, Jopp D. Attitudes of community-living staff members toward persons with mental retardation, mental illness, and dual diagnosis. Ment Retard 1996;34:367-379.

(7.) Henry D, Keys C, Jopp D, Balcazar F. The Community Living Attitudes Scale, Mental Retardation Form: Development and psychometric properties. Ment Retard 1996;34:149-158.

(8.) Lennox N, Chaplin R. The psychiatric care of people with intellectual disabilities: The perceptions of trainee psychiatrist and psychiatric medical officers. Aust N Z J Psychiatry 1995;29:632-637.

(9.) Lunsky Y, Bradley E. Developmental disability training in Canadian psychiatry residency programs. Can J Psychiatry 2001;46:138-143.

(10.) Menolascino FJ, Fleisher MH. Training psychiatric residents in the diagnosis and treatment of mental illness in mentally retarded persons. Hosp Community Psychiatry 1992;43:500-503.

(11.) Ouellette-Kuntz H, Burge P, Henry DB, et al. Attitudes of senior psychiatry residents toward persons with intellectual disabilities. Can J Psychiatry 2003;48:538-545.

(12.) Phillips A, Morrison J, Davis RW. General practitioners' educational needs in intellectual disability health. J Intellect Disabil Res 2004;48:142-149.

(13.) Potter H. Mental deficiency and the psychiatrist. Am J Psychiatry 1927;83:691-698.

(14.) Ruedrich S, Dunn J, Schwartz S, Nordgren L. Psychiatric resident education in intellectual disabilities: One program's ten years of experience. Acad Psychiatry 2007;31:430-434.

(15.) Schwartz SA, Ruedrich SL, Dunn JE. Training psychiatry residents in mental retardation and developmental disabilities. In: Jacobson JW, Holburn S, Mulick JA (eds), Contemporary Dual Diagnosis: MH/MR Service Models Volume II: Partial and Supportive Services. Kingston, NY: NADD Press, 2002:129-140.

(16.) Schwartz SA, Ruedrich SL, Dunn JE. Psychiatry in mental retardation and developmental disabilities: A training program for psychiatry residents. Ment Health Aspects Dev Disabil 2005;8:13-21.

(17.) U.S. Public Health Service. Closing the Gap: A National Blueprint to Improve the Health of Persons with Mental Retardation; Report of the Surgeon General's Conference on Health Disparities and Mental Retardation. February 2001. Washington D.C.


[1] Case School of Medicine, Cleveland, OH

[2] Ascentia, Cleveland, OH 2

[3] Case School of Medicine, Cleveland, OH 3

[4] Cuyahoga County Board of Mental Retardation/Developmental Disabilities, Cleveland, OH 4

CORRESPONDENCE: Stephen Ruedrich, M.D., Associate Professor of Psychiatry, Case School of Medicine, 2500 MetroHealth Drive, Cleveland, OH 44109; tel.: 216-778-4626; fax: 216-778-8412;

 Ex- Current
 Resident Resident
Question Factor Mean Mean t df p

1 Empowerment 5.15 3.44 3.83 34 0.0005
2 Empowerment 5.19 4.13 2.11 35 0.0420
3 Empowerment 5.05 3.31 4.19 35 0.0002
4 Empowerment 4.52 3.06 3.48 35 0.0014
5 Empowerment 4.19 3.94 0.68 35 0.5019
6 Sheltering 4.57 5.38 -1.97 35 0.0568
7 Exclusion 1.05 1.81 -2.95 35 0.0057
8 Exclusion 2.10 2.38 -0.59 35 0.5592
9 Exclusion 2.15 2.94 -1.40 34 0.1703
10 Exclusion 2.38 2.06 0.66 35 0.5133
11 Sheltering 3.48 4.00 -1.42 35 0.1644
12 Similarity 5.45 4.94 1.32 34 0.1972
13 Similarity 5.67 5.38 1.28 35 0.2078
14 Similarity 5.62 5.38 1.01 35 0.3213
15 Similarity 5.75 5.63 0.64 34 0.5259
16 Sheltering 1.80 3.25 -3.88 34 0.0005
17 Sheltering 2.95 3.94 -2.18 34 0.0361


Factor SS df MS SS

Mean 13.89345 1 13.89345 19.56952
Exclusion Mean 1.28549 1 1.28549 32.25618
Sheltering Mean 7.01195 1 7.01195 25.05562
Similarity Mean 0.83278 1 0.83278 10.54222

Factor df MS F p

Mean 35 0.559129 24.84837 0.000017
Exclusion Mean 35 0.921605 1.39483 0.245554
Sheltering Mean 35 0.715875 9.79494 0.003520
Similarity Mean 35 0.301206 2.76480 0.105290


 U.S. Resident Canadian Senior
 Graduates Residents
 N = 21 N = 58

 Mean SD Mean SD

Empowerment 4.81 -0.69 4.32 -0.65
Exclusion 1.92 -0.85 1.75 -0.71
Sheltering 3.26 -1.00 3.63 -0.75
Similarity 5.63 -0.52 5.3 -0.61
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Author:Ruedrich, Stephen; Schwartz, Stephan; Dunn, Jonathan; Nordgren, Lynlee
Publication:Mental Health Aspects of Developmental Disabilities
Article Type:Report
Date:Oct 1, 2008
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