Abstract

Direct support professionals (DSPs) provide integral support to many individuals with intellectual and developmental disabilities (IDD). Yet, individuals' access to qualified DSPs is often compromised as organizations struggle to hire and retain DSPs. Despite a vast body of research exploring factors associated with turnover, adverse childhood experiences (ACEs) among DSPs remain absent from the literature. ACEs encompass abuse and familial dysfunction prior to the age of 18 and, in the general population, have been linked to compromised well-being and work-related challenges in adult life. An online survey was conducted to explore the prevalence of ACE categories and ACE scores (i.e., the sum of each ACE category experienced by a person) among DSPs (n = 386) working in licensed settings. Seventy-five percent of DSPs experienced at least one ACE and 30% had an ACE score of four or more. DSPs who identified as female and those who had been in their position less than one year had significantly higher ACE scores than males and others who had been in their position longer, respectively. In comparison with other studies, the four most common ACE categories among DSPs (i.e., divorce, emotional abuse, mental illness, and substance abuse) were the same, however, DSPs in the present study had a higher average ACE score and nearly twice the percentage of persons having an ACE score of four or more. The potential implications of ACEs among DSPs, at the intersection of their work with individuals with IDD, are discussed.

Direct support professionals (DSPs) are integral to the realization of full inclusion set forth by the Americans with Disabilities Act for approximately 17% of the estimated 6.2 million individuals with intellectual and developmental disabilities (IDD) living in the United States (Bogenschutz, Hewitt, Nord, & Hepperlen, 2014; Braddock et al., 2015; Larson et al., 2016). The number of DSPs required to meet the needs of the IDD population continues to grow as individuals with IDD experience greater life expectancy, as family caregivers age, and as community–based services advance. However, the capacity of organizations to assure individuals access to, and to provide, quality community-based supports continue to be strained by challenges with the recruitment, training, and retention of DSPs (Braddock et al., 2011; Hewitt & Larson, 2007; U.S. Department of Health and Human Services [USDHHS], 2006). Despite a vast body of research associated with DSP burnout and turnover, there is a dearth of research exploring other plausible contributing factors, such as adverse childhood experiences (ACEs). Given that maximization and retention of the DSP workforce continue to be of critical importance, a closer analysis of alternate factors that might influence their experiences and longevity is warranted.

Adverse Childhood Experiences

In 1998, Felitti and colleagues published the premier study on ACEs in the general population “to describe the long-term relationship of childhood experiences to important medical and public health problems” (Felitti et al., 1998, p. 246). Adverse childhood experiences are defined as three categories of abuse (i.e., psychological, physical, and sexual abuse) and four categories of exposure to household dysfunction (i.e., exposure to substance abuse, mental illness, violence toward mother/stepmother, and criminal behavior) that occur prior to the age of 18 years old. Felitti et al. (1998) created the ACE measure comprised of a series of items as displayed in Table 1 to elicit self-reported retrospective responses. An ACE score which can range from zero to 10 is calculated from the sum of items endorsed by a person. For example, if a person indicated that a parent hit them and a family member went to prison, that person would have an ACE score of two.

Table 1

ACE Survey Items

ACE Survey Items
ACE Survey Items

Because the original study almost two decades ago, ACEs have been repeatedly identified as prevalent experiences in the general population, with half to two thirds of the adult population having experienced at least one ACE and subsequent exposure to an additional ACE category ranging from 65% to 98% (Dong et al., 2004; Felitti et al., 1998). Further, ACE scores have been associated with a dose-response/graded effect with compromised well-being in adulthood. That, as the number of ACEs a person experiences increases, his/her risk of health, behavioral, and social problems across the lifespan also increases (Merrick et al., 2017; Substance Abuse and Mental Health Services Administration, n.d.). When compared with persons who have not experienced any ACEs, those with ACE histories have significant and sustained losses in health-related quality of life in adulthood, including increased psychiatric diagnoses, substance use, and risk of suicide (Cabrera, Hoge, Bliese, Castro & Messer, 2007; Corso, Edwards, Fang, & Mercy, 2008; Ford et al., 2011; Kalmakis & Chandler, 2014).

Variability and ACES

Adverse childhood experiences are approximately equal in their impact, however sources of variability such as ACE type, gender, age, and culture warrant consideration (Felitti & Anda, 2010). For example, despite a graded relationship between ACEs and psychiatric diagnoses, exposure to emotional abuse further compromised mental health and demonstrated an increased association with headaches over other ACE types (Anda, Tietjen, Schulman, Felitti, & Croft, 2010; Edwards, Holden, Felitti, & Anda, 2003). In addition, particular types of ACEs have been associated with different levels of impact on quality of life between age groups. For example, emotional neglect was found to have the strongest influence on marginal loss of health-related quality of life, however, among adults ages 60 to 69 years, only sexual abuse and emotional neglect significantly impacted the loss of quality of life (Corso et al., 2008).

The relationship between ACEs and gender is noteworthy as females are at a greater risk than males for experiencing at least one ACE (Ford et al., 2011; Merrick et al., 2017). In addition, studies have noted that females are 50% more likely than males to have experienced five or more ACE types (Felitti & Anda, 2010) with all but three ACE types more prevalent among females: physical abuse, parental divorce/separation, and incarceration (Cavanaugh, Petras, & Martins, 2015). Likewise, persons with lower levels of education and those living in poverty are at risk for higher ACE scores than persons with more education and financial resources (Nurius, Logan-Greene, & Green, 2012; The Research & Evaluation Group, 2013).

Cultural differences have been noted regarding the prevalence and impact of ACEs. For example, it has been found that Hispanics have a lower prevalence of at least one ACE and a lower prevalence of smoking than other racial or ethnic groups (Ford et al, 2011). Some studies have noted significant differences in types of ACEs, but not ACE scores, by cultural groups. Thomas (2016) noted that African Americans were significantly less likely to have experienced emotional neglect than Latinos or Whites, yet they were more likely to experience divorce than Asians, Whites, Latinos, or indigenous people. However, no differences in ACE scores by gender or ethnic group were noted.

ACEs and employment

An understanding of the impact of ACEs on employment is emerging in the literature. Although each type of ACE has been associated with an increased likelihood of work-related challenges, exposure to ACEs has also been associated with decreased ability to attain employment, (Anda et al., 2004; Birnbaum et al., 2010; Topitzes, Pate, Berman, & Medina-Kirchner, 2016). Workers with higher levels of exposure to early life adversity (i.e., an ACE score of 4 or higher) are more than twice as likely to report job problems, financial problems and absenteeism compared with workers who had no ACEs. Furthermore, health and well-being have been identified as mediating the relationship between ACEs and job performance, such that relationship problems, emotional distress, somatic symptoms, and substance abuse were associated with poorer job performance (Anda et al., 2004). This nascent body of research suggests the importance of considering the potential impact of early life adversity on an employee's well-being, productivity, and longevity, particularly for those who are at greater risk of higher ACE scores, such as females and people of color.

ACEs, Trauma, and Human Services

Bloom (2010) noted that human service workers frequently present with early life adversity and past trauma that they continue to contend with while engaging in service delivery. Given the nature of working in human services (e.g., supporting persons in their daily life, many of whom might come from disadvantage), there is considerable potential for a worker's past adversity to manifest. Yet, “(d)espite increasing knowledge about the prevalence of trauma in the general population, little is known about the prevalence of ACEs among…service providers” (Esaki & Larkin, 2013, p. 31). The dearth of literature in this substantive area necessitates consideration of earlier research (Esaki & Larkin, 2013; Thomas, 2016). Initial studies demonstrated associations between early life trauma, as well as frequency of adversity (e.g., familial substance abuse), and the selection of social work as a profession (Black, Jeffreys, & Hartley, 1993; Rompf & Royse, 1994; Russel, Gill, Coyne, & Woody, 1993). Bloom and Farragher (2010) indicated that more than 80% of their residential staff experienced some form of childhood adversity. More recently, Esaki and Larkin (2013) explored the prevalence of ACEs among direct and indirect care providers (n = 94) from residential, educational, and day treatment services in a child welfare agency for children with trauma histories. They found that 70% of the staff members experienced at least one ACE—a higher prevalence than a five-state population-based study in which 59.4% of those surveyed reported having experienced at least one ACE (Bynum et al., 2010). Using a sample of graduate-level social work students (n = 79), Thomas (2016) noted that approximately 80% of students experienced at least on ACE and 42% had experienced four or more ACEs, 2.7 times more likely than the same population study (Bynum et al., 2010). Emergent data suggest a higher prevalence of ACEs among persons in human services and those preparing to enter the helping profession workforce than in the general population, however the implications of this warrant further investigation.

Theoretical Framework

The importance of understanding ACEs among DSPs is grounded in social ecological theory and the diathesis-stress model. Social ecological theory indicates that human behavior and well-being are influenced by the interaction of intrapersonal (e.g., biological and psychological), interpersonal (e.g., social and cultural), and organizational factors, as well as factors associated with the community and policies (Stokols, Lejano, & Hipp, 2013). The diathesis-stress model posits that the occurrence of stress activates underlying vulnerabilities or diatheses (e.g., childhood abuse, genetics, and inherited traits) which contribute to subsequent distress and psychopathology (Auerbach, Bigda-Peyton, Eberhart, Webb, & Ho, 2011; Roisman et al., 2012). Although the degree of stress necessary to activate a diathesis is largely dependent upon the individual, the required severity of the stressor decreases as the degree or number of diatheses increases (McKeever & Huff, 2003).

The utility of the social ecological theory and the diathesis-stress model are exemplified in an understanding that DSPs work in a myriad of contexts and settings (e.g., group homes, family homes, and offices), and may experience demands and stress from their supervisor, the individuals they support, and the individuals' families. Despite necessitating a vast skillset to fulfill growing responsibilities, direct support positions continue to require minimal levels of education and experience (Bogenschutz, Nord, & Hewitt, 2015; Hewitt & Larson, 2007). DSPs are often presented with the opportunity to make important decisions in contexts that might be challenging or uncomfortable yet provide them with little support (e.g., family dynamics, challenging behavior among individuals with IDD, and blurred boundaries in their role with individuals/families). Additionally, many DSPs are females and people of color, who may experience additional stress associated with having second jobs, children, and higher ACE scores (Merrick et al., 2017; The Research and Evaluation Group; 2013). Based upon the theories presented, along with the context and challenges associated with the work of DSPs, ACEs are a noteworthy factor that potentially influence DSPs' professional quality of life, longevity, and the quality of their work.

Purpose

To date, there is a lack of research exploring ACEs among DSPs. Given the implications of ACEs as identified in the broader literature and the ongoing challenges in the IDD field with DSP turnover, inquiry into ACEs among DSPs provides additional insight into their experiences. As part of a larger project that utilized a sample of DSPs working in licensed settings (i.e., residential, day, and educational services) for individuals with IDD, the purpose of this study was to explore ACEs among DSPs. This study sought to answer the following research questions: (a) What is the prevalence of ACEs among DSPs? (b) What are the ACE scores for DSPs? (c) Do ACE scores differ by demographic characteristics?

Methodology

Overview

In 2015, following approval by the University Institutional Review Board, an online survey comprised of multiple measures was conducted via SurveyMonkey to explore aspects of DSPs' personal and professional experiences. Inclusion criteria required respondents to have worked as a DSP for at least 1 month in a licensed setting for individuals with IDD (e.g., residential, day, and educational services) and to have spent 50% or more of their time in direct contact with individuals with IDD. Criteria were specified as such given the different titles allocated by agencies to persons fulfilling the role of a DSP and the nature of the other measures included in the larger study. Respondents were granted access to the survey after providing their consent by electronically selecting a response option which indicated that they met the criteria and consented to participation. At the end of the survey, respondents were given access to a separate link to provide personal contact information at their discretion for an incentive by drawing (i.e., 75 gift cards, $25 each).

Purposive and snowball sampling were used to recruit DSPs from seven agencies (i.e., six in New York State and one in Alaska) with whom the researcher had prior communication and two Facebook groups for DSPs (i.e., one at the state-level and the other at the national-level). Various recruitment methods were necessitated by agency preference and included: electronic/hard-copy flyers, presentations to staff by the primary researcher, and flyers disseminated through management or attached to paychecks. Information was typically disseminated only twice by a given agency to DSPs. One agency permitted the researcher to e-mail DSPs directly, in which case monthly e-mails were sent. For Facebook groups, information was posted monthly. Data collection lasted for 6 months (i.e., April, 2015–September, 2015). Of 480 DSPs who responded to the overall survey, 386 DSPs responded to the ACE measure and comprise the sample for the present study. Most DSPs were White females between the ages of 20 and 39 years old with less than a 4-year college education working in residential settings. Demographics are described in greater detail in the results section and in Table 3.

Table 3

Employment Demographics

Employment Demographics
Employment Demographics

Measurement

This study uses data from two measures (i.e., demographic measure and the ACE measure) that were embedded in a larger online survey. The complete survey was comprised of six measures with a total of approximately 125 items and took approximately 30 min to complete. The initial page of the survey provided consent information and indicated the potential risk to participants given that some questions were sensitive and asked about trauma. Demographic questions subsequently elicited information regarding gender, ethnicity, age, education, and work-related factors (e.g., type of program worked in, length of time in current position, etc.). The ACE measure was used to gather data regarding the adverse childhood experiences of DSPs. The ACE measure is a retrospective measure comprised of 17 questions regarding exposure to abuse and household dysfunction in the first 18 years of life (Table 1). An ACE score, ranging from zero to 10, is calculated for a person as the sum of the number of categories of adverse experiences that person experienced (Felitti & Anda, 2010). The ACE score does not tally incidents within a category, rather, the occurrence of any one category of adverse experience is scored as one point. All categories of ACEs have been found to be significantly associated with each of the others (Dong et al., 2004). The ACE measure has demonstrated good test-retest reliability for every ACE and overall ACE score (range of Cohen's kappa: 0.46-0.86; Dube et al., 2004). The reliability of the ACE measure in this study was α = 0.783, which is acceptable (Nunnally, 1978).

Data analysis

Data was exported from Survey Monkey into IBM SPSS Statistics 22 for data management and analysis. All non-missing values were used. Descriptive statistics identified prevalence of each ACE category and total ACE score (i.e., the sum of each ACE category experienced by a respondent). Independent-samples t tests were computed to identify significant differences in ACE scores by gender, ethnicity, work status (i.e., full-time and part-time), and program type (i.e., residential and day/education). ANOVAs with post hoc tests and Bonferroni correction were computed to identify significant differences in ACE scores by age, education, shift, overtime, length of time in field, length of time with employer, and length of time in current position.

Results

Respondents

Three hundred eighty-six DSPs provided responses to the ACE measure. No significant differences by demographic variables were noted between DSPs who responded to the ACE measure and those who participated in the larger study, but did not respond to the ACE measure. Differences between DSPs from agencies known to the researcher and DSPs recruited through social media could not be accurately assessed due to potential overlap in recruitment strategies (i.e., respondents from one of the seven agencies known to the researcher could have responded to the survey via social media).

Sample demographics including gender, age, ethnicity, and education are displayed in Table 2. A majority of respondents were White females (87%; statistic not presented in the table) and 20 to 39 years of age (62%). More than half (60%) of DSPs had less than a 4-year college education. Additional demographics describing employment experiences are displayed in Table 3. A majority of DSPs worked full-time (86%) and in residential settings (66%); more than half worked first shift (57%). Slightly more than one third of DSPs (37%) acquired overtime often or very often. Sixty percent of DSPs had worked in the IDD field for at least 5 years and one half had been in their current position for 2 years or less.

Table 2

Sample Demographics

Sample Demographics
Sample Demographics

Descriptive Analyses

Descriptive analyses identified the prevalence of each ACE category and total ACE scores among DSPs. The percentages of DSPs who endorsed having experienced a given ACE category are displayed in Table 4. All but three ACE categories (i.e., incarceration, neglect, and domestic violence) were endorsed by more than 20% of DSPs. The percentages of DSPs' total ACE scores are displayed in Table 5. The average ACE score was 2.50 (SD = 2.44). Although one quarter of DSPs indicated that they had never experienced any ACE, approximately 30% had an ACE score of four or greater.

Table 4

Endorsement of Adverse Childhood Experiences (ACE)

Endorsement of Adverse Childhood Experiences (ACE)
Endorsement of Adverse Childhood Experiences (ACE)
Table 5

Total ACE Scores

Total ACE Scores
Total ACE Scores

Independent-Samples t Tests

Independent-samples t tests were used to identify differences in ACE scores by gender, ethnicity, work status, and program type. Significant differences were noted for gender, t(371) = −2.40, p = .017 such that the average ACE score for females (was higher than for males (. No significant differences were noted in ACE scores by ethnicity, work status, or program type.

Analysis of Variance

ANOVAs were calculated to identify differences in ACE scores by age, education, shift, overtime, length of time in field, length of time with employer, and length of time in current position. Significant differences were noted for length of time in current position, F(4, 349) = 2.42, p = 0.48. Post hoc tests indicated a significant difference in mean ACE scores between DSPs who had been in their current position for less than 1 year ( and DSPs who had been in their current position for 5 to 10 years ( Thus, on average, newer DSPs had experienced an additional ACE compared to DSPs who had been in their position for 5 or more years. Although significant differences were noted for overtime, F(4, 367) = 2.46, p = 0.45, differences were no longer significant after Bonferroni correction. No significant differences in ACE scores were noted for age, education, shift, overtime, length of time in IDD field, or length of time with employer. (Length of time with employer and length of time in current position were assessed with different items to account for fluctuation in positions which is not uncommon in direct support.)

Discussion

This research provides an initial exploration of ACEs among DSPs working in licensed settings, including residential, day, and educational services. Overall, 75% of DSPs had experienced at least one ACE and 30% of DSPs experienced four or more ACEs. On average, female DSPs had higher ACE scores than male DSPs. In addition, persons who were newer to the DSP role (i.e., less than 1 year) had higher mean ACE scores than all other DSPs and a statistically significant difference from DSPs who had been in their position for 5 to 10 years.

Comparisons between the present study and other DSP studies are not possible given the lack of research in this area. However, a study by Esaki and Larkin (2013) that explored ACEs among staff members in children's residential services presents some utility as a comparative study given similarities by occupation and demographics. They noted that ACEs were more prevalent among the child care workers when compared with a population-based study conducted by the Center for Disease Control (CDC; Bynum et al., 2010). Notably, however, ACEs were more prevalent among DSPs in the present study than the sample of child care workers. For example, DSPs had an average ACE score of 2.5 in contrast to the average ACE score of 2 noted in Esaki and Larkin (2013). Similarly, nearly 30% of DSPs has an ACE score of 4 or more in comparison to 16% of child care workers.

The frequency of ACE categories and ACE scores from the present study are contrasted with the results from the CDC study in Table 6 and Table 7, respectively. Each ACE category, except for exposure to domestic violence, is more prevalent among DSPs than in the general population (Bynum et al., 2010). When considering ACE scores, three quarters of DSPs experienced at least one ACE, about 15% higher than the general population. In addition, of those who had an ACE score of 5 or more, DSPs had more than double that of the general population. This is noteworthy given earlier findings which increased employment problems (e.g., absenteeism) among workers ACE scores of 4 or more (Anda et al., 2004). Nonetheless, it is important to consider differences in study demographics. The CDC sample was comprised of 64% females, 75% White, 44% were between the ages of 45 and 54 years old, and 62% had more than a high school education. Thus, the CDC sample represented greater diversity in gender, ethnicity, and age, but was less educated than the sample of DSPs in the present study. Across all three studies (i.e., Bynum et al., 2010; Esaki & Larkin, 2013; and the present study), divorce, emotional abuse, mental illness, and substance abuse comprised the four most common ACE categories (without regard to specific order).

Table 6

Comparison of Frequencies of ACE Categories

Comparison of Frequencies of ACE Categories
Comparison of Frequencies of ACE Categories
Table 7

Comparison of Frequencies of ACE Scores

Comparison of Frequencies of ACE Scores
Comparison of Frequencies of ACE Scores

To understand the elevated ACE scores among DSPs it is important to consider DSP demographics. Several studies have identified that DSPs tend to be females with limited education and who have more than one job for financial reasons (Gray-Stanley et al., 2010; Hewitt & Larson, 2007; Mutkins, Brown, & Thorsteinsson, 2011). Across the United States, about 90% of DSPs are female, 51% are people of color, and 33% to 66% have a high school education or less (Gray-Stanley & Muramatsu, 2011; Hewitt et al., 2008). With that being said, previous research has noted higher ACE scores among females compared with males in the general population, as well as an inverse relationship between ACE scores and adult income and education (Dube et al., 2006; Felitti & Anda, 2010; Ford et al., 2011, Nurius et al., 2012; The Research & Evaluation Group, 2013). In general, persons living below the poverty line tend to experience higher ACE scores than those living with greater financial means. Thus, the elevated ACE scores among DSPs can be contextualized given the trend for DSPs to be female, along with the basic requirements of the DSP position (i.e., high school diploma or its equivalent), its relatively low pay grade, and the association between prior adversity and careers in helping professions (Esaki & Larkin, 2013; Thomas, 2016). It is unclear why newer DSPs in this study had higher ACE scores than those who had been in their position for more than 5 years. It is possible however, that DSPs with higher ACE scores are among those who experience turnover early on in their careers.

The implications of adversity for DSPs' professional lives and for the quality of the services they provide warrant further investigation. This need for investigation is supported by the social ecological theory and the diathesis-stress model which provided the foundation for the conceptualization of this study. The interaction of intrapersonal, interpersonal, and organizational factors is paramount for persons' behavior and well-being (Stokols et al., 2013), however, stress amid the interaction of these factors can activate a person's underlying vulnerabilities which contribute to subsequent distress and psychopathology (Auerbach et al., 2011; Roisman et al., 2012). The implications of stress and burnout in the lives and work of DSPs has been well cited, but the intersection of stress and prior adversity in the lives of DSPs has yet to be considered.

The present study provides a preliminary understanding of ACE scores among a sample of DSPs, thus there is opportunity for further research, including recent trauma in the lives of DSPs, the intersection of early life adversity among DSPs, and various work-related experiences (e.g., challenging behavior among individuals with IDD, familial dynamics and environment while supporting an individual with IDD, etc.), and the risk for re-traumatization. Since the initial work of Felitti et al. (1998), the long-standing impact of early life adversity and trauma in the general population has been well documented. This, in conjunction with emerging literature that suggests elevated ACE levels among human service providers (Esaki & Larkin, 2013; Thomas, 2016) and the findings of the current study, provide direction for future research in considering not only the impact of ACEs on DSPs' well-being and work-related experiences, but also on the quality of services they provide to the individuals they support.

As compared with other helping professions, DSPs may have a greater risk of exposure to challenging behavior, including destructive and aggressive behavior, among the individuals they support. For example, Hensel, Lunsky, and Dewa (2012) found that 25% of DSPs in community settings were exposed to aggression nearly every day. Approximately 20% of DSPs experienced physical aggression towards themselves that resulted in injury, 20% had witnessed aggression causing injury to another person, 40% witnessed self-injurious behavior that resulted in injury, and 40% witnessed property destruction (Hensel et al., 2012). DSPs' responses to challenging behavior might be influenced by the impact of adversity and trauma in their lives. A thorough discussion of the impact of early life adversity and trauma on the brain is beyond the scope of the present article, however, it is important to note its impact on brain function and a person's behavior response (i.e., fight-flight-freeze responses; Lupien, McEwen, Gunnar, & Heim, 2009; Stark et al., 2015). Although exposure to challenging behavior has the potential to be perceived as life-threatening or traumatic, the interaction of exposure to challenging behavior with DSPs' trauma histories also presents a viable concern for re-traumatization (Hensel et al., 2012, 2014; Shannon, Simmelink, Im, Becher, & Crook-Lyon, 2014). Witnessing or directly experiencing challenging behavior can be a trigger for a DSP, causing memories and feelings associated with earlier adverse experiences to resurface. Challenging behavior is but one potential trigger for DSPs who may have experienced trauma, yet little is known about the impact of such on DSPs' professional quality of life and the quality of life for individuals with IDD.

Despite a vast body of literature on burnout among DSPs, ACEs and trauma-related concerns might be factors that contribute to DSP turnover which have not yet been explored. Although strategies to address and prevent burnout (e.g., schedules, time-off, supervision, team-building exercises) can be helpful for trauma-related experiences among DSPs, they are likely insufficient to fully and appropriately prevent and respond to trauma-related experiences and re-traumatization. Augmented strategies could include (a) creating awareness among DSPs and supervisors regarding trauma, triggers, and trauma responses; (b) promoting supervisory styles that are sensitive to the implications of adversity and trauma; and (c) fostering cultures within organizations that are trauma-informed (Keesler, 2014). As organizations continue to contend with fiscal restraints and DSP turnover, these strategies can be integrated, in some cases with little additional expense, through the utilization of existing resources and/or learning from the broader mental health and behavioral health fields.

Implications for Policy

Given the pervasiveness of ACEs and trauma across the human experience, federal organizations have urged for the adoption of trauma-informed policies and practices among behavioral health and human services, often to the exclusion of the IDD field. As trauma-informed practices have begun to emerge in the IDD field, the focus largely remains on treatment practices toward individuals with IDD (e.g., Harvey, 2012). Yet, the present literature provides some evidence of the prevalence of adversity and trauma in the lives of DSPs who could potentially benefit from work environments that are trauma-informed. Trauma-informed care (TIC), as conceptualized by Harris and Fallot (2001), is rooted in an organizational culture that exemplifies choice, collaboration, empowerment, safety, and trustworthiness, and it is intended to impact individuals receiving services and the staff members providing services. Despite a rapid expansion of TIC in the general field of healthcare and human services, there is scant literature surrounding TIC in the IDD population. However, the complementary nature of TIC and IDD services, and preliminary evidence of its efficacy, have been noted (Keesler, 2014, 2015). Trauma-informed organizations, policies, and practices have the potential to positively influence DSP wellness and retention, as well as outcomes for individuals with IDD.

Limitations

The present study was innovative in its inquiry of ACEs among DSPs, however the findings cannot be generalized given limitations with the study design, recruitment methods, and sample. Respondents were from specific environments (i.e., licensed settings, including residential, educational, and day services) and many individuals with IDD receive services within the context of private family homes or in other community settings. Thus, DSPs working in community-based rehabilitation or vocational services were not represented in this study. In addition, respondents were asked to reflect upon sensitive experiences from their first 18 years of life. Recall bias is a potential concern yet some earlier research has refuted this concern (Edwards et al., 2001). This study did not consider current adversity and trauma that might be significant to DSPs' work relations and professional quality of life.

Notably, recruitment strategies were driven by the preferences of individual organizations. For example, one organization attached flyers to DSP paychecks whereas a different organization had management distribute flyers to their DSPs. Although adapting recruitment methods afforded broader dissemination of recruitment information, it is impossible to determine response rates for organizations or the frequency with which information reached DSPs. Furthermore, although this study used an online survey and social media which can facilitate data collection and access to a broader sampling pool (Wright, 2005), they also present limitations, including accessibility, self-selection bias, and an inability to determine nonresponse rate. In addition, DSPs who are active in DSP-specific social media groups may not represent the broader pool of DSPs.

Recommendations for Future Research

Despite the limitations of the current research, it presents a novel area for inquiry within IDD services. Future research should use a broader sampling to more accurately represent the DSP population, including those who work in community settings and private family homes, as well as a national perspective. It is important to consider the prevalence and implications of ACE scores on DSPs and their potential contribution to DSP turnover. Subsequent studies should explore how ACEs relate to DSP professional quality of life, particularly burnout and turnover. Furthermore, research should also consider the implications of ACE scores on DSP responses to individuals, particularly in situations where challenging behavior is prevalent or environments are particularly stressful.

Conclusion

DSPs are critical to the quality of life and inclusion of many individuals with IDD. Despite their importance, organizations continue to struggle with DSP retention. In an initial effort to explore alternative factors influencing DSPs, the present study explored the prevalence of ACE categories and ACE scores among DSPs. In contrast to other studies, DSPs presented with a higher mean ACE score, a higher percentage of persons with an ACE score of at least 1, and nearly double the percentage of persons with an ACE score of 4 or more. This study begins a discussion regarding ACEs among DSPs and presents the opportunity for further inquiry into the implications of ACEs among DSPs and their work with individuals with IDD. Trauma-informed care may be one possible response among organizations.

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