Running head: CROSSING A CANYON 1 Crossing a Canyon: Identifying and Remediating Service Delivery Gaps for Individuals with Cognitive Disabilities in Rural British Columbia, Canada Amery Schultz Student # SOWK 799 University of the Fraser Valley Primary Reader – Jeff Wood CROSSING A CANYON 2 ACKNOWLEDGEMENTS “I'm no prophet, but I've seen things. When right and wrong become too close. In that moment of my greatness, I become afraid and watch it go.” – Crossing A Canyon, Lyrics by 54-40 As social workers we continually make the conscious decision to cast aside our personal fears, rise to the occasion, and stand up to the injustices of this world. Daily, we must stand at the edge of vast canyons, most of which are systemic in nature, and assist individuals with crossing them. As social workers we wield tremendous power and influence, and with these attributes comes incredible responsibility. I would be remiss if I did not take this opportunity to acknowledge the individuals that have enabled me to arrive at this point in my academic career. Arguably, I could have compiled myriad excuses for giving up before I even started, as the song alludes, but through the sheer grace of God, I forged on. But this was not without the dedication, support, and the sacrifices of those whom I shall name in this brief inexhaustive litany. I am eternally grateful to my major paper supervisor Jeff Wood, for his encouragement, ideas, and inspiration in undertaking this tremendous endeavor. I also cannot express enough appreciation to the multitude of academic inspirations that have directly influenced my studies with their continued support and encouragement: Timothy Dueck, Dr. Darrell Fox, Kim Grzybowski, Elaine Herbert, Mil Juricic, Gwen Miller-Watt, Jeff More, Dr. Rebecca Sanford, Sue Sterling-Bur, and Dr. Anita Vaillancourt. This is by no means a finite list, and I offer my sincere gratitude for the learning opportunities provided by all the teachers, supervisors, and mentors who have crossed my path. My completion of this project could not have been accomplished without the support of CROSSING A CANYON 3 my entire MSW cohort that have been on this wild ride with me from the beginning. We have laughed, cried and commiserated together, and we have finally arrived at the end of this journey. To my children: Stephanie, Michelle, Emilie, Cole, Jacob, Andrew, Matthew, Simon, Daniel, and Olivia – thank you for inspiring me to undertake this research path, recognizing that there are many systemic gaps that you will all encounter along your life’s journey, and showing me that through sheer resilience you all can and do overcome insurmountable odds. Finally, to my amazing, caring, loving, and supportive wife, Christiane: my deepest gratitude. Your encouragement when the times got rough are much appreciated and duly noted. It was a great comfort and relief to know that you were willing, without reservation, to provide management of our family, and afford me the time to focus on my education. When the world returns to normal, you deserve a vacation. CROSSING A CANYON 4 Table of Contents Abstract ....................................................................................................................................... 7 Introduction ..................................................................................................................................... 8 The Study Population .................................................................................................................. 8 Research Summary and Components .......................................................................................... 9 Neglect From Families and Society ............................................................................................ 9 Purpose of Research .................................................................................................................. 10 Thematic Findings From Literature .............................................................................................. 12 Theoretical Underpinnings Explaining the Research ................................................................ 13 Piaget’s Theory...................................................................................................................... 13 Importance of the Theoretical Framework ............................................................................ 16 Vygotsky’s Sociocultural Theory ........................................................................................... 17 Bandura’s Observational Learning ....................................................................................... 18 Challenges that Indigenous People in Canada Face .................................................................. 19 Research Findings ......................................................................................................................... 23 Interpersonal Violence in Cognitively Disabled People ........................................................... 23 Reduced Intrapsychic Flexibility and Poor Adaptation ............................................................ 24 Social Determinants to Health and Inclusion in Society ........................................................... 28 Estimation of Judicial Costs Associated With FASD ............................................................... 28 Cost of Corrections Among Youths With FASD In Canada .................................................... 29 High Costs of Corrections Associated with FASD ................................................................... 30 Living Environment of Cognitively Disabled People ............................................................... 30 Boundary Challenges for People Living With FASD ............................................................... 31 CROSSING A CANYON 5 Other Challenges Faced by People With FASD ....................................................................... 31 Professional Training for Identification of FASD is Important ................................................ 33 Historic and Ongoing Segregation from Society ...................................................................... 35 The Roles of Social Workers .................................................................................................... 40 Future Research ......................................................................................................................... 45 Conclusion .................................................................................................................................... 53 References ..................................................................................................................................... 56 CROSSING A CANYON List of Abbreviations, Acronyms, Initials, and Symbols APA American Psychiatric Association ASD Autism Spectrum Disorder BC British Columbia BCMA British Columbia Medical Association CD Cognitive Disability CHRT Canadian Human Rights Tribunal CLBC Community Living British Columbia CMAJ Canadian Medical Association Journal DD Developmental Disability DSM – V Diagnostic and Statistical Manual of Mental Disorders Fifth Edition ER Emergency Room FASD Fetal Alcohol Spectrum Disorder GAD Generalized Anxiety Disorder GP General Practitioner (Physician) ICD – 10 International Classification of Diseases Tenth Edition ID Intellectual Disability IQ Intelligence Quotient MCFD Ministry of Children and Family Development MDD Major Depressive Disorder NP Nurse Practitioner PSI Personalized Supports Initiative PAC Provincial Assessment Centre PTSD Post Traumatic Stress Disorder PWD Persons With Disabilities (Income Assistance Benefit) RSW Registered Social Worker SW Social Worker 6 CROSSING A CANYON 7 Abstract This paper explores the service delivery gaps for individuals living with cognitive disabilities in rural British Columbia, Canada. It covers the difficulties faced by people living with cognitive disabilities in the rural areas of British Columbia and indicates solutions for a number of identified problems. It goes beyond by providing concrete recommendations on what needs to be done to ensure that every individual living with cognitive disabilities has access to the required care and support from their caregivers and society as a whole. The topic is introduced with a concise statement of the research problem. The researcher consulted several peer-reviewed scholarly sources to obtain relevant information regarding the service delivery gaps for people living with cognitive disabilities. The paper undertakes an extensive literature review which focused on identifying and remediating service delivery gaps for individuals with cognitive disabilities in rural British Columbia, Canada. This research required a multifaceted approach which involved the author’s personal and work experience, as well as extensive review of available peer-reviewed journal publications. The paper makes a number of important recommendations for future research pertaining to individuals living with Cognitive Disabilities both in rural British Columbia, Canada, but also around the world. CROSSING A CANYON 8 Introduction The Study Population There is a growing population of people living with cognitive disabilities (CD) around the world, and that number continues to rise as the total population of the Earth grows (Chinn, Levitan, & Murrells, 2017). Some of these disabilities are age-related, while in some cases, children are born with disabilities, otherwise known as congenital disorders. According to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM–V) by the American Psychiatric Association (2013) regarding cognitive disabilities, dementia is one of the most common illnesses that affect people around the world. Additional examples of cognitive disabilities include Down syndrome, Fetal Alcohol Spectrum Disorder (FASD), and Autism Spectrum Disorder (ASD). Both developing regions and developed countries record-high numbers of people living with cognitive disabilities. It is not a phenomenon that is exclusive to one area of the world as in a regional-based infection or disorder (American Psychiatric Association, 2013). A person is said to have a cognitive disability if he or she has limitations in cognitive functioning (American Psychiatric Association, 2013). Most of the common symptoms displayed by people with these disabilities include problems in communication, difficulties in comprehension, socializing, and challenges in basic self-care (Chinn et al., 2017). The named challenges may cause both children or adults with such disabilities to have problems in learning, hence slow and sometimes a complete lack of comprehension of learned information. They might also perceive their environment in a completely different manner compared to their neurotypical peers who lack such cognitive disabilities. CROSSING A CANYON 9 Research Summary and Components The research entails recommended approaches through which service delivery gaps faced by people living with cognitive disabilities in rural British Columbia, Canada, can be mended. Based on current research, people living with cognitive disabilities in British Columbia face challenges such as discrimination, marginalization, and exploitation. These challenges result from the traditional service delivery models of health, education, and criminal justice are not designed with the needs of people with cognitive disabilities in mind (Ribet, 2011). This paper is, therefore, a comprehensive study that explores what needs to be done to ensure that service delivery gaps for individuals with cognitive disabilities are identified and remediated. The research states that crossing such a “canyon” requires a multidisciplinary collaborative approach towards interventions. The life of each person matters, including those cognitive disabilities. These people form crucial parts of our society, and all of them form essential components of their families. Whether young or old, their health and well-being mean a lot to those who love them. The study goes beyond describing the challenges faced by these people but also provides recommendations on what needs to be done to ensure that every individual living with a cognitive disability has access to the required care and support from their caregivers, and society as a whole. It is the hope of the researcher that this study will form a basic foundation upon which future research regarding the same topic can be based. Neglect From Families and Society Presently, individuals living with cognitive disabilities run into many obstacles when trying to access services in British Columbia. Some of these challenges include neglect from their families. Unfortunately, many families place the blame for the financial burdens they CROSSING A CANYON 10 experience on the members of their family with cognitive disabilities (Ribet, 2011). As a result, many people living with cognitive disabilities become alienated and lack support from their families. A majority of these people have challenges in communication and, or comprehension. They, therefore, require assistance from family members in almost everything they do. However, the latest research studies indicate that most of these people with disabilities experience discrimination from their families (Ribet, 2011; Mcconkey et al. 2004). Ribet (2011) articulates that the majority of people living with disabilities experience discrimination from society at large. This discrimination is two-fold when a person also comes from a visible minority group, particularly if they are Indigenous (Rahaman, et al. 2017). Stigmatization in rural areas is still rampant, as it is in society as a whole (McNally & Martin, 2017). Based on the latest research, the majority of the people living with these disabilities are considered burdens on society. Such stigmatization, therefore, prevents families of these people from seeking the required supports that they need. They fear that should they become open regarding the challenges of their children or elderly family members, then other society members would look down upon them. Purpose of Research This research paper, therefore, aims to fill the gaps as mentioned above by studying and comparing several kinds of literature. The recommendations included in this research study will further inform and benefit the social service professionals who work with people with these disabilities. Furthermore, this research should prove to be of benefit to the family members of people living with cognitive disabilities. This research can also be useful for researchers who are interested in knowing how to identify and remediate the care gaps faced by people living with cognitive disabilities, and the entire matrix of interdisciplinary professionals concerned with CROSSING A CANYON people living with these disorders. It is, therefore, a comprehensive research study that aims at satisfying various stakeholders in society. 11 CROSSING A CANYON 12 Thematic Findings From Literature Current scholarly sources were reviewed to obtain relevant information regarding the service delivery gaps for people living with cognitive disabilities. Peer-reviewed journal articles within the last 5-7 years were used as resource material, but there are several older scholarly sources included as well, as they were deemed relevant to the present research. ResearchGate and PubMed internet databases were used, and the search terms were cognitive disabilities, as well as a comprehensive search of phrases such as “cognitive disabilities in Canada,” “service delivery gaps for people living with cognitive disabilities,” and “appropriate means to close the service delivery gaps among people living cognitive disabilities.” Using this approach helped in narrowing down the scholarly resources into a few out of the thousands of articles that were retrieved in the internet search. Additionally, condensing such research articles into a small number helped in selecting the most appropriate scholarly sources used in this research article. After identifying several sources regarding the topic based on the search terms, the researcher started screening the source articles based on the dates of publications. The researcher was interested in the latest research studies, especially those published within the last 5 to 7 years. The main reason for such precision is that recent articles have relevant outcomes compared to those published many years ago. One challenge faced in trying to exclusively use current journal articles is that older research articles obtained from the databases contained far more detail. This research paper aimed at incorporating the most comprehensive, relevant information, so the researcher considered incorporating the older articles into the study. The researcher narrowed in on the geographical focus of research articles, and articles that focused on the rural areas of British Columbia and Canada, in general, were given more priority. Many articles were reviewed, which focused on other geographical regions, such as the United States CROSSING A CANYON 13 and other developing countries. Most of these articles were not included in this study because they were not geographically related. Theoretical Underpinnings Explaining the Research Several theories explain the subject considered in this study. There are similarities and differences, and the researcher included these theories to understand cognitive disabilities better. The findings of these theories are, therefore, included. Piaget’s Theory The first underpinning theory used in this research is called Piaget’s theory of cognitive development (Chowdhury & Benson, 2011). The theory helped in understanding the cognitive development of a child. Before identifying the service delivery gaps for people living with cognitive disabilities, it is first crucial to understand how cognitive development occurs among children. The researcher considered this move as the best route of determining the growth and development of cognitive abilities. According to Piaget, children move through four different mental stages before they reach adulthood; the theory focuses not only on the means of acquiring information but also explains in detail the nature of such intelligence. Sensorimotor stage: According to Piaget, the first cognitive development stage is the sensorimotor stage (Chowdhury & Benson, 2011). This stage of cognitive development encompasses children aged between birth and two years. One key characteristic of this stage is that infants understand the world through movements and sensations because they do not necessarily understand everything yet but can suck the instinctually feed from their mother’s breast, grasp using their fingers, listen to their parents talk, and lastly, look at the basic things that surround him or her (Chowdhury & Benson, 2011). At this particular juncture, children understand that there are a lot of basic ideas that exist, though they cannot see all of them. CROSSING A CANYON 14 Another important feature of children who are in this category is their ability to separate human beings from other objects. For example, at this stage, children can already isolate the voices of their parents, and when one speaks, they know their tone and can differentiate it from the movements of pets like cats and dogs. Lastly, children who are at the sensorimotor stage understand that their actions can have a sensory response from objects in their surroundings. Preoperational stage: According to Piaget’s theory, the second stage of cognitive development is called the preoperational stage. At this stage, children start learning symbols and can differentiate objects based on the words attached to them, and they may distinguish between a father and siblings just by looking at an image of them. It is worth noting that children who are in this stage often struggle to see things, not in their perspectives, but the perspectives of other people. Empathy is still not yet formed (Lunsky, Garcin, Morin, Cobigo, & Bradley, 2007). At this stage, children learn the pretend play, and can still differentiate between real-life occurrences and fantasy that is only occurring in their minds. At this level, the child still does not know how to differentiate sizes. For instance, when given two lumps of clay, one rolled into a cylindrical shape, and the other flattened, he or she may choose the flattened one, thinking that it is bigger compared to the cylindrical clay. Even though they are in a position to master an oral language and develop progressively in their thinking, their thinking is still based on concrete terms. The concrete operational stage: The third stage is called the concrete operational stage. In this kind of cognitive development strategy, children tend to think logically about specific events. For example, they start thinking of what life is and where people go after death (Morrow, Dagg, & Pederson, 2008). They are more egocentric at this stage and become open to conversations. Additionally, at this stage, they begin to master sizes and are capable of understanding that an CROSSING A CANYON 15 equal amount of water poured into a sizeable short cylinder will still be the same as the amount of water poured into a tall thin bottle of the same size. Children who fall into this category are often between 7 and 11 years of age and have not yet become organized in their communication (Mcconkey, Truesdale-Kennedy, & Conliffe, 2004). This timeframe is a crucial age category among children because it is the same age when children take part in primary education. They are required to have proper mastery of age-related curriculum and to start practicing on how to read and write. They, therefore, require good teachers who understand their learning needs (Lunsky et al., 2017). In the same class, there might be a child who has a much slower speed in learning compared to the rest. They should, however, be accommodated in the learning environment, because they are still growing and have a chance of fully developing their brain into the expected capacity (Mcconkey et al., 2004). Educators of these children should, therefore, become considerate and support the struggling young ones in all the activities that they do. In the same stage, children are so keen on the kind of approach given to them by the teachers, guardians, and all adults in their lives. Failure to show them appreciation would, therefore, break their hearts and lead to potentially permanent disappointments. Formal operational stage: The fourth and last stage is called the formal operational stage. It refers to the stage where children have reached the adolescent age of 12 years and above. At this level, children tend to reason logically on conditional statements. For them, abstract reason emerges at this point. It is at this very moment that children begin to think of morality and become organized in life. It is worth mentioning that at this juncture, children need more direction from their parents and the utmost care because they have reached one of the most vulnerable points in their lives, puberty (Morrow et al., 2008). It is worth noting that Piaget CROSSING A CANYON 16 viewed intellectual development as a qualitative approach, not a quantitative increase in piles of information. Piaget’s theory of cognitive development, therefore, informs the public of a qualitative change in their children’s thinking and reasoning capacities. It is a fundamental theory to focus on when tackling the service gaps that people with cognitive development face (Morrow et al., 2008). The method educates mental health professionals on the appropriate means of handling people with cognitive disabilities. In theory, older individuals require different approaches toward their care due to the differences in their reasoning based on their ages. Importance of the Theoretical Framework The theoretical framework of cognitive development is appropriate for this field as it informs of the mental development progress of human beings. The theory indicates what parents /guardians of newborn babies should expect in terms of their development. Additionally, the theory has well-defined stages of cognitive development. As a result, a caregiver to an individual with a cognitive disability would easily trace the cognitive development of the child as he/she grows. Having this foreknowledge is crucial as any deviations in the expected cognitive development would require urgent medical interventions. Tracing of cognitive disorders is also accessible through the use of this theoretical framework. From birth, children born with FASD can be identified and located relatively easily and given the care they require, such as physical therapy, occupational therapy, speech and language therapies, and psychosocial interventions. Furthermore, cognitive disabilities that originate from old age, such as dementia, would easily be assessed and proper care delivered. Underdiagnosis of many cognitive disabilities has led to huge gaps in service delivery for people living with cognitive disabilities (Lach et al., 2009). According to the British Columbia CROSSING A CANYON 17 Medical Association (2019), all cognitive disabilities require appropriate diagnostic interventions. However, the latest research indicates that most people living with cognitive disabilities do not receive the necessary medical and social support due to misdiagnosis or outright missed diagnosis of their health conditions. These people end up receiving wrong and untimely treatments. It is, therefore, crucial for medical practitioners to understand the various signs of cognitive development in healthy people so that they can treat individuals with intellectual impairments (British Columbia Medical Association, 2019). Little information is known on the exact signs and symptoms of the vast array of cognitive disabilities. Each year there are many new diagnoses and disorders discovered. In most cases, these disabilities have similarities, such as lack of skills to perform required daily activities. Hence healthcare providers face many challenges in identifying the specific cognitive disability and appropriate treatments (British Columbia Medical Association, 2019). It is, however, crucial to note that as researchers become better acquainted with the various concepts outlined in the theories of cognitive responses, they are in a more suitable position to determine the appropriate treatment for their patients. It might take considerable time to diagnose specific disabilities, but with more efforts and comparisons of various literature, an individual is capable of knowing the development of multiple disabilities such as ASD, FASD, and many more. Vygotsky’s Sociocultural Theory Vygotsky’s Sociocultural Theory. proposes that an individual’s social network plays a vital role in the way they think and relate to objects surrounding them. According to this theory, an individual’s interaction with culture plays a crucial role in defining whom the person becomes and what the person needs to do (Ouellette-Kuntz, 2005). Vygotsky, therefore, believed that a CROSSING A CANYON 18 person would first learn from their surroundings and use that learned information from society to initiate how he or she thinks (Morrow et al., 2008). Communities where people with mental illnesses are discriminated against, young people would first learn such unethical behaviors from their parents or caregivers, and finally, internalize such actions before they display them in public. Unlike Piaget, who believes that cognitive development is a universal process, Vygotsky argued that different cultures greatly influence cognitive events, so they are different from one society to another. Bandura’s Observational Learning Another theoretical approach that assisted in understanding this concept is called Bandura’s Observational Learning. According to Bandura, children rely on people (models) and select appropriate behaviors from such people to determine their life path. These actions are called coding, and while so doing, the children tend to focus on activities that relate to their gender (Mansell & Ericsson, 1996). As mentioned by Piaget, such children tend to choose factors that are following their cultures. As a result, young people tend to follow the practices that are performed by their peer groups. Primarily, observational learning occurs through observation. This theoretical approach argues that children and adults learn through observing their given environments. According to Mansell & Ericsson (1996), some concepts must be learned through observations, in which case, there may be no theoretical approaches that apply. According to Bandura, people best learn in an environment where things are physically arranged and demonstrated. In such situations, children grasp ideas and retain them long-term. What children observe in their environment when they are young children affect their overall life in later years. According to Emerson (2003), children are imitators, and they do all they can to learn from their surrounding environments. As a result, they take most of their time CROSSING A CANYON 19 learning by observing what older people do. In circumstances when the demonstrator misbehaves or misguides the young people, such children would also be misled. The consequence of every action that children encounter is a crucial feature of Bandura’s principle. Emerson (2003) mentions that people living with cognitive disabilities require appropriate education so that they can fit well into society. However, most of these people have difficulties in comprehending the information that is available to them in their environment. According to Emerson (2003), introducing a learning approach that allows people living with such disabilities to learn and participate actively is essential. The collaborative learning environment would also reduce the chances of discrimination or diminished self-esteem among people living with such disabilities (Emerson, 2003). It is, therefore, essential for teachers to become well versed in the varying emotional swings of the individuals living with intellectual disabilities. It is imperative that individuals with cognitive disabilities learn emotional regulation as early and to the fullest extent possible. Challenges that Indigenous People in Canada Face Matthew (2017) noted that Indigenous People in Canada encounter multiple challenges that emanate from the disparities that exist in Canada’s healthcare and disability services delivery models. Indigenous people in Canada, by virtue of colonization, are marginalized. They are subjugated through legislation such as the Indian Act, and this is especially true for those Indigenous people who also have cognitive disabilities (Matthews, 2017). The resultant determinants of health caused by this oppressive legislation, such as poverty, education, and social status, have historically had a racially stereotyped response from the healthcare system as if Indigenous people have brought poverty, addiction, and intergenerational trauma upon themselves (Matthews, 2017). Systemic racism that exists within Canada’s healthcare system CROSSING A CANYON 20 requires a route forward to increase anti-oppressive practice amongst those working within the healthcare system in Canada (Matthews, 2017). According to Matthews (2017), the lived experiences of Indigenous people in Canada have a high probability of lowering their health outcomes. This aspect is heightened by the inadequacies of access to quality medical services and their lower socio-economic statuses within Canadian society. Furthermore, Browne et al. (2016) explain that Indigenous Canadian people living in remote areas of the country also experience deficiencies in their ability to access satisfactory medical services and infrastructure. These deficiencies are especially correct for Indigenous people with cognitive disabilities, for even when an Indigenous community has adequate healthcare services on reserves, services such as group homes and community inclusion programs are often non-existent (Browne et al., 2016). The Canadian healthcare system lacks equal care access and medical facilities for remote communities, which also affects people with cognitive disabilities (Martin, Miller, QuesnelVallée, Caron, Vissandjée, & Marchildon, 2017). McDonnell et al. (2017) reiterate that the country’s healthcare management system experiences failures in ensuring that the existing regulations, strategies, and policies guiding the healthcare of people living with cognitive disabilities are implemented. Canada has a long history of legislation and policy enactment that has altruistic aims in principle but fails in execution. An example of this is the findings of the Canadian Human Rights Tribunal, which found that child welfare services for Indigenous children in Canada were not equitably funded. After four years, the recommendations from that tribunal are still being implemented on a minimal basis. Rahaman, Holmes, and Chartrand (2017) explain that issues of racism, such as systemic prejudice in the Canadian medical system, have acted as noteworthy contributors to the lower CROSSING A CANYON 21 health outcomes seen in Canada’s Indigenous population and particularly, among people living with cognitive disabilities. Rousseau et al. (2017) reveal that racial prejudices in the Canadian healthcare system are not only tied to interpersonal relationships of Indigenous People when interfacing with individual medical practitioners but also in the organizational and administrative dimensions that these people practice within. Services to adults with developmental disabilities are no different. Community Living BC policies are not inherently racist, but provisions for the delivery of CLBC funded services in Indigenous communities has only been in place since 2014 (CLBC, 2018). Goodman et al. (2017) explain that structural discrimination against Indigenous people is evident in the regulatory frameworks, policies, and practice, an aspect that imposes profound adverse effects on the ability of this populace to access critical services. According to McNally and Martin (2017), the issues of colonization and racial discrimination in Canada are related and do play a crucial role in imposing detrimental effects on the health status of the Indigenous population in Canada. Rousseau et al. (2017) reveal that colonization is considered one of the most critical determinants of health outcomes of the Indigenous populations living around the world, and this is compounded for Indigenous people with cognitive disabilities. For instance, the government of Canada puts considerable emphasis on the role played by issues such as social segregation, inadequacies in the levels of self-determination, racist ideologies, and colonization in fostering the current state of health disparities experienced by the Indigenous population. Donna Baines (2017) reveals that for well over 100 years, Canada’s Indigenous people have been managing prejudice and its associated effects in their personal, family, as well as social lives. Again, this is compounded for Indigenous people living with cognitive disabilities. CROSSING A CANYON 22 They are continually demonstrating their abilities to persevere even through tormenting circumstances such as communal violence, culture-based genocides, legislated discrimination, and economic oppression. Although the current study does not have the explicit aims of critically analyzing the oppressive situations that Indigenous people in Canada are forced to bear due to the underlying issues of racial discrimination perpetrated by the country’s Government at all levels, a discussion of service delivery gaps in rural BC would not be complete without including it in the conversation. CROSSING A CANYON 23 Research Findings The findings of this study noted that individuals living with cognitive disabilities experience interpersonal violence. Moreover, it is established that healthcare professionals should solve the challenges of reduced intrapsychic flexibility and poor adaptation to stressful challenges among people living with cognitive disabilities (Focht-New et al., 2008). For the most part caregivers have inadequate training in identifying symptoms relating to trauma or helping a person through recovery from trauma. In this regard, it is essential for caregivers and people living with cognitive disabilities to receive training on how to cope with the aftermath of interpersonal violence. Interpersonal Violence in Cognitively Disabled People Focht-New et al. (2008) mentioned that “there are many forms of interpersonal violence encountered by persons with developmental disabilities (DD), and they have an alarmingly higher risk, estimated at 4–10 times greater of becoming a crime victim than persons without disabilities.” Interpersonal violence includes conflicts between the immediate family members, friends, intimate partners, caregivers, and strangers. According to Focht-New et al. (2008), people with developmental disabilities are often involved in conflicts with their housemates, caregivers, family members, friends at school, and potentially anyone that is in their vicinity. Individuals living with cognitive disabilities have poor coping skills. Unlike people with good cognitive responses, individuals living with cognitive disabilities cannot control their feelings well. Many are easily agitated and ready to fight anyone when they get angry (Focht-New et al., 2008). CROSSING A CANYON 24 Reduced Intrapsychic Flexibility and Poor Adaptation Additionally, Focht-New et al. (2008) state that healthcare professionals must focus on solving the challenges of reduced intrapsychic flexibility and poor adaptation to stressful challenges among people living with cognitive disabilities. The researchers report that in the recent past, people living with cognitive disabilities have been classified as “wild or uncooperative” (Focht-New et al., 2008). Focht-New et al. (2008) argue that such classifications are not accurate. According to these scholars, medical practitioners should assess the extent of the moral reasoning of such patients to help them to learn to reason appropriately without prejudging their capacities. Nurses’ attitudes towards the treatment of individuals living cognitive disabilities are, therefore, crucial determinants of the quality of care that such patients obtain in healthcare facilities (VanZomeren-Dohm et al., 2013). When a healthcare provider believes that a patient is non-cooperative or not suitable for the recommended care, then people living with cognitive disabilities will continue suffering in the hands of such caregivers. Apart from assessing the moral reasoning capacities of such patients, Focht-New et al. (2008) recommend that healthcare professionals conduct a thorough examination of a patient’s surroundings to determine various possible causes of conflicts among such individuals. It is, therefore, crucial for healthcare providers to train people living with cognitive disabilities on the best ways of controlling their instinctual and ingrained desires so that they cannot cause more chaos in their environment or to people living close to them. Training in Identifying Trauma Symptoms: “Very often, supporters have had little training in identifying symptoms relating to trauma or helping a person through recovery from trauma” (Focht-New et al., 2008, p. 91). A lack of trauma-informed training is a significant setback to people living with cognitive disabilities because the majority of caregivers lack the skillset to CROSSING A CANYON 25 know the various challenges they encounter. According to Focht-New et al. (2008), caregivers should adjust their assessment and treatment approaches to minimize conflicts between themselves and individuals living with cognitive problems. The same study conducted by FochtNew et al. (2008) stated that primary caregivers are tasked with a role to provide a conducive environment for these individuals, such as encouraging them to live a stress-free life. In so doing, the professionals mobilize such patients to develop a positive attitude towards themselves, hence uplifting the self-esteem of such individuals. In most cases, caregivers make assumptions about the signs and symptoms displayed by those receiving care. According to Focht-New et al. (2008), most professionals in the healthcare system are not proficient with the challenges of cognitive disabilities. The signs and symptoms displayed are often mistaken for mental illness symptoms; there is a close association between cognitive disabilities and mental illness. Cognitive disabilities involve the impairment of general mental abilities. Knowing the differences is crucial for nurses and other medical practitioners who often interact with patients who may present with a cognitive disability, a mental health issue, or the concurrence of both. Coping with violence aftermath: Both caregivers and people living disabilities should receive training on how to cope with the aftermath of interpersonal violence. “Education is critical to assisting persons with DD and their caregivers to cope with the result of interpersonal violence.” (Focht-New et al., 2008, p. 95). Interpersonal conflicts should be considered an everyday norm among people living with cognitive disabilities. As a result, caregivers should receive training on how to perceive the aftermaths that come along with such challenges. Instead of viewing the people living with disabilities as a burden on society, it is crucial to educate them and make them understand that violence is not appropriate. One reason why interpersonal conflict is on the rise CROSSING A CANYON 26 is that most people living with cognitive disabilities do not possess the same level of intuition as neurotypical people; many do not understand what is happening in their environment and may perceive well-intentioned people as threats (Obrien & Rose, 2010). As a result, people who are close to them should receive training such as de-escalation through communication (Focht-New et al., 2008). Caregivers of individuals with cognitive disabilities also need training in recognizing their personal limits and knowing when to seek out external therapeutic interventions. Focht-New et al. (2008), therefore, indicate that a significant gap in service delivery for people living with cognitive dysfunction is a lack of training of both the caregivers and the individuals themselves on the appropriate means of reading interpersonal violence. Ability to identify potential scenarios for interpersonal violence assists in effective caring for people with cognitive disabilities. “The purpose of trauma therapy is to help the person feel the feelings that were too overwhelming during the trauma, integrate the feelings and experience, and learn to live with the “new self” that has been traumatized but healed” (Focht-New et al., 2008, 96). People living with cognitive disabilities frequently experience the symptoms of Post-Traumatic Stress Disorder (PTSD) and should have trauma therapy made available to them so that they can be relieved and live a better life away from stress and interpersonal conflicts. According to Focht-New et al. (2008), trauma therapy expands the feelings vocabulary of people living with cognitive disabilities. As a result, they train themselves to use words such as happy and joyous, more often, instead of language, which provokes their feelings, such as angry or mad. Such primary education would also train the people living with cognitive disabilities on how to view their surroundings and what they need to do to ensure that they live as fulsome a life as possible. Treating people living with cognitive disabilities should involve a broad approach and expansive CROSSING A CANYON 27 consideration of the issues at hand. Rather than disparaging them as “challenging people to work with” or, as stubborn people, whose primary work is to cause trouble and violence to the people who serve them, these individuals are still worthy of dignity and respect (Obrien & Rose, 2010). Notably, prenatal exposure to alcohol increases the risks of adverse health outcomes, for the infant, including Fetal Alcohol Spectrum Disorder (FASD) (Popova, Lange, Burd, & Rehm, 2015). Further, Popova et al.(2015) noted that high alcohol consumption among pregnant women is one of the leading causes of intellectual disabilities in infants. With an observed increase in alcohol consumption among women, the number of cognitive disabilities cases is expected to rise tremendously over the coming years (Popova et al., 2015). The federal and regional governments have put in place public health prevention efforts such as banning alcohol sale to expectant mothers to ensure that every child has the highest probability of being born with stable cognitive abilities and generally good health of body. Despite these initiatives, alcohol drinking remains a common cause of intellectual problems among people living with cognitive issues. The cognitive impairments among children are most likely to result in more severe challenges such as mental illness and other neurological issues as the child grows (Popova et al., 2015). On the same note, the researchers argued that people living with cognitive disabilities are more likely to develop severe mental health illnesses. A combination of such limitations contributes exponentially to stress and trauma experienced by people. The researchers, therefore, caution on alcohol drinking among pregnant women due to the adverse health impacts that such practices have on the lives of the unborn babies. Popova et al. (2015) added that individuals with FASD often interface with the criminal justice system. According to these researchers, people with FASD are more prone to primary and secondary disabilities, which makes them more vulnerable to be involved in criminal activity. As CROSSING A CANYON 28 a result, children born with such disorders are more likely to be involved with the youth criminal justice system. Secondary disabilities, such as mental illness, drive children into interpersonal conflicts because they cannot reason as normal children do with no cognitive disabilities. According to Popova et al. (2015), FASD causes damage to vital structures within the frontal lobe of the brain, which mediates impulse control and judgment. It is no surprise that poor comprehension is observed among children who have such disorders. Social Determinants to Health and Inclusion in Society Individuals living with FASD often have problems with employment due to their inability to socialize well with others. As a result, most of them remain unemployed or given minor roles due to fear of or actual conflicts in the workplace. Additionally, a high percentage of people living with cognitive disabilities are homeless. Many who do not meet the eligibility criteria of Community Living British Columbia (CLBC) experience homelessness or are at risk of homelessness due to a lack of employment or ability to earn a decent living. Furthermore, these individuals, through no fault of their own, frequently face conflict within conventional tenancy situations. Popova et al. (2015) note that people living with FASD suffer from many social problems such as poverty because of their inability to maintain employment. Estimation of Judicial Costs Associated With FASD “There are only a few studies in Canada and the USA that have attempted to estimate the overall cost associated with FASD” (Popova et al., 2015, 77). Based on the recent research concerning people living with FASD, very few studies have estimated the exact judicial costs associated with the FASD. Consequently, there is little known regarding the sheer cost associated with people living with such disabilities within the legal system. A study conducted by Popova et al. (2015), therefore, studied the legal expenses incurred by such individuals. CROSSING A CANYON 29 According to their research, the number of people living with cognitive disabilities who were in the Canadian correctional system is over thirty-nine thousand every year. The study shows that many Canadian citizens living with cognitive disabilities are incarcerated for charges such as domestic violence, robbery, mischief, and a host of other infractions related to poor judgment. This study further goes on to state that the state incurs an average of $172 daily per inmate in custody (Popova et al., 2015). The government spends a considerable amount of money, incarcerating people living with cognitive disabilities. Taxpayers shoulder this funding burden. Cost of Corrections Among Youths With FASD In Canada “The total cost of corrections among youths with FASD was estimated to be approximately $1.1 million in Canada in 2011/2012 (approximately $818.1 thousand for males and $251.7 thousand for females).” (Popova et al., 2015, 79). This expenditure represents a considerable sum of money that could be better used by the government to deliver basic amenities such as healthcare, clean water, food, and shelter to its citizens. Instead, this money goes to the budgets for correctional facilities and an increasingly beleaguered court system. Based on the same research, Ontario led in terms of the total costs used in correctional facilities. Such budgets were relatively high across the nation. Popova et al. (2015) argued that the costs of the correctional services formed just one component of the direct judicial costs. Therefore, the researchers argue that to comprehensively account for the legal costs incurred by the Canadian government from people living with FASD, several factors such as costs of policing, court costs, and probation facilities must be put into consideration too. It is, therefore, worth noting that several factors make up the entire judiciary costs. On the same note, Popova et al. (2015) mentioned that several societal costs also form a crucial part of the total direct costs of law enforcement. CROSSING A CANYON 30 High Costs of Corrections Associated with FASD The study conducted by Popova et al. (2015), added that the costs of corrections associated with FASD are enormous; however, based on their research, it is clear that such costs are understated because most of the criminal cases in Canada go unreported to the police. It is worth noting that people living with cognitive disabilities experience significant stress due to frequent arrests and isolation from their families. Additionally, the reported correctional costs do not account for the extra expenses undergone by the judicial system to contain people living with disabilities due to their exceptional needs. Cognitive disabilities are an expensive group of illnesses that cost the government large amounts of money when it comes to budgeting for correctional services. Families of people with cognitive disabilities also experience many challenges; for example, there can be an extraordinarily high financial burden associated with hiring attorneys for legal defenses and to pay for the damages of the interpersonal conflicts in which their family members are involved. In extreme situations, families can find themselves forced to sell their assets to afford the enormous sums of money required by the legal system. It is, therefore, evident that the FASD is not only a family problem but a social problem that affects the government’s budgeting every year. Additional studies should focus on the appropriate means through which such legal costs can be mitigated. Living Environment of Cognitively Disabled People According to a report published by Hulbert-Williams & Hastings (2008), individuals need to develop resilience despite the odds that they face in their lives. According to the authors, both children and adults should develop resilience in circumstances when they think of giving up. Such conditions may include situations when a parent has a child or other family member with a cognitive disability. Living with these individuals may be a challenge at times due to the CROSSING A CANYON 31 interpersonal conflicts involved, but family members of the individuals living with cognitive disabilities should always strive to maintain a positivist view towards life. Hulbert-Williams & Hastings (2008) added that staying close to these family members in times of difficulty is an example of resilience in its purest form. The same study showed that the neurotypical caregiver members of a family unit should try and maintain harmony and find peace within their chaotic existence in an attempt to create a nurturing environment and trust among their family members living with cognitive disabilities. Boundary Challenges for People Living With FASD “Some individuals with suspected or diagnosed FASD experience difficulties with establishing healthy boundaries with persons in their communities” (Brown, J., 2015, 01). According to Brown (2015), people living with Fetal alcohol spectrum disorder (FASD) often experience boundary challenges. They often encroach on the personal space of strangers or people who may not want to be associated with them. As a result, they have a tendency to be over-friendly, which causes discomfort to others. According to Brown (2015), a majority of people living with FASD find themselves caught in conflicts with others due to their lack of a mental filter, which frequently causes them to act in manners that breach social convention; unwanted sexual advances and verbal comments which might be considered impolite by the recipients of such advances. Other Challenges Faced by People With FASD They have trouble forming relationships, have difficulty foreseeing the consequences of their actions, are often people-pleasers, and can become victimized easily, both financially and socially, become overstimulated in public places full of strangers. More discussions on these are in the following subsections; CROSSING A CANYON 32 They have trouble forming relationships: Additionally, people living with FASD often have trouble forming relationships, both friendships and romantically. In many cases, they become attached to people that would ordinarily be considered non-age appropriate; very young people as their friends, while in other cases, they become attached to the elderly as their most preferred friends (Brown, 2015). According to Brown (2015), such friendships are often superficial and short-lived in nature. They have difficulty foreseeing the consequences of their actions: Also, people living with FASD have difficulty foreseeing the consequences of their actions. Therefore, many of them become the perpetrators of criminal conduct without thinking of the ramifications of their actions. Although these are mental health issues associated with the cognitive disabilities that they have, neurotypical people in society have difficulty understanding this. Brown (2015), therefore, cautions of the severe effects of interpersonal conflicts and actions of the people living with cognitive disabilities. They are often people pleasers and can become victimized easily: On the same note, Brown (2015) added that people living with cognitive disabilities such as FASD are often people pleasers and can become victimized easily, both financially and socially. These are the same people that would consider stealing valuable commodities to please a friend, someone who might not be directly related to them in any way. Additionally, Brown (2015) stated that people living with cognitive disabilities, such as FASD, tend to carry on inappropriate and unwanted conversations. Such individuals often demand much attention from everyone they meet and can become violent when that attention is not given. They frequently become overstimulated in public places full of strangers: Brown (2015) mentioned that people living with cognitive disabilities frequently become overstimulated in CROSSING A CANYON 33 public places full of strangers. Because of the way they interact with their environment, which is often not considered socially acceptable, individuals with cognitive disabilities tend to attract considerable attention in public places. Such actions are often considered disturbing to by neurotypical individuals who do not understand such behavior. In situations where an individual meets such a person for the first time, they are often disturbed by their actions. Lack of emotional regulation is a common feature displayed by people living with cognitive disabilities. Emotional regulation or control is a crucial skill that enables individuals to cope with various situations in life. According to Brown (2015), most of the people living with FASD often find it difficult to control their emotions or regulate emotions based on the setting. They might, therefore, display sadness in circumstances where a happy mood is required or expected. Such an atypical display of emotion makes it riskier for people who live near them. People living with cognitive disabilities, therefore, require proper care and observation to reduce the chances of harm to them and people living close to them. It is worth mentioning, however, that most individuals with cognitive disabilities bear qualities that many neurotypical individuals have difficulty expressing, such as being non-judgmental and accepting of difference. Professional Training for Identification of FASD is Important “Because many individuals with FASD do not exhibit visible signs, professional training for the identification of FASD is important” (Brown, 2015, 01). The author argued that most of the people living with cognitive impairments such as FASD face obstacles in the judicial system because of both the police officers in charge and the legal team in the courtroom lack education on the best approaches of identifying these mental problems. As a result, most end up penalized for non-compliance without noticing the mental challenges that they are experiencing. Brown (2015), therefore, calls for the introduction of a standardized, validated screening protocol to CROSSING A CANYON 34 help in identifying FASD among the inmates. Such protocols would also become handy in forensics, judicial systems, and to the psychiatrists who would want to assess the extent to which cognitive disabilities influence people. Quick attention to such problems would also help relevant authorities, whether judicial, forensic, or health departments, to refer the screened individual for the required treatments and comprehensive care. The DSM-V (American Psychiatric Association, 2013) defines a grouping of conditions with onset between the prenatal stage of development to the toddler stage of childhood as neurodevelopmental disorders. These disorders typically begin early in fetal development, but almost always before a child enters school, and are identified by delays in development that that impact academic, social, and occupational functions (Ono, Friedlander, & Salih, 2019). The range of deficits that exist under the umbrella of neurodevelopmental disorders varies greatly from specific limitations of understanding and learning to decrease of executive function to global delays of social skills, as well as lower global IQ. The significant diagnoses in the classification of the neurodevelopmental disorder include autism spectrum disorder (ASD), fetal alcohol spectrum disorder (FASD), intellectual disability (ID), and genetic conditions such as Down syndrome, Prader-Willi, and fragile X. Individuals with a diagnosis of cognitive disability and their families frequently face multiple barriers when trying to access support services. Ono et al. (2019) argue that service delivery in BC is very fragmented, with the various health authorities and different governmental and non-profit agencies, programs, and contracted service providers delivering a myriad of care and funding. For children and youth, this is almost exclusively through the Ministry of Children and Family Development (MCFD) and CLBC as adults. Through this model, service delivery gaps have emerged, similar to those seen across the entirety of Canada (Ono et al., 2019). CROSSING A CANYON 35 Historic and Ongoing Segregation From Society Historically individuals with cognitive disabilities, particularly profound syndromes like severe autism or traumatic brain injuries, saw these individuals institutionalized, or at a minimum sequestered away from society in some capacity (Hulbert-Williams & Hastings, 2008). Beginning in the 1970’s public pressure to provide better care to individuals with cognitive disabilities started to grow. The government of the day was beset upon reducing overall healthcare expenditures, resulting in individuals systematically moved from staffed institutions into community living where supports were not readily available, with almost zero oversight of the individual’s overall well-being (Hulbert-Williams & Hastings, 2008). A review of the literature surrounding the needs of people with cognitive disabilities illustrates that it is a topic that researchers have studied extensively. However, there is still much work to be done regarding immediate service delivery gaps that exist not only for the individuals who have a cognitive disability but for those who support them as well (Chowdhury & Benson, 2011). The impact on the well-being of the individuals, as well as the impacts on the often-unpaid support networks surrounding them, has been neglected in research. In British Columbia, many individuals qualify for publicly funded services and support through Community Living BC (CLBC). There are two categories within which an individual can be eligible for services through CLBC (CLBC, 2018). The first category is the Developmental Disabilities category. Under these criteria, an adult must have significantly impaired intellectual functioning (functional IQ less than 70), as well as considerably reduced adaptive functioning; these limitations must have started before age 18. The second eligibility category for CLBC funding is the Personalized Supports Initiative (PSI). Under this criteria, a person qualifies if they are an adult who does not have a developmental disability but has a CROSSING A CANYON 36 significant limitation in adaptive functioning (3 standard deviations below the mean) and either a diagnosis of FASD or, a diagnosis of Autism Spectrum Disorder. Under DSM-V Asperger’s Syndrome is now included under the diagnostic criteria for ASD. Under ICD-10 diagnostic criteria that are used by most of the world outside North America, Asperger’s Syndrome is still a recognized diagnosis. CLBC presently services more than 22,000 individual clients (CLBC, 2018). However, outside of this program eligibility criteria, thousands of individuals find themselves excluded from qualifying for funded service through CLBC. Under the conventional developmental disability stream, a person who has an IQ that falls outside the 70-point IQ cutoff without severe adaptive functioning impact will not qualify (Morrow et al., 2008). Additionally, an individual who has an acquired brain injury that occurred on or after their 18th birthday will not meet CLBC eligibility criteria. Within the Personal Supports Initiative (PSI) which was first introduced in 2010 to include individuals with a diagnosis of Autism or FASD, a person must also have been assessed to have adaptive functioning three standard deviations below the mean, meaning that their ability to plan, execute and goal setting are impacted in more than 95% of their daily activities (CLBC, 2018). It has been argued that a person who does not quite meet that cut off is still significantly affected in their daily lives and is not without a need for support to get through everyday life (Morrow et al., 2008). This tight eligibility window poses a significant gap within the present system that exists within BC. The available literature indicates that the gap between CLBC’s traditional service offering and the population it serves has been evident at the regional operations level for some time. Large portions of a region's annual budget are disproportionately allocated to a small number of individuals for whom no best service solution is apparent (American Psychiatric CROSSING A CANYON 37 Association, 2013). Conversely, available services are cobbled together in an attempt to avoid significant health and safety outcomes for the individual and those around them. Furthermore, this has not even begun to address the additional inequities faced within a system that is illequipped to accommodate the unique cultural and spiritual needs of individuals who come from other non-Eurocentric cultures, particularly Indigenous people. Within the homeless and street-entrenched populations of large urban cities as well as in rural communities, many of these people have significant cognitive impairments, some diagnosed, many not (American Psychiatric Association, 2013). Most of these individuals interface with the healthcare system (ER) and the criminal justice system on a revolving door basis. There is a substantial piece of the equation that is resultant from historical and ongoing trauma, especially for Indigenous people. The loss of culture for Indigenous people has had a catastrophic impact on their ability to fit into a world that is already by its very nature alien to them. The literature is severely lacking in researching the Indigenous People of British Columbia. Further steps forward towards studying the gaps that exist within this population can help individuals and policymakers to appreciate the role that Indigenous Culture plays and how traditional ways of knowing and being can contribute to better health outcomes for Indigenous individuals and communities. CROSSING A CANYON 38 Social Workers Current Knowledge About This Topic Individuals with cognitive disabilities are of increasing concern within healthcare circles. Individuals with cognitive disabilities face more serious mental health, physical health, and social challenges from substance-use related issues than neurotypical individuals. Still, substance use issues and related treatment needs such rehabilitation among individuals of this population are understudied. Well-designed, theory-driven research studies are required to establish base rates of substance use for this populace and its subgroups, such as teenagers, and those with mild or borderline cognitive impairments (Maniatopoulos, Couteur, Vale & Colver, 2018). This research needs to incorporate evaluations of the types of substances used (or misused) by this population (e.g., alcohol, inhalants, diet pills, prescription-type drugs). This research must also portray how these substances are being used (socially or in isolation?), and clarify pathways to substance misuse care. The primary purpose of the social worker within this context is to ensure that an individual with cognitive disabilities is appropriately assessed and receives the correct diagnosis. Although, unless someone is determined to lack the capacity to act on their behalf, this can prove to be a challenging endeavor. Within British Columbia and the rest of Canada, healthcare services and mental health assessment are voluntary services. Therefore, if an individual does not wish assessment for how their cognitive disabilities are impacting their daily living, they will not receive the appropriate treatment and support that they may require (CLBC, 2018). One way for social workers to influence this is by including the people (family and friends) in the immediate social sphere of the person in the dialogue when contemplating a psychological assessment (Nottestad & Linaker, 1999). As it is a common occurrence for individuals with cognitive disabilities to not follow through with often lengthy multi-day multidisciplinary assessments, an CROSSING A CANYON 39 excellent strategy to ensure that these individuals receive proper assessment and diagnosis would be for them to stay with their family members before and after diagnosis, as well as during the evaluation, planning, and coordination of care services (Maniatopoulos et al., 2018). It is the role of social workers to raise awareness and educate the community regarding cognitive disabilities. In Canada, it has been well documented that individuals with cognitive disabilities experience violence and crime (Focht-New et al., 2008). Recent campaigns for cognitive disability awareness have encouraged social workers to engage with individuals with cognitive disabilities closely. As cognitive disabilities affect people of all ages, social workers working as primary care providers within healthcare settings are in a unique position to advocate for people with intellectual disabilities. Through professional training, social workers are equipped with the knowledge to understand the antecedents of a cognitive disability, whether it is a congenital anomaly such as a genetic disorder or FASD, or an acquired brain injury caused by significant head trauma, stroke, or a degenerative condition such as dementia or Alzheimer’s disease. It is the role of social workers to make sure that the patient understands his or her diagnosis as well as effective interventions. Social workers also offer support as the individual with the cognitive disability make adjustments in their lifestyle to cope with their condition (Chowdhury & Benson, 2011). People with cognitive disabilities require assistance with transportation, access to facilities, and numerous logistical issues. Research has established that improvements in the standards of care, especially for people with cognitive disabilities, enhance their quality of life (McFadden, Manthorpe, & Mallett 2018). “Social workers work with individuals with a disability, with families who have a child or family members with a disability as well as with communities both domestically and internationally” (McFadden et al., 2012). CROSSING A CANYON 40 People with disabilities have been marginalized, discriminated against, excluded, or ultimately exterminated throughout the developed world. The attitudes towards individuals with disabilities vary depending on the values, social norms, cultural perspectives shaping people’s lives (CLBC, 2018). Within recent history, people with disabilities were isolated in specialized facilities, away from family members and friends. They were frequently mistreated. The BC Provincial Government began moving away from this model in the 1980s and 1990s, closing most of these institutions which, by today’s standards, were cold, isolationist, and outright barbaric. The current system of offering care to patients with cognitive disabilities requires the recognition of the changes in practice as well as the legislation in place to ensure the highest standard of care (Beaulaurier & Taylor, 2001). Social workers must understand the need for encouraging people with cognitive disabilities so that they can “live lives filled with possibilities” (CLBC, 2018), and learn to cope best with wide-ranging challenges arising from their condition. The Roles of Social Workers Social workers are brokers: The roles of the social worker include being a broker. This means that they ensure that families and other people connected to a person with cognitive disability access the required resources to cope with the various challenges arising from the condition. The social worker understands that their role does not merely entail the provision of information related to caring for cognitive disability patients (Beaulaurier & Taylor, 2001). They must communicate with other members of a person’s care team, including their family, to ensure that the necessary resources are in place. Being a competent broker requires the social worker to understand the eligibility criteria, the cost involved, how to access subsidized services, and the location of the tertiary care centers (Nottestad & Linaker, 1999). All this ensures that people with CROSSING A CANYON 41 cognitive disabilities are identified, remediating the existing gaps to form a comprehensive system of care. Social workers are advocates: Social workers are advocates because they understand the nature of the patient’s case, the challenges they experienced, and the financial situations of the family, the social worker stands up as the primary advocate for the patient (Beaulaurier & Taylor, 2001). They must be able to convince the stakeholders within the system of care delivery that certain things are needed to achieve the intended objectives in treating patients. Understanding the vulnerability of this population, they act as primary advocates where the rights of the patient are overlooked or exploited. Social workers are educators: The role of the social worker is to educate and empower the family, friends, and patients on effective ways to cope with the condition. They can also assist in financial planning and management to ensure that they can service the different costs involved. Social workers are case managers. In this regard, social workers understand that they are the case manager for some instances within the community context (Beaulaurier & Taylor, 2001). As case managers, they locate the services needed and remediate any existing gap in the system of care delivery. Social workers are facilitators: In this role, the social worker works to keep the community together and engage in activities that enhance the wellbeing of people with cognitive disabilities. These opportunities ensure that the community can support its members and seal the service delivery gap. They will also be playing a role in enhancing the overall wellbeing of the community. Social workers are organizers and managers: Social workers understand that they are organizers and managers in the process of caring for an individual with cognitive disabilities. At CROSSING A CANYON 42 various levels of the community, they must take part in enhancing the response levels, promoting economic wellbeing, and assess the impact of the current service delivery strategy (Beaulaurier & Taylor, 2001). They can also work as managers and supervisors in programs that involve families, community members, and patients. Social Worker and Cognitive Domains Complex Processes Substantial literature regarding cognitive functions term cognitive domains as a complex process that involves perception, attention, memory, language, and executive function. According to Obrien and Rose (2010), some of those cognitive functions decrease within typical ages. Most of all, though human language processes remain intact throughout aging, a lot of other mental processes decline over the same timeframe. As neuroscience continues to be understood more and more, information concerning cognition has outlined various risk factors for the development of cognitive impairment; of these, age is one of the most significant factors (Chowdhury & Benson, 2011). There are many positive factors, such as physical activity, social participation and involvement, and academic and intellectual activity, that remain intact for a long time. The kind of diet that an individual has is also a significant determining factor as well. The colloquialism “you are what you eat” is entirely appropriate in this regard. Rather literally, failure to exercise one’s brain through lifelong learning, or ensuring it receives appropriate nutrition is a surefire way to ensure cognitive decline as a person ages (Chowdhury & Benson, 2011). CROSSING A CANYON 43 The Gaps in The Collective Knowledge About This Topic A search of available literature indicates that very little information is currently available on the best means of enhancing resilience among people living with cognitive disabilities. These individuals face many challenges, such as secondary disabilities like mental illnesses (Bonta & Andrews, 2007). The family members who live together with them are, in turn, expected to stay firm and support them over their entire life. However, in most cases, handling people with cognitive disabilities proves daunting. An ever-increasing trend is that of individuals who have been cared for by their parents their entire lives. Over the coming years, thousands of senior citizens whose elderly parents either die or become unable to care for the needs of the individual any longer, leading to a mass-influx of high needs individuals into geriatric care facilities that are ill-prepared to receive and care for them (Bonta & Andrews, 2007). According to Doig, Mclennan, and Urichu (2009), caregivers must first understand the health situations of their clients, and later on, devise ways of helping them out. One approach of helping children with cognitive disabilities is first, placing them into care facilities such as the Pacific Assessment Centre. The Pacific Assessment Centre (PAC) is a multidisciplinary 10-bed inpatient facility located in Burnaby, BC, which is run and funded by CLBC (CLBC, 2018). This program provides long-term tertiary assessment and treatment for individuals with developmental disabilities. A significant gap that exists is that they are only able to accept patients who are aged 14, who also must meet the eligibility criteria for CLBC services. For children under the age of 14, and for those who are over 14 but in acute psychiatric crisis, these individuals presently are reliant on a community-based response which are either non-existent, understaffed or has clinicians who are unqualified and unable to deal with individuals with cognitive disabilities. CROSSING A CANYON 44 According to Doig et al. (2009), parents should comply with the doctor’s directives to ensure that their children living with cognitive disabilities, receive proper medication, and appropriate medical support from the caregiver. Doig et al. (2009) added that most parents are unwilling to let their children go into facilities. In BC, part of the reason for this is the historically poor treatment and abuse that individuals received in these facilities. Due to stigma, most parents are reluctant to open up and talk about the state of their children. Because most of these children cannot speak or express themselves well, it becomes challenging even for the parents to understand what they need quickly. Doig et al. (2009) point out that children should have access to these care facilities to help them learn and improve mentally to the medications given. In BC in 2020, these facilities are just not existent even if a parent wished to go that route. Despite research evidence on the prevalence of interpersonal violence there is a gap of effective ways of reducing conflicts among people living with cognitive disabilities. The British Columbia Medical Association (2019) argued that persons with cognitive disorders are more exposed to interpersonal violence, unlike those who lack such mental complications. The authors mention that an individual’s ability to cope and relate to their environment and neighborhood is dependent on his/her cognitive ability. There is a debilitating effect from this, which results in them developing learned helplessness. This outlook significantly affects their interactions within the public arena and harms their relationships with their support networks. (British Columbia Medical Association, 2019). Looking, where conceivable, at the particular battles of people with scholarly inabilities during the different phases of contention. CROSSING A CANYON 45 Future Research Based on a recent study, the majority of people living with cognitive disabilities lack adequate housing, and many are homeless (Community Living BC, 2018). Further research on the best ways of ensuring proper housing for people living with cognitive disabilities is needed. A research study conducted by Community Living BC (2018) examined various ways that proper housing could be allocated to people living with intellectual disabilities in British Columbia. CLBC (2018) mentioned that over twenty thousand adults aged fifteen years and above had developmental disabilities in the province of BC. The stated figure indicated an increase of approximately 31% since 2001. These figures do not even capture those individuals who do not qualify for CLBC services, or may qualify but have never been assessed for eligibility. This number could easily dwarf the known estimate of individuals with developmental disabilities. Based on the tremendous increase in people living with cognitive disabilities, there is an urgent need for more appropriate housing for them. A vast majority of these people are unemployed, so they do not have enough money to rent or purchase the housing of their choosing. According to CLBC (2018), the majority of people living with cognitive disabilities remain in the family home living with their parents. When they grow old, they require homes. Unfortunately, many families do not independently have the resources to secure this housing, and so they must search for extra finances to procure this new housing. In circumstances when parents lack the financial capacity to make such acquisitions, their family members living with cognitive disabilities can be rendered homeless. More research studies are, therefore, required to identify the best means through which people living with cognitive disabilities can secure appropriate housing. CROSSING A CANYON 46 More research studies are necessary to fill the gaps in service delivery for people living with cognitive disabilities. For example, new and emerging research studies are just starting to advise on the effective means of identifying trauma symptoms among people living with cognitive disorders (Sari & Başbakkal, 2010). As a result, the majority of caregivers still do not understand how to work effectively with people with cognitive disabilities. Healthcare providers should receive training on the effective ways of identifying the signs of trauma among people living with disorders. Such training might involve more practical experiences and new approaches, as explained by the latest research (Sari & Başbakkal, 2010). However, the literature is lacking in articulating ways of identifying trauma symptoms such as stress induced illness, and heightened mental health disorders. Healthcare providers and/or caregivers cannot handle an individual living with a concurrent cognitive disability and trauma response appropriately because most of them do not understand the needs of these individuals due to the patient's difficulty in articulating what internal conflict they are experiencing. New research studies should, therefore, explore this area and its association with the general body of knowledge that exists about cognitive disabilities. This knowledge will additionally inform further research in the coming years. Limited literature focuses on the appropriate ways of enhancing care for people living with cognitive disabilities in rural areas, such as the rural regions of British Columbia. Most of the literature consulted focused on how to provide better care for people living with cognitive disabilities in general, without giving more focus to the geographical settings of these individuals (Mcconkey et al., 2004). Geographical settings determine the quality of care given to people living with cognitive disabilities. For example, the rural regions of BC have very few competent caregivers compared to urban areas. Poor infrastructure in most of the rural areas of British CROSSING A CANYON 47 Columbia hinders the settlement of the majority of healthcare providers in such settings. As a result, most healthcare organizations prefer urban regions with advanced infrastructural settings. Many people are living with cognitive disabilities in the rural areas of British Columbia, therefore, experience several challenges, such as few medical resources, and lack of competent care providers. More research is, therefore, required to explore practical ways of providing proper care to people living in rural areas concerning the various challenges that they experience in the rural setting. Tackling the challenges faced by individuals living with cognitive disabilities should, therefore, be a multifaceted approach that focuses on the concerns of these people in the rural areas. New policies, practice models, and funding need to be allocated based on the identified needs of those living in rural communities and Indigenous communities, rather than decisions being made by bureaucrats in Victoria based on what works best in a highly populated urban area with extensive resources and minimal logistical challenges. Adopting a more traumainformed and anti-oppressive approach would ensure heightened success in this regard. Future research should study appropriate means of reducing interpersonal conflicts experienced by people living with cognitive disabilities. The current research studies indicate that interpersonal conflicts are rampant among people living with cognitive disabilities. However, there is still little information known on the most appropriate ways of reducing instances of such interpersonal conflicts. As indicated in most of the literature, cognitive disabilities often result in several secondary disorders/challenges, such as mental illness, homelessness, criminal justice system involvement, among many others. Little information regarding the stoppage of interpersonal conflicts has yet to be published. It is, therefore, crucial for the current researchers to dig deep into this research to inform the public as a whole on the appropriate ways of minimizing conflicts between them and those who live cognitive disabilities. CROSSING A CANYON 48 The caregivers and entire family members should cope with the repercussions of such conflicts, though, precise approaches towards reducing the chances of conflicts are crucial. Additionally, there are gaps in the effective means of reducing discrimination of people living with cognitive disorders. Based on current research, discrimination happens everywhere, whether in the workplace, at home, in social places, and schools (Nottestad & Linaker, 1999). For Indigenous people, there exists double jeopardy; they must also navigate systemic racism with how the Federal government allocates funds to them. They also lack resources in their home communities and are negatively impacted by a lack of culturally appropriate resources in urban settings. To this day, many people have prejudged opinions regarding individuals living with cognitive disabilities. In society, because of such prejudices, people living with cognitive disabilities are often viewed as stubborn or troublemakers. As a result, many of them fail to secure employment, educational opportunities, and cultural participation due to fear that they may “cause a scene.” Most of this demographic living in rural areas of British Columbia also faces such challenges. More research studies that specifically address the challenges that exist in and are unique to rural areas are required. Discrimination prevents people from attaining their goals and may result in more harmful effects such as trauma and conflict within society. Future research studies should not be simplistic in their explanation of what remedial measures to reduce discrimination against people living with disabilities should be taken (Nottestad & Linaker, 1999). Despite the need to incorporate appropriate ways of involving people living with cognitive disabilities in various life events such as employment and education. Future research studies should also focus on how to create peaceful co-existence between them and people whom they reside with (Nottestad & Linaker, 1999). As explained in the literature, people living with cognitive disabilities are neglected in workplaces, schools, and cultural participation. CROSSING A CANYON 49 The field additionally needs more research on the means of cutting direct costs of the people living with cognitive disabilities who are over-represented in the judicial system. Based on the latest research studies, very little information is available in Canada on the exact costs the Federal government incurs in criminalizing people living with cognitive disabilities. It is evident from the consulted research studies that people living with cognitive disabilities are more likely to be charged with criminal offenses compared to those who lack cognitive disabilities. There is a correlation between the rise in the number of people living with cognitive disabilities and the rise in finances directed to correctional services (Nottestad & Linaker, 1999). In addition to the direct costs incurred in the budgets for correctional facilities, there are intangible costs associated with ensuring a safe stay for people living with disabilities in correctional facilities. For instance, these individuals have many more unique needs such as drugs to lessen pain, and professional caregivers to look after them in jails. Correctional facilities, therefore, require additional resources such as qualified personnel and more funds to keep inmates living with cognitive disorders in custody. Although the judicial system has increasingly become more trauma and disability informed, individuals with cognitive disabilities are still grossly overrepresented in the criminal justice system and correctional facilities (Nottestad & Linaker, 1999). Redistributing vast amounts of money from correctional services towards services that better life for the entirety of the nation would be a win-win for everybody. Developing the economy and providing essential services such as clean water, better roads, and quality care to everyone is a much better approach than continuing to marginalize this population. More research is additionally needed to explore practical ways of reducing prenatal alcohol exposure. As witnessed in the consulted literature, alcohol consumption among pregnant women is the leading cause of cognitive disorders such as FASD. Little information is, however, CROSSING A CANYON 50 present on the best ways of reducing alcohol consumption among the expecting mothers. Binge drinking, for instance, is a personal life issue, and the government has little control over it. It is, therefore, difficult for any government, whether local or national, to completely curb drinking of alcohol among expectant women. Addressing the gaps in the literature should, therefore, be addressed by conducting a more robust research study which explores better means of encouraging women not to drink. The new research must illustrate how adopting alternative life practices would help unborn babies from getting FASD. The recommended approaches should, therefore, be easy to adopt and less strenuous and stigmatizing for expectant women. Expectant women need more professional support, and resources and education on the harmful effects of binge dirking when they are pregnant. The financial, social, and economic burdens that come along with such alcohol consumption should, therefore, remain in the new research studies. Accordingly, this would inform the public about the need to stop alcohol consumption during pregnancy. Additional research on the importance of trauma therapy in lessening the stress levels of people living with disabilities is needed. Based on the latest research, people living with cognitive disabilities are more likely to experience traumatic events, abuse, and neglect. Trauma therapy has been a recommendation in various research studies as the most appropriate means of reducing the traumatic experiences of an individual with such intellectual impairments. However, more studies should focus on how this therapy can be delivered in the rural areas of British Columbia and any poorly resourced area of Canada to people living with such disorders. The same studies would also determine whether a combination of trauma therapy and other therapeutic approaches would help in solving most of the challenges faced by people with such CROSSING A CANYON 51 disabilities. The current literary sources are an essential foundation upon which future research should be conducted. There is an additional need for research on how to best address children living with disabilities in out-of-home care. According to a study carried out by Moore and Riley (2015), children who have FASD are at a much higher risk of being convicted of criminal conduct in their adult lives. These experiences further complicate already complicated lives as they age. Moore and Riley (2015) argued that biological parents should, therefore, try to keep their children living with them as much as possible prevent the chances of them being caught up within the criminal justice system at later stages. More studies are, however, needed to explore this area to prove what exactly happens to the children who live away from their biological parents, and what resources need to be in place and funded to ensure that children can remain in their family units. With very few studies in this regard, they cannot be relied upon in making conclusions regarding a crucial topic like this one. With more studies, future researchers could move beyond the various weaknesses that exist in the study conducted by Moore and Riley (2015). Research is continuous, and therefore, further research should use the information gained from the past studies to form more comprehensive results on the pressing issues like the one discussed in this literature. Analysis of suitable conducive environments for children living with disabilities should be undertaken to help educate the public on the best environmental components that would ensure sufficient growth for children with cognitive disabilities. A recent research study conducted by Allan et al. (2016) shows that the treatment of substance misuse among people living with cognitive disabilities would help in improving their mental health conditions. The research indicated that most people living with cognitive disabilities are prone to drug misuse. One of the possible causes of such abuse is a lack of proper CROSSING A CANYON 52 comprehension or forethought of what their actions might cause. Additionally, most such individuals are often over-stimulated, and as a result, they find joy in consuming excess medical drugs or consuming illegal drugs such as cocaine. Allan et al. (2016) said that stress and loneliness might also lead to drug misuse among people living with cognitive disabilities. According to this study, most of the people living with such impairments often need people by their side. However, due to discrimination, they might remain lonely. Such situations might, therefore, force individuals to consume drugs to escape the torment of their lived experience. This added challenge often comes in and ruins the entire life of such individuals. Such individuals, therefore, require support from their families to relieve them of stress. It is paramount that more research is conducted on the most appropriate ways of reducing drug misuse among people living with cognitive disabilities. CROSSING A CANYON 53 Conclusion Overall, identifying and remediating service delivery gaps for individuals with cognitive disabilities in rural British Columbia, Canada, requires a multifaceted approach. Several research findings are discussed in this paper. The themes obtained from the selected scholarly sources have those same themes detailed throughout them. People living with cognitive disabilities in Canada and all parts of the world, including developing nations, are on the rise. As a result, there is more research needed on how to provide individuals living with intellectual impairments quality care. Based on the research of literature, the author concluded that where care providers have positive attitudes, positive relationships and, likewise, positive avenues are created for supporting people living with cognitive disorders. From the research findings, discrimination of people living with cognitive disorders is one of the major impediments in delivering quality healthcare services to them. It is, therefore, essential for not only healthcare providers but all care providers who live and interact with them to have positive attitudes towards helping these individuals. Individuals living with cognitive disabilities are often involved in interpersonal conflicts. Their care providers should receive training on the most appropriate means of handling such conflicts. As discussed in the scholarly sources, trauma-informed therapies should be encouraged by their physicians and psychiatrists to boost the self-esteem of people living with disabilities and to ensure that they are living life to its fullest and happiest. Moreover, more research is required to fill the various gaps in the literature identified in this research. Research is a continuous process, and new information is released regularly through the various peer-reviewed journals available in print and online. Studies, moving CROSSING A CANYON 54 forward, should indulge in research that has more of an impact on the lives of neurotypical people. It is not until this population has a better understanding of the challenges faced by people living with cognitive disabilities that we will start to see a meaningful change towards a more inclusive society. Additionally, the Canadian government should introduce more suitable policies that help in reducing the direct costs incurred by the government in correctional facilities. As a diversionary tactic, systems should promote the peaceful coexistence of people living with the impairments and the entirety of society. Most of the incidents of crime perpetrated against and by people living with cognitive disabilities are contributed to by a lack of employment, challenges in socializing with peers, and neglect by family and other members of their formal and informal support networks. All individuals living with cognitive disabilities should, therefore, receive proper service delivery in all aspects of life. This study stopped short of undertaking a critical analysis of the oppressive situations Indigenous people in Canada are forced to bear due to the underlying issues of racial discrimination found within the country’s care systems. The Indigenous population of Canada faces multiple challenges that emanate from the disparities that are present in all systems with which they interface. Indigenous people living with cognitive disabilities have this compounded for them. Racist prejudices in the Canadian healthcare system are not only tied to the interpersonal relations experienced at the time of receiving medical services but also in the organizational and administrative frameworks that must deliver those services. For hundreds of years, Indigenous people have been managing prejudice and its associated effects. The effects of racism on their personal and family lives, as well as societal dimensions where racism permeates, are faced head-on by demonstrating their abilities to persevere whenever they encounter tormenting circumstances such as communal violence, culture-based genocides, legislated CROSSING A CANYON 55 discrimination, and economic oppression. Future research should be conducted to determine how individuals living with cognitive disabilities are being further discriminated against and marginalized by them also being Indigenous. Those who work with this client population should receive training in culturally safe practices. There exist people in Canada who will never understand that individuals with cognitive disabilities have a lived experience that is any different from the lived experience of neurotypical people. Likewise, there exist people in Canada who do not believe Indigenous people have a history of lived experience that is any worse than non-Indigenous Canadians. It is the hope of this writer that through wide dissemination of historical truth through the Canadian education system that the hearts and minds of all Canadians be changed to see the tremendous injustices which have been perpetrated against Canada’s Indigenous people and those living with cognitive disabilities. As social work practitioners, we have an ethical duty to further this goal through anti-oppressive practice and through advocating for changes within systems that support these individuals. CROSSING A CANYON 56 References American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders. Fifth edition. Arlington, VA: American Psychiatric Publishing; 2013. Baines, D. ed., (2017). Doing anti-oppressive practice: Social justice social work. 3rd edition, Halifax, Nova Scotia: Fernwood, 2017. Beaulaurier, R. L., & Taylor, S. H. (2001). Dispelling fears about aging with a disability: Lessons from the disability rights community. Journal of Gerontological Social Work, 35(2). Bonta, J., & Andrews, D. A. (2007). Risk-need-responsivity model for offender assessment and rehabilitation. Rehabilitation, 6(1), 1-22. British Columbia Medical Association. (2019) Closing the gap—youth transitioning to adult care in BC. Accessed 30 January 2020. www.doctorsofbc.ca/sites/default/files/1984bcma youth transitions.pdf Brown, J. (2015). Fetal alcohol spectrum disorders in the criminal justice system: A review. The Journal of Law Enforcement, 3(6), 1-10. Browne, A. J., Varcoe, C., Lavoie, J., Smye, V., Wong, S. T., Krause, M., & Fridkin, A. (2016). Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study. BMC health services research, 16(1), 544. Chinn, D., Levitan, T., & Murrells, T. (2017). Equity in social care for- people with intellectual disabilities? A cross‐sectional study examining the distribution of social care funding across local authorities in England. Health & Social Care in The Community, 25(3), 901911. Retrieved March 22, 2020, from https://onlinelibrary.wiley.com/doi/pdf/10.1111/hsc.12378 CROSSING A CANYON 57 Chowdhury, M., & Benson, B. A. (2011). Deinstitutionalization and Quality of Life of Individuals with Intellectual Disability: A Review of the Interna----------tional Literature. Journal of Policy and Practice in Intellectual Disabilities, 8(4), 256–265. CLBC: Adult Guardianship Procedures and Practice Guidelines Critical Incidents Policy. (2018, April). CLBC: Planning with People Practice Guidance for CLBC Staff PRINT BOOKLET VERSION (2018, August) Doig, J. L., Mclennan, J. D., & Urichuk, L. (2009). ‘Jumping through hoops’: parent’s experiences with seeking respite care for children with special needs. Child: Care, Health and Development, 35(2), 234–242. Emerson, E. (2003). Mothers of children and adolescents with intellectual disability: social and economic situation, mental health status, and the self-assessed social and psychological impact of the child's difficulties. Journal of Intellectual Disability Resea-rch, 47(4-5), 385–399. Focht-New, G., Barol, B, & Clements, P., & Dice, T. (2008). Persons With Developmental Disability Exposed to Interpersonal Violence and Crime: Approaches for Intervention. Perspectives in Psychiatric Care. 44. 89 - 98 Goodman, A., Fleming, K., Markwick, N., Morrison, T., Lagimodiere, L., Kerr, T., & Society, W. A. H. R. (2017). “They treated me like crap, and I know it was because I was Native”: the healthcare experiences of Aboriginal peoples living in Vancouver's inner city. Social Science & Medicine, 178, 87-94. CROSSING A CANYON 58 Hulbert-Williams L. & Hastings R.P. (2008) Life events as a risk factor for psychological problems in individuals with intellectual disabilities: a critical review. Journal of Intellectual Disability Research 52(11), 883-895. Lach, L. M., Kohen, D. E., Garner, R. E., Brehaut, J. C., Miller, A. R., Klassen, A. F., & Rosenbaum, P. L. (2009). The health and psychosocial functioning of caregivers of children with neurodevelopmental disorders. Disability and Rehabilitation, 31(8), 607– 618. Lunsky, Y., Garcin, N., Morin, D., Cobigo, V., & Bradley, E. (2007). Mental Health Services for Individuals with Intellectual Disabilities in Canada: Findings from a National Survey. Journal of Applied Research in Intellectual Disabilities, 20(5), 439–447. MacDonnell, J. A., Dastjerdi, M., Khanlou, N., Bokore, N., & Tharao, W. (2017). Activism as a feature of mental health and wellbeing for racialized immigrant women in a Canadian context. Health care for women international, 38(2), 187-204. Maniatopoulos, G., Couteur, A. L., Vale, L., & Colver, A. (2018). Falling through the gaps: exploring the role of integrated commissioning in improving the transition-+n from children’s to adult services for young people with long-term health conditions in England. Journal of Health Services Research & Policy, 23(2), 107–115. Mansell, J., & Ericsson, K. (1996). Conclusion: integrating diverse experience. Deinstitutionalization and Community Living, 241–253. Martin, D., Miller, A. P., Quesnel-Vallée, A., Caron, N. R., Vissandjée, B., & Marchildon, G. P. (2018). Canada's universal health-care system: achieving its potential. The Lancet. Matthews, R. (2017). The cultural erosion of Indigenous people in health care. CMAJ: Canadian Medical Association Journal, 189(2), E78. CROSSING A CANYON 59 Mcconkey, R. & Truesdale-Kennedy, M. & Conliffe, C. (2004). The Features of Short-Break Residential Services Valued by Families Who Have Children with Multiple Disabilities. Journal of Social Work. 4. 61-75. McFadden, P., Manthorpe, G., & Mallett, J. (2018) Commonalities and differences in social work with learning disability and child protection: findings from a UK ‘burn-out’ national survey, The British Journal of Social Work, 48 (5) 1199–1219 McNally, M., & Martin, D. (2017). First Nations, Inuit and Métis health: Considerations for Canadian health leaders in the wake of the Truth and Reconciliation Commission of Canada report. In Healthcare management forum (Vol. 30, No. 2, pp. 117-122). Sage CA: Los Angeles, CA: SAGE Publications. Moore, E. M., & Riley, E. P. (2015). What Happens When Children with Fetal Alcohol Spectrum Disorders Become Adults?. Current developmental disorders reports, 2(3), 219–227 Morrow, M., Dagg, P., & Pederson, A. (2008). Is deinstitutionalization a “failed experience”? The ethics of re-institutionalization. J Ethics Ment Health 2008; 3:1-7. Nottestad, J. A., & Linaker, O. M. (1999). Psychiatric health needs and services before and after complete deinstitutionalization of people with intellectual disability. Journal of Intellectual Disability Research, 43(6), 523–530. Obrien, A., & Rose, J. (2010). Improving mental health services for people with intellectual disabilities: service users’ views. Advances in Mental Health and Intellectual Disabilities, 4(4), 40–47. CROSSING A CANYON 60 Ono, E., Friedlander, R., Salih, T. (2019) Falling through the cracks: How service gaps leave children with neurodevelopmental disorders and mental health difficulties without the care they need. BC Medical Journal, Vol. 61, No. 3, April, 2019, Page(s) 114-124 Ouellette-Kuntz, H. (2005). Understanding Health Disparities and Inequities Faced by Individuals with Intellectual Disabilities. Journal of Applied Research in Intellectual Disabilities, 18(2), 113–121. Popova, S., Lange, S., Burd, L., & Rehm, J. (2015). The cost attributable to fetal alcohol spectrum disorder in the Canadian correctional system. International Journal of Law and Psychiatry, 41, 76-81. Rahaman, Z., Holmes, D., & Chartrand, L. (2017). An opportunity for healing and holistic care: Exploring the roles of health care providers working within Northern Canadian Aboriginal communities., 35(2), 185-197. Ribet, B. (2011). Emergent disability and the limits of equality: a critical reading of the un convention on the rights of persons with disabilities . Yale Human Rights and Development Journal, 14(1), 155–203. Retrieved from https://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article= 1101&context=yhrdlj Rousseau, C., Oulhote, Y., Ruiz-Casares, M., Cleveland, J., & Greenaway, C. (2017). Encouraging understanding or increasing prejudices: A cross-sectional survey of institutional influence on health personnel attitudes about refugee claimants' access to health care. PloS one, 12(2). CROSSING A CANYON 61 Sari, H. Y., & Başbakkal, Z. (2010). Depression among mothers of children and adults with an intellectual disability in Turkey. International Journal of Nursing Practice, 16(3), 248– 253. VanZomeren-Dohm, A., Ng, R., Howard, K., Kenney, M., Ritchmeier Cyr, L., Gourneau, J., & Michaels, C. (2013). How trauma gets under the skin: Biological and cognitive processes of child maltreatment.