Intellectual disability and body image

DSM-5 defines ID as a disorder that begins in the developmental period and includes significant deficits in intellectual functioning and adaptive behaviour in the conceptual, practical, and social domains (^{American Psychiatric Association; APA, 2013}). There exist different severity levels of ID (mild, moderate, severe, profound) based on adaptive functioning and the level of support needed by a person (intermittent, limited, extensive, pervasive).

In Spain there are a total of 268,633 people with ID, meaning 9% of all people with disabilities (^{Instituto de Mayores y Servicios Sociales; IMSERSO, 2015}). This constitutes the largest group of people with special educational needs (^{Ministry of Education, 2022}). Few studies have examined physical self-perception of people with ID depending on their percent body fat (^{Bertapelli et al., 2022}) or Body Mass Index. The studies suggest that adolescents and young adults with overweight or obesity usually present lower levels of general and physical self-esteem than those with underweight or normal weight (^{Bégarie et al., 2011}; ^{Maïano, 2011}). By contrast, ^{Reel et al. (2013}) reported that a large number of adolescents with ID and obesity identified their body shape as ideal, in contrast to their peers without disability. This suggests that people with ID may present an incorrectly self-assessment of their body shape (^{Ayaso-Maneiro et al., 2014}).

This study aims to investigate the body image perceptions of people with ID and assess their alignment or divergence from existing literature. Recognizing the influence of body image on the quality of life of people with ID (^{Rice et al., 2021}), this research delves into their unique perspectives. Limited research exists on the subjective experiences of people with ID regarding body image, making this study valuable for filling the gap. Through qualitative methodology, the study sheds light on the perceptions of participants. The findings could contribute to a better understanding of the factors shaping body image perceptions.

Given the lack of studies in this regard, the aim of the present study was to examine body satisfaction or dissatisfaction in adults with ID based on the following research questions: 1) Are people with ID satisfied with their bodies related to physical appearance? 2) In case body dissatisfaction is detected, which behaviours do participants modify in order to alleviate it?

Method

Procedure

Data collection. Participants were provided introductory information about the aim of the study so that they could discuss it with a family member and then decide about their participation. After being explained once more the aim of this research, data anonymity, volunteer participation, and the possibility of withdrawing at any moment, they provided verbal informed consent to participate in the study and to be recorded during the interviews. Figure 1 present a summary of the data collection process. After we have analyzed the results of the first data collection session (study 1), some cases of body dissatisfaction were detected based on the desire to change their physical appearance and their feelings to be less physically attractive in comparison to someone else. Therefore, a second semi-structured interview was designed in order to delve into this disorder of the cognitive-affective component and how it affected their daily lives, through questions related to the behavioural component (see Figure 1). After audio and video recording the interviews, they were transcribed and carefully read in order to get an overview of the content and then analyze them. A total of 33 individual interviews, 18 to 20 minutes long were conducted (M = 19.49, SD = 6.23). The study was conducted according to the guidelines of the Declaration of Helsinki.

Figure 1. Information about the administration of the interviews with the participants in both studies 

Results

Table 2 showed a summary of themes and subthemes derived from the analysis.

Discussion

The aim of the present study was to determine whether people with ID presented body image satisfaction or dissatisfaction based on physical appearance (cognitive-affective component), and how it modified their behavior related to this dis-satisfaction (behavioral component). On the whole, the results findings in the study 1 showed that the vast majority of participants present a positive physical appearance related with body image, in accordance with the results obtained by ^{Eden & Randle-Phillips (2017}). The rest of the sample which took part in the study 2 declared wanting to change any specific part of their body due to dissatisfaction. Although this finding is rare in this population, ^{Ramírez et al. (2015}) analyzed 256 unidentified young adults ages 18-40 and found that they were moderately satisfied with their bodies, as evidenced by body satisfaction scores in their study.

However, several participants in study 1 were concern about weight and physical appearance, despite showing no other indications of body dissatisfaction. The findings regarding theme 1.1 revealed that most of the participants wished to be “thinner” and “more muscled” in accordance with the results obtained by ^{Reel et al. (2013}).

The influence of the closest environment on the participants’ body-image assessment was remarkable (Theme 1.2). Results showed that most of the participants in study 1 did not consider their environment’s opinion very important. By contrast, some participants taking part in studies 1 and 2 considered a negative influence of the comments about their physical appearance. It must be highlighted that various studies have confirmed that positive or negative effects on people with ID’s lives are not only generated by their limitations but also, to a great extent, by the comments that their closest relatives make about them (^{Andrade & Roldán, 2007}). In line with this, ^{Rumsey et al. (2004}) proved that people with physical disabilities are very concerned about others’ perception of their appearance and they experience psychosocial problems that contribute to body dissatisfaction. Furthermore, some studies confirmed that people who received negative comments about their body and/or weight, according with the opinion of several participants interviewed in this study, reported higher level of body dissatisfaction. Verbal and physical harassment were found to produce greater body dissatisfaction in men (^{Farrow & Fox, 2011}), while criticism and mockery had the same effect in women, mostly among those with overweight (^{Quick et al., 2013}).

With regard to theme 1.3, various studies have proved that messages shown on social media can shape self-perception and, therefore, body satisfaction, having relevant consequences on health and psychological well-being (^{Sabik et al., 2019}). As described by ^{Sibilia (2008)}, social media are a public stage and a proof of identity that can positively or negatively affect body image. Nonetheless, contrary to expectations, this study found many participants to be influenced by what they saw on social media.

The results from theme 2.1 of the study 2 differed from some recent studies. For example, ^{Sala and Levison (2016}) observed that the participants who were more concerned about their weight would more likely restrict unhealthy food from their diet. By contrast, most of the participants of this study reported not restricting any unhealthy food from their diet. In this regard, it is noteworthy that some studies that analyzed the relationship between eating habits and body image detected a positive correlation between consuming unhealthy food and body dissatisfaction (^{Esnaola, 2007}).

^{Dalley et al. (2019}) pointed out that body checking behaviours like weighing themselves frequently or looking in the mirror are part of a monitoring process that provides the individual with comparative information on the distance to the goal (the ideal body). Related to this, the results from Theme 2.2 revealed that most of the interviewees which presented body dissatisfaction reported frequent checking behaviours like looking in the mirror three times daily. Moreover, a large number of participants paid most attention to the part of their body they considered least attractive in line with Jansen et al. (2017) in a clinic eating disorder sample. Moreover, many interviewees weighed themselves frequently or asked their family or people from their environment about their physical appearance. According to ^{Walker et al. (2009}), individuals who are satisfied with their body tend to spend longer checking those aspects they like most, while people who are dissatisfied focus more on those parts they dislike most and criticise them severely. Similarly, various studies reported that the higher the level of body dissatisfaction, the more frequent the checking behaviours (Leahley et al., 2011). Furthermore, certain checking behaviours have been proved to be common among the Western world population (^{Walker et al., 2009}), like checking the appearance in front of the mirror or checking weight.

Apart from identifying certain checking behaviours, avoidance behaviours were detected in two of the participants, as ^{Xu and Lui (2020}) found in people with physical disabilities. ^{Walker et al. (2009}) stated that body-image avoidance behaviours may appear due to various reasons like helplessness, negative thoughts, or lack of mental, physical, or emotional energy. In these cases, avoiding the scales or the mirror may be used as a means for temporary relief from their concerns. Nonetheless, in the long term, fear and anxiety may intensify.

As regards the weekly practice of physical activity (theme 2.3), the participants of study 2 reported to be active, in agreement with the results obtained by ^{Robertson and Emerson (2010}). They analysed the physical activity of people with ID and observed that 41% of the participants had practised sport in the previous month and 34% wished to do it. By contrast, ^{McKeon et al. (2013}) found that most adults with ID had a sedentary lifestyle and were less active than general population.

However, the vast majority reported participating in physical activity due to aesthetic reasons. These results are in line with ^{Reel et al. (2013}), who found in a study with people with ID that some of the participants practized sport to improve their physical appearance. Moreover, ^{Ayaso-Maneiro et al. (2014}) demonstrated that the control of exercise and caloric restriction in people with ID which took part in a weight loss therapy program influenced in a distortion of body image. Besides, ^{Abellán and Januário (2017}), in a sample of 23 athletes with ID, observed that two of the main reasons for participating in physical activity were “to be healthy” and “to expand and keep my social environment”.

In general terms, the present research represents a novel effort with the purpose to gain knowledge on people with ID’s concerns regarding body satisfaction, since research on this population is scarce. This study employs qualitative methodology as an initial step to enhance our understanding of body image perception in people with ID, aiming to contribute to a deeper knowledge on this topic. Nevertheless, some limitations were identified. The first of them was, despite the participants having adequate comprehension and expression abilities, their answers during some of the semi-structured interviews were not very long or elaborated, making it difficult to obtain information for the analysis. Future studies could complement the data provided by participants by incorporating interviews with family members and friends. This additional perspective can enhance our understanding of body image perception in people with ID. Building upon the suggestion to incorporate interviews with family members and friends, future studies could focus on understanding the role of social support networks in shaping body satisfaction among people with ID. By examining the perspectives of those close to the people with ID, researchers can gain insights into the social dynamics, influences, and support systems that contribute to body image perception within this population.

Conclusion

To date, research on body image and body satisfaction has focused on children, adolescents, and adults, addressing in very few cases body image in people with ID. It must be highlighted that most of the participants in study 1 reported accepting their body and being satisfied with it. The participants were found to have an established and accepted body identity. However, in study 2 most of them wished to change their body shape to become “thinner” or “more muscled” and reported participating in physical activity with the aim to become more attractive. A notable proportion of participants who manifested body dissatisfaction about their physical appearance revealed checking behaviours and were strongly influenced by the negative comments that they have received regarding their body in accordance with TIM, accurately the same participants with a fat body self-description. For all participants, body weight, body shape, and muscle mass were identified as the greatest sources of dissatisfaction (^{Roberts et al., 2022}). These findings provide additional support to the need to develop programmes that promote a positive body image of the people with ID, presented such as a future research need. That programmes should be included in school environments (special schools or mainstream schools) through the subject of physical education; or in ID associations, working together with adapted physical activity specialists and other therapists, such as psychologists or occupational therapists. Also, it is important to involve people with ID to co-create their own programs (^{Rice et al., 2021}).

Further research is needed to examine the levels of body-image concerns in people with ID and the cause of it, and to develop, test, and evaluate the effect of that interventions in the levels of body image showed by people with ID. Given the limited research on body image perception in people with ID, it would be valuable to develop and evaluate intervention programs specifically designed to improve body satisfaction in this population based on positive body image. By implementing and assessing the outcomes of such interventions, researchers can contribute to the development of evidence-based strategies that support the functionality of the body and well-being in people with ID.