Effects of Texas State Agency Integration on Mental Health Service Use Among Individuals with Co-occurring Cognitive Disabilities and Mental Health Conditions.

This study uses Texas's 2017 integration of the state disability and mental health agencies as a case study, combining interviews with Texas agency and advocacy organization leaders to examine perceptions of agency integration and augmented synthetic control analyses of 2014-2020 Medical Expenditure Panel Survey to examine impacts on mental health service use among individuals with co-occurring cognitive disabilities (including intellectual and developmental disabilities) and mental health conditions. Interviewees described the intensive process of agency integration and identified primarily positive (e.g., decreased administrative burden) impacts of integration. Quantitative analyses indicated no effects of integration on receipt of mental health-related services among people with co-occurring conditions. While leaders identified some potentially beneficial impacts of state agency integration, the limited impact of integration beyond the agency suggests that interventions at multiple levels of the service system, including those targeting providers, are needed to better meet the mental health service needs for this population.

Tobacco Use, Dependence, and Age of Initiation among Youths with Cognitive Disability.

OBJECTIVES: To examine the prevalence of tobacco use by product type among youths with cognitive disability; the prevalence of tobacco dependence among youths with cognitive disability; and the relationship between age of tobacco use initiation and cognitive disability. STUDY DESIGN: This cross-sectional study analyzed data from the 2019 National Youth Tobacco Survey (NYTS). Participants were a nationally representative sample of 19 018 students in grades 6-12. Estimates were calculated for ever use, current use, age of tobacco use initiation, and tobacco dependence. Associations between use patterns and cognitive disability status were examined using bivariate analyses and multivariable logistic regression. RESULTS: Compared with youths without cognitive disability, youths with cognitive disability had significantly greater odds of ever using any tobacco product (aOR, 1.49; 95% CI, 1.31-1.70), currently using any tobacco product (aOR, 1.41; 95% CI, 1.26-1.58), and currently using electronic cigarettes (e-cigarettes), cigarettes, cigars, hookahs, roll-your-own cigarettes, and heated tobacco products, specifically. They had higher prevalence and odds of reporting younger age of tobacco use initiation (aOR, 1.25; 95% CI, 1.10-1.43). Higher prevalence and odds of tobacco dependence were also observed among youths with cognitive disability compared with youths without cognitive disability (P < .001). CONCLUSIONS: These findings reinforce the importance of developing early primary prevention efforts to reduce or delay tobacco use among adolescents with cognitive disability. They also suggest the need to address co-occurring disorders during tobacco cessation programs with this high-risk group.

Undue burdens created by the Texas Abortion Law for vulnerable pregnant women.

The new Texas abortion law requires the physician to determine whether a fetal heartbeat is present and prohibits abortion after a heartbeat has been documented. An exception is allowed when a "medical emergency necessitated the abortion." These and other provisions of the statute are to be enforced through "civil actions" brought by private citizens. This article identifies 3 populations of vulnerable women who will experience undue burdens created by the Texas abortion law. We begin with an account of the concept of undue burden in the jurisprudence of abortion, as expressed in the 1992 US Supreme Court case, Planned Parenthood v. Casey of Southeastern Pennsylvania. We then provide an evidence-based account of the predictable, undue burdens for 3 populations of vulnerable women: pregnant women with decreased freedom of movement; pregnant minors; and pregnant women with major mental disorders and cognitive disabilities. The Texas law creates an undue burden on these 3 populations of vulnerable women by reducing or even eliminating access to abortion services outside of Texas. The Texas law also creates an undue burden by preventably increasing the risks of morbidity, including loss of fertility, and mortality for these 3 populations of vulnerable women. For these women, it is indisputable that the Texas law will create undue burdens and is therefore not compatible with the jurisprudence of abortion as set forth in Planned Parenthood v. Casey because a "significant number of women will likely be prevented from obtaining an abortion." Federal courts should therefore strike down this law.

Conflicts between parents and clinicians: Tracheotomy decisions and clinical bioethics consultation.

BACKGROUND: The parent of a child with profound cognitive disability will have complex decisions to consider throughout the life of their child. An especially complex decision is whether to place a tracheotomy to support the child's airway. The decision may involve the parent wanting a tracheotomy and the clinician advising against this intervention or the clinician recommending a tracheotomy while the parent is opposed to the intervention. This conflict over what is best for the child may lead to a bioethics consult. OBJECTIVE: The study explores the conflicts that may arise around tracheotomy placements. RESEARCH DESIGN: This study is a retrospective cohort study of pediatric patients for whom a tracheotomy decision required a bioethics consult. PARTICIPANTS AND RESEARCH CONTEXT: Pediatric patients aged birth to 18 years old with a bioethics consult for a tracheotomy decision conflict between April 2010 and December 2016. A standardized data collection tool was used to review notes entered by the palliative care team, social workers, primary clinical team interim summaries, and the bioethics consult service. ETHICAL CONSIDERATIONS: The study was reviewed and approved by the medical center's institutional review board. RESULTS: There were 248 clinical bioethics consults during the identified study period. There were 31 consults involving 21 children where the word tracheotomy was mentioned in the consult, and 13 of the 21 consults were for children with profound cognitive disability. DISCUSSION AND CONCLUSION: Clinicians need to be aware of their own biases when discussing a child's prognosis and treatment options while also understanding the parents' values and what the parent might consider to be burdensome in the care of their child and the acceptable burden for the child to experience.

Altered brain network function during attention-modulated visual processing in multiple sclerosis.

BACKGROUND: Multiple sclerosis may damage cognitive performance in several domains, including attention. Although attention network deficits were described during rest, studies that investigate their function during task performance are scarce. OBJECTIVE: To investigate connectivity within and between task-related networks in multiple sclerosis during a visual attention task as a function of cognitive performance. METHODS: A total of 23 relapsing-remitting multiple sclerosis (RRMS) patients and 29 healthy controls underwent task-functional magnetic resonance imaging (fMRI) scans using a visual attention paradigm on a 3T scanner. Scans were analysed using tensor-independent component analysis (TICA). Functional connectivity was calculated within and between components. We assessed cognitive function with the Brief International Cognitive Assessment for MS (BICAMS) battery. RESULTS: TICA extracted components related to visual processing, attention, executive function and the default-mode network. Subject scores of visual/attention-related and executive components were greater in healthy controls (p < 0.032, p < 0.023). Connectivity between visual/attention-related and default-mode components was higher in patients (p < 0.043), correlating with Brief Visuospatial Memory Test-Revised (BVMT-R) scores (R = -0.48, p < 0.036). Patients showed reduced connectivity between the right intraparietal sulcus (rIPS) and frontal eye field (rFEF), and bilateral frontal eye fields (p < 0.012, p < 0.003). Reduced rIPS-rFEF connectivity came with lower Symbol Digit Modalities Test (SDMT)/BVMT-R scores in patients (R = 0.53, p < 0.02, R = 0.46, p < 0.049). CONCLUSION: Attention-related networks show altered connectivity during task performance in RRMS patients, scaling with cognitive disability.

Single MRI-Based Volumetric Assessment in Clinical Practice Is Associated With MS-Related Disability.

BACKGROUND: The added value of brain volume measurements in the clinical practice of multiple sclerosis (MS) has been questioned. PURPOSE: To investigate the contribution of volume measures obtained with magnetic resonance scans performed as part of regular care to predict measures of cognitive and physical MS disability in a real-world setting. STUDY TYPE: Retrospective. SUBJECTS: In all, 470 adults with diagnosed MS. FIELD STRENGTH/SEQUENCE: 3D fluid attenuation inversion recovery (FLAIR) and 3D T1 -weighted MR images at 3.0T MR. ASSESSMENT: Lesion and brain volume were measured by an automated method, MSmetrix, developed by icometrix. STATISTICAL TESTS: We used stepwise linear regression models to assess the added value of a single volumetric assessment in predicting Expanded Disability Status Scale (EDSS) and Symbol Digit Modalities Test (SDMT). Brain volumes categorized into quartiles were used as predictive variables in a time-to-event analysis and Cox proportional hazard regression with time to worsening from baseline as outcome measures. RESULTS: Brain and lesion volume in relapsing onset MS strongly contributed to the best models, with a substantial role for age in the EDSS model and a modest role for education in the SDMT model. Adding MR volumetric information increased the explained variance from 17% to 28% in the best model for EDSS and from 9% to 25% in the best model for SDMT. A significantly reduced hazard (P < 0.05) of SDMT worsening was found in the highest normalized brain volume quartiles (1375-1608 ml), compared with the lowest quartile (1201-1374 ml) in the total study population. DATA CONCLUSION: Our findings indicate that a single brain volumetric assessment contributes to the prediction of MS-related disability, with distinct patterns for EDSS as a measure of physical disability, and SDMT as a measure of cognitive disability. A threshold effect for the lowest brain volumes with regard to SDMT worsening over time was found. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1312-1321.

Severity of cognitive disability and mental health court determinations about fitness to stand trial.

BACKGROUND: Little is known about the socio-demographic, clinical and legal determinants of mental health court decisions of unsoundness of mind and unfitness to stand trial for people with cognitive disability. We aimed to estimate the association between severity of cognitive disability and mental health court determinations of unsoundness or unfitness and describe the socio-demographic, clinical and legal factors that predict these determinations. METHODS: Case file data were extracted on 92 individuals who had a criminal case referred to the Queensland Mental Health Court between 1 January 2013 and 31 December 2014 due to cognitive disability. We fit a modified multivariable Poisson regression model to estimate the association between severity of cognitive impairment and mental health court determination, controlling for socio-demographic, clinical and legal factors. RESULTS: Adjusting for covariate effects, severity of cognitive impairment was positively associated with being found unfit to stand trial (adjusted prevalence risk ratio = 1.57; 95% confidence interval: 1.07, 2.33; P = 0.023), and comorbid psychotic disorder predicted an increased risk of being found unsound of mind at the time of offence (adjusted prevalence risk ratio = 3.63; 95% confidence interval: 1.38, 9.54; P = 0.009) by the Queensland Mental Health Court. CONCLUSIONS: Severity of cognitive disability is associated with determinations of unfitness but does not predict determinations of unsoundness in the Queensland Mental Health Court. Psychiatric assessments of cognitive impairment play a pivotal role in mental health court determinations for people with cognitive disability.

Unpacking the complexity of planning with persons with cognitive disability and complex support needs.

BACKGROUND: Planners will engage with people with cognitive disability and complex support needs in the Australian National Disability Insurance Scheme, but the specific skills needed to build sustainable plans with this group are not yet known. METHOD: A qualitative study was conducted to explore the barriers and facilitators to planning with people with cognitive disability and complex support needs. Focus groups were held with 99 planning practitioners across metropolitan and regional locations in New South Wales, Australia. RESULTS: Thematic analysis showed planners need to build a partnership based on mutual trust and respect with a person with complex support needs and harness a range of skills to respond to individual support needs, learning capacity, systemic hurdles and life challenges. CONCLUSIONS: Planner skills can be used to address barriers to planning for people with cognitive disability and complex support needs. Gaining skills took professional support and personal commitment.

Parents with Intellectual Disabilities Experiencing Challenging Child Routines: A Pilot Study Using Embedded Self-Determination Practices.

BACKGROUND: Practices to facilitate self-determination have not received appropriate attention in research concerning parents with intellectual disabilities (ID). Likewise, parenting interventions for adults with intellectual disabilities have seldom observed both parent and child behavioural outcomes. METHODS: This study evaluated the effectiveness of a parenting intervention embedded with self-determination facilitation practices for two dyads of a parent with intellectual disabilities and their young child. The interventions focused on increasing parents' ability to correctly implement steps of a parenting routine while reducing occurrence of challenging child behaviour. RESULTS: The results of the study demonstrated two basic effects of correctly completed steps of the parenting routine and a reduction of challenging child behaviour. Parents also reported decreased feelings of stress during the routine following completion of the intervention. CONCLUSIONS: Implications for future research and replication of this pilot study are discussed.

Discoursive Humanity as a Transcendental Basis for Cognitive (Dis)Ability Ethics and Policies.

This article explicates two approaches to the basis of moral worth and status: Eva Kittay's relational view and Jeff McMahan's psychological personhood view. It is argued that these theories alone do not provide adequate support for the conclusions Kittay and McMahan want to draw concerning individuals whose entitlement to fundamental protections can be challenged-infants with severe cognitive disabilities and infants without the support of their families and social environments. The real justification can in each case be found in deeply held convictions regarding entities that must and entities that must not be included in the core community of moral equals. Philosophical discussions about these convictions would be more useful for the advancement of our moral thinking than vain attempts to show that the absolute truth lies on either side of the ongoing debate.

Optic neuropathy, cardiomyopathy, cognitive disability in patients with a homozygous mutation in the nuclear MTO1 and a mitochondrial MT-TF variant.

We report on clinical, genetic and metabolic investigations in a family with optic neuropathy, non-progressive cardiomyopathy and cognitive disability. Ophthalmic investigations (slit lamp examination, funduscopy, OCT scan of the optic nerve, ERG and VEP) disclosed mild or no decreased visual acuity, but pale optic disc, loss of temporal optic fibers and decreased VEPs. Mitochondrial DNA and exome sequencing revealed a novel homozygous mutation in the nuclear MTO1 gene and the homoplasmic m.593T>G mutation in the mitochondrial MT-TF gene. Muscle biopsy analyses revealed decreased oxygraphic Vmax values for complexes I+III+IV, and severely decreased activities of the respiratory chain complexes (RCC) I, III and IV, while muscle histopathology was normal. Fibroblast analysis revealed decreased complex I and IV activity and assembly, while cybrid analysis revealed a partial complex I deficiency with normal assembly of the RCC. Thus, in patients with a moderate clinical presentation due to MTO1 mutations, the presence of an optic atrophy should be considered. The association with the mitochondrial mutation m.593T>G could act synergistically to worsen the complex I deficiency and modulate the MTO1-related disease.

Experiences of health care services among people with cognitive disabilities and mental health conditions.

BACKGROUND: People with cognitive disabilities such as intellectual and developmental disabilities face significant barriers to accessing high-quality health care services. Barriers may be exacerbated for those with co-occurring mental health conditions. OBJECTIVE: This study compares patient experiences of health care services between adults with and without cognitive disabilities and, among people with a cognitive disability, those with and without co-occurring mental health conditions. METHODS: Cross-sectional analyses were conducted using 2021 Medical Expenditure Panel Survey data, a national U.S. survey, to examine differences in Consumer Assessment of Healthcare Providers and Systems measures. RESULTS: Adults with cognitive disabilities reported lower satisfaction with health care services compared to the general population (7.62 (95% confidence interval (CI): 7.41-7.83) vs. 8.33 (95% CI: 8.29-8.38) on scale from 0 to 10). Adults with cognitive disabilities were less likely to report that providers listened carefully to them (odds ratio (OR): 0.55, 95% CI: 0.42-0.71), explained things in a way that was easy to understand (OR: 0.48, 95% CI: 0.35-0.66), showed respect for what they had to say (OR: 0.38, 95% CI: 0.29-0.51), spent enough time with them (OR: 0.52, 95% CI: 0.40-0.69), or gave advice that was easy to understand (OR: 0.40, 95% CI: 0.28-0.58) compared to the general population. Among adults with cognitive disabilities, there were no differences based on co-occurring mental health conditions. CONCLUSIONS: Adults with cognitive disabilities report lower satisfaction with health care services driven by worse experiences with the health care system. Policies to increase provider capacity to support this population should be prioritized.

Investigating Acoustic and Psycholinguistic Predictors of Cognitive Impairment in Older Adults: Modeling Study.

BACKGROUND: About one-third of older adults aged 65 years and older often have mild cognitive impairment or dementia. Acoustic and psycho-linguistic features derived from conversation may be of great diagnostic value because speech involves verbal memory and cognitive and neuromuscular processes. The relative decline in these processes, however, may not be linear and remains understudied. OBJECTIVE: This study aims to establish associations between cognitive abilities and various attributes of speech and natural language production. To date, the majority of research has been cross-sectional, relying mostly on data from structured interactions and restricted to textual versus acoustic analyses. METHODS: In a sample of 71 older (mean age 83.3, SD 7.0 years) community-dwelling adults who completed qualitative interviews and cognitive testing, we investigated the performance of both acoustic and psycholinguistic features associated with cognitive deficits contemporaneously and at a 1-2 years follow up (mean follow-up time 512.3, SD 84.5 days). RESULTS: Combined acoustic and psycholinguistic features achieved high performance (F1-scores 0.73-0.86) and sensitivity (up to 0.90) in estimating cognitive deficits across multiple domains. Performance remained high when acoustic and psycholinguistic features were used to predict follow-up cognitive performance. The psycholinguistic features that were most successful at classifying high cognitive impairment reflected vocabulary richness, the quantity of speech produced, and the fragmentation of speech, whereas the analogous top-ranked acoustic features reflected breathing and nonverbal vocalizations such as giggles or laughter. CONCLUSIONS: These results suggest that both acoustic and psycholinguistic features extracted from qualitative interviews may be reliable markers of cognitive deficits in late life.

Therapeutic approach to epileptic encephalopathies.

Epileptic encephalopathies (EEs) are electroclinical entities with a peculiar course of disease; seizures and electroencephalographic (EEG) epileptiform abnormalities, ictal and interictal, contribute to progressive disturbance of cerebral functions. Frequently EEs are drug resistant, and consequences may be catastrophic. The main goal of treatment is to stop the peculiar course of epilepsy, operating on three parameters: seizure control, reduction of EEG abnormalities, and developmental outcome. For a correct therapeutic approach it is mandatory to have an as accurate as possible syndromic and etiologic diagnosis. Given the poor efficacy of conventional antiepileptic drugs (AEDs), the use of specific drugs for EEs, such as adrenocorticotropic hormone (ACTH) and corticosteroids or stiripentol is suggested. In some cases the choice of treatment is strictly related to the etiology: vigabatrin in tuberous sclerosis, ketogenic diet in glucose transporter type 1 (GLUT-1) deficiency, and pyridoxine in pyridoxine deficiency. Some AEDs combinations, such as sodium valproate with lamotrigine, have also provided interesting results, for example, in Lennox-Gastaut syndrome, although controlled studies are lacking. Finally, early surgery can be an option in children with focal structural abnormalities responsible for EEs preferably before irreversible damage on developmental outcome. Multispecialist support is recommended in EE. Management should be global from the onset, integrating not only seizure control but also all issues related to comorbidities, particularly neuropsychological and psychiatric.

What Do 'Humans' Need? Sufficiency and Pluralism.

Sufficientarians face a problem of arbitrariness: why place a sufficiency threshold at any particular point? One response is to seek universal goods to justify a threshold. However, this faces difficulties (despite sincere efforts) by either being too low, or failing to accommodate individuals with significant cognitive disabilities. Some sufficientarians have appealed to individuals' subjective evaluations of their lives. I build on this idea, considering another individualized threshold: 'tolerability'. I respond to some traditional challenges to individualistic approaches to justice: 'expensive' tastes, and adaptive preferences. Finally, I end by offering some suggestions about how this relates to policymaking.

Cognitive Disability Among Arab Americans by Nativity Status and Arrival Year: Lack of Evidence for the Healthy Migrant Effect.

Limited research exists on cognitive disabilities among Arab Americans, especially as it relates to arrival year among the foreign-born. The objectives of this study were to estimate the age- and sex-adjusted prevalence and associations of cognitive disability by (1) nativity status and (2) arrival year (pre-1991, 1991-2000, 2001-2013, and 2014-2018). We analyzed 11 years (2008-2018) of data from the American Community Survey (ACS) Public Use Microdata Samples (weighted n = 264,086; ages ≥ 45 years). Weighted means, percentages, age- and sex-adjusted prevalence estimates, and logistic regression results (crude and adjusted) were calculated. Among all Arab Americans, the age- and sex-adjusted prevalence of cognitive disability was 6.5%. The prevalence was lower for US-born (4.0%) compared to foreign-born (6.0%) (p-value < 0.0001). In logistic regression results, foreign-born Arab Americans were more likely to have a cognitive disability compared to US-born Arab Americans after adjusting for age and sex (OR = 1.41; 95% CI = 1.24, 1.61). Among foreign-born, Arab Americans arriving in 2014 or later had a lower prevalence of cognitive disability (3.4%) compared to all other arrival years at approximately 4.7%. With those arriving prior to 1991 as the reference category, those arriving between 1991 and 2000 were more likely to report a cognitive disability (OR = 1.05; 95% CI = 1.00, 1.08). However, those arriving between 2014 and 2018 were less likely to report a cognitive disability (OR = 0.81; 95% CI = 0.73, 0.88). These findings challenge the universality of the "healthy migrant effect" and highlight the relevance of socioeconomic disparities for Arab American cognitive health.

The State of Web Accessibility for People with Cognitive Disabilities: A Rapid Evidence Assessment.

Increased digitisation of day-to-day activities was occurring prior to the COVID-19 pandemic. The pandemic only accelerated the virtual shift, making web accessibility an urgent issue, especially for marginalised populations. Despite decades of work to develop, refine, and implement web accessibility standards, people with cognitive disabilities regularly experience many barriers to web accessibility. To inform ongoing work to improve web accessibility for people with cognitive disabilities, a systematic review was conducted. The main question guiding this review is: what are the state-of-the-art of interventions that support web accessibility for citizens, 9 years of age and up, living with cognitive impairment? A set of 50 search strings were entered into three academic databases: SCOPUS, ProQuest, and Web of Science. Systematic screening procedures narrowed the search returns to a total of 45 included papers. A data analysis revealed themes associated with the lived experiences of people with cognitive disabilities, tools for improving web accessibility, and methodological best practices for involving people with cognitive disabilities in research. These findings have immediate implications for ongoing research and the development of meaningful solutions to the problem of web accessibility for people with cognitive disabilities.

Tetrahydroxy stilbene glucoside alters neurogenesis and neuroinflammation to ameliorate radiation-associated cognitive disability via AMPK/Tet2.

Along with the extensive application of radiation in medical, military and other fields, human beings carry a greater risk of exposure to radiation environment that causes a range of physical injure, particularly to the brain in cognition. However, the radiation-associated cognitive disability is poorly understood and there is no effective prevention or long-term treatment. Here, we demonstrate that neurogenesis and neuroinflammation disorder are primarily involved in the pathophysiological basis of irradiation-induced cognitive decline. Furthermore, we discovered that tetrahydroxy stilbene glucoside (TSG), a natural active ingredient from Heshouwu that has been well known for its unique anti-aging effect as the Chinese herb, can be a promising mitigator to improve learning-memory ability by facilitating the neurogenesis in the proliferation and differentiation of the surviving neural progenitor cells via AMPK/Tet2, and attenuating the neuroinflammation in the microglial NLRP3 inflammasomes activation via AMPK in vivo. Additionally, TSG was also revealed to activate AMPK by molecular docking and kinase enzyme system assay in vitro. Taken together, our findings identify TSG, as the AMPK activator, prevents radiation-induced cognitive dysfunction by regulating neurogenesis and neuroinflammation via AMPK/Tet2 in rodents, and represents a very promising candidate for developing drugs that can be used for radiation-associated brain injury.

A survey of research trends in assistive technologies using information modelling techniques.

BACKGROUND: Despite the rapid proliferation and emphasis on technology, the use of assistive technology among individuals with varying disabilities and age is different. This situation instigates the need for a systematic review to gain a realistic understanding of prominent issues, research trends and assistive technology applications with minimal bias. OBJECTIVE: Identification of leading researchers and prominent publications in assistive technologies. Subsequently, semantic relation between qualitative and quantitative research literature on assistive technologies was explored to future research directions. METHODS: A manual search across reputed research databases was done to find out relevant literature from January 2005 to April 2020. In this paper, latent semantic analysis (LSA) was done to develop an information model for achieving defined objectives. RESULTS: A corpus of 367 research papers published during 2005-2020 was processed using LSA. Term frequency, inverse document frequency of high loading terms provided five major topic solutions. Marcia Scherer, Rory Cooper and Stefano Federici are most noticed authors in assistive technology research. "Smart Assistive Technologies" and "Wearable Technologies for Rehabilitation" came out as contemporary research trends within assistive technologies. CONCLUSIONS: The manuscript concludes the fact that assistive technologies for rehabilitation are experiencing a transition from standalone mechanical devices towards smart, wearable and connected devices.Implications for RehabilitationCustomized assistive devices could be programmed for multiple uses.User data privacy and internet dependency of smart assistive technologies must be taken care of while designing smart assistive devices for rehabilitation.Fog devices could eliminate the latency issues associated with cloud-based rehabilitation services.

The impact of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) on Victorian guardianship practice.

PURPOSE: Article 12 of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) emphasises full and equal legal capacity of all citizens to participate in decisions. This paper examines whether the principles of Article 12, also reflected in other reform documents, were evident within 12 guardianship hearings conducted in Victoria, Australia from 2001 to 2016 involving adults with cognitive disability. The issues this study raises resonate loudly across the globe as multiple signatory nations to the CRPD grapple with the complexities of implementing Article 12. METHODS: Reports of VCAT decisions with written reasons of Guardianship List hearings from 2001 to 2016 were selected from the Australasian Legal Information Institute site and analysed thematically. RESULTS: Thematic analysis of proceedings revealed three consistent trends. Firstly, a presumption of incapacity based on disability excluded Proposed Represented Persons (PRP) from involvement in decision-making. Secondly, external perceptions of PRPs best interest were dominated by safeguarding concerns and conflict between supporters. Finally, in multiple cases, although a PRP's preference had been established, it was considered immaterial to the final decision. CONCLUSIONS: The paper concludes with a promising discussion of the new Guardianship and Administration Act 2019 (Vic), which came into force on 1 March 2020, and recommendations for guardianship practice both locally and internationally.IMPLICATIONS FOR REHABILITATIONLegal capacity should be recognised as inherent in all people, and therefore decision making incapacity should not be assumed based on a person's cognitive and/or communication disability;The supported decision making mechanisms, born from Article 12 of the CRPD, that facilitate acknowledgment, interpretation and acting upon a person's expression of will and preference need to be recognised and promoted within the context of Guardianship proceedings and by health professionals when assessing decision making capacity of people with cognitive disability;Significant knowledge and attitudinal changes are required within the Tribunal and incorporated into the practice of health professionals informing the Tribunal, in order to counter many conceptual underpinnings embedded within current guardianship legislation across the globe;Ascertaining the will and preference of the proposed represented person should be prioritised by Guardianship tribunal members' rather than the management of conflict between interested parties.