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Evidence-based Practices for IDD

Psychotherapy can be effective for persons with I/DD, but requires adaptation and flexibility from the therapist. Here are some general guidelines follow:
  1. Language: Assess the person’s expressive and receptive language skills and adapt your language to their ability.
  2. Frequency: Sessions may need to occur more frequently at the beginning of therapy (2 times/week for a brief period, then weekly) because it takes more time to develop relationships compared to a neuro-typical person. Meeting new people may be particularly stressful.
  3. Shorter sessions: With attention span challenges, a 30 minute session may provide maximum benefit.
  4. Duration of therapy: Treatment length may need to increase to allow for sufficient repetition, generalizing skills outside session and for a more graduated termination process.
  5. Structure / Directive Approach: Useful to maintain focus, increase meaningful interaction. Silence can be perceived as rejection.
  6. Communicate with collaterals: With permission (and signed releases) act as part of the care planning team (psychiatrist, parents, residential staff, etc) to gather and share information and provide holistic treatment,
  7. Modify interventions for the person’s developmental abilities: discuss one issue at time, attending to beginning, middle and end of material. Break interventions into smaller pieces to ensure understanding. Ask client to reflect back material to ensure understanding. Repetition is important.
  8. Support: Give recognition to even small improvements. Provide hope and lots of support.
  9. Flexible: Lack of progress means you need to try a different approach. Don’t assume resistance, assume you need to try an alternative.

There are five Evidence-based Practices that are easily incorporated into therapy settings and can increase the effectiveness of treatment for mental health problems in individuals with I/DD. These techniques help bridge the gap when teaching complex concepts in mental health settings.  These are:

  • Functional Behavior Assessment
  • Social Skills Training
  • Parent-Implemented Interventions
  • Visual Supports
  • Technology/Video Modeling 

People don’t usually have much insight into why they behave the way they do, especially individuals with cognitive limitations or concrete learning styles. You can’t figure out how to change a behavior until you know what purpose the behavior serves. A Functional Behavior Assessment (FBA) helps determine the function of a problematic behavior, so that the therapist can develop strategies to address it. It is usually done through direct observation of the patient and parent, and through parent interviewing. There are four steps in FBAs:

  1. Define the behavior
  2. Identify specific examples of times the behavior happened
    Determine what happened immediately prior to the behavior (antecedent)
    Determine what happened immediately after the behavior (consequence)
  3. Analyze data and form hypotheses:
    Does the child lack the skill to do the behavior?
    Does the behavior lead to attention?
    Does the behavior lead to escaping a task or situation?
  4. Use the hypothesis to develop a strategy
    Can we teach the skill?
    Is there another more positive behavior that will serve the same function?

For many patients, impairments in communication play a role in their mental health problems or keep them from getting the support they need from others. These are often deficits in making eye contact, having back-and-forth conversations, making friends, or negotiating. In Social Skills Training, the clinician and parent identify deficits in the person’s social skills and help improve their communication with others through training and practice.  An example would be a patient who tends to have one-sided conversations, ignoring the comments of the other person.  The clinician can teach the steps for having a back-and-forth conversation (like turn-taking in a game), practice having two-way conversations (talk, listen, respond) in the session, and giving them immediate feedback on each step in their performance. This can be done individually or in groups.

Because parents are often their child’s most important teacher, know their own child better than others do, and spend more time with the child than other adults, parents make ideal teachers.  Therapists teach the concepts to parents, having them practice the technique in sessions with the child.  This allows them to learn how they can naturally reinforce the interventions at home and increases the repetition of the intervention. It helps the child generalize the skills they are learning to settings outside the therapy room.

Visual Supports (pictures, illustrations, objects, written words) can be used to explain a concept, aid memory, or support a person’s ability to communicate ideas. These supports are almost always used with clients who have I/DD.  Some common examples are  using pictures depicting emotion faces to help identify feelings,  giving homework to-do lists,  having physical boundary markers,  posting images of calming techniques like blowing out a candle (deep breathing) or using objects in the room creatively (throwing away negative thoughts into the trash can).  These aids are also helpful with clients who use spoken language when concepts are complex, or to when you want to prompt memory.

Using technology can increase a client’s engagement in treatment sessions and motivate attendance.  Many people with neurodevelopmental differences gravitate toward technology and have expertise with these tools. Technology and videos can model behaviors for the client or help explain difficult concepts (for instance, how to complete a desired behavior). Video can be particularly helpful when goals include building social skills like group discussion, or particular behaviors, like brushing teeth.

They can be used to reinforce concepts or remind a child with difficulties in organization, such as phone apps to track tasks, or help with calming or distracting activities.

These technologies are also used as rewards: allowing the child to intermittently play a video or a song when they have engaged in part of their session.

This webinar covers the three certification levels for the National Association for the Dually Diagnosed (NADD). The three certification levels are Direct Support Professional (DSP), Clinical, and Specialist. The DSP certification is for the direct care staff who support the dually diagnosed population. DSPs are often the ones charged with supporting skill-building. They help the person engage in recommended therapies on a day-to-day basis. The Clinical certification is defined as an individual who provides clinical supports or services for persons with intellectual/developmental disabilities and mental health needs. Finally, the Specialist certification is defined as an individual who delivers, manages, trains, and/or supervises services for persons with intellectual/developmental disabilities and mental health needs.

NADD is an organization dedicated to providing education to the community on the unique challenges of those who are dually diagnosed, address the absence of research on the population, and to increase access to effective services for those who have mental health and intellectual/developmental needs.

Any therapist who plans to conduct therapy to address mental health challenges for clients with neurodevelopmental differences should have an understanding of the basic evidence-based practices for I/DD.  Attempting to teach complex therapeutic concepts to individuals with different learning styles will be difficult, time-consuming, and often frustrating.  Integrating techniques discussed here into mental health settings can help to bridge the gap.