Intellectual

Disability
 Intellectual Disability

By

Aiman Javed

Supervisor: Madam Nilofur Afaq

 Content Page No.

Chapter 1
Introduction to Intellectual Disability

Chapter 2
Assessment of Intellectual Disability

Chapter 3
Etiology of Intellectual Disability

Chapter 4
Management of Intellectual Disability

References

Appendices
Pakistan’s Statistics on Disabilities
Myths and Facts
Tips for Parents
Tips for Teachers
Activities for Children
C hapter 1 INTRODUCTION TO INTELLECTUAL DISABILITY
 Chapter 1

Introduction

Neurodevelopmental disorders are a group of conditions with onset in the developmental period.
The disorders typically manifest early in development, often before the child enters grade school,
and are characterized by developmental deficits that produce impairments of personal, social,
academic, or occupational functioning.

Neurodevelopmental
Disorders

Autism Attention Deficit/ Specific Tic

Intellectual Communication Hyperactivity Motor
Spectrum Learning
Disabilities Disorders Disorder Disoders Disorders
Disorder Disorder

Intellectual Disability

Global Developmental
Delay

Unspecified Intellectual
Disability

Intellectual disability (intellectual developmental disorder) is characterized by deficits in general

mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment,
academic learning, and learning from experience. The deficits result in impairments of adaptive
functioning, such that the individual fails to meet standards of personal independence and social
responsibility in one or more aspects of daily life, including communication, social participation,
academic or occupational functioning, and personal independence at home or in community
settings. Global developmental delay, as its name implies, is diagnosed when an individual fails
to meet expected developmental milestones in several areas of intellectual functioning. The
diagnosis is used for individuals who are unable to undergo systematic assessments of
intellectual functioning, including children who are too young to participate in standardized
testing. Intellectual disability may result from an acquired insult during the developmental period
from, for example, a severe head injury, in which case a neurocognitive disorder also may be
diagnosed.

DSM V Criteria for Intellectual Disability

Intellectual disability (intellectual developmental disorder) is a disorder with onset during the
developmental period that includes both intellectual and adaptive functioning deficits in
conceptual, social, and practical domains. The following three criteria must be met:

A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract

thinking, judgment, academic learning, and learning from experience, confirmed by both clinical
assessment and individualized, standardized intelligence testing.

(These mental abilities are measured by IQ tests. A score of approximately two standard
deviations below average represents a significant cognitive deficit. These scores would occur
about 2.5% of the population. Or stated differently, 97.5% of people of the same age and culture
would score higher. The tests used to measure IQ must be standardized and culturally
appropriate. This is typically an IQ score of 70 or below)

B. Deficits in adaptive functioning that result in failure to meet developmental and socio-cultural
standards for personal independence and social responsibility. Without ongoing support, the
adaptive deficits limit functioning in one or more activities of daily life, such as communication,
social participation, and independent living, across multiple environments, such as home, school,
work, and community.

(Deficits in adaptive functioning are measured using standardized, culturally appropriate tests)

Various skills are needed for daily living are defined as follows:
Communication: This refers to the ability to convey information from one person to another.
Communication is conveyed through words and actions. It involves the ability to understand
others, and to express one's self through words or actions.

Social skills: This refers to the ability to interact effectively with others. We usually take social
skills for granted. However, these skills are critical for success in life. These skills include the
ability to understand and comply with social rules, customs, and standards of public behavior.
This intricate function requires the ability to process figurative language and detect unspoken
cues such as body language.

Personal independence at home or in community settings: This refers to the ability to take
care of yourself. Some examples are bathing, dressing, and feeding. It also includes the ability to
safely complete day-to-day tasks without guidance. Some examples are cooking, cleaning, and
laundry. There are also routine activities performed in the community. This includes shopping
for groceries, and accessing public transportation.

School or work functioning: This refers to the ability to conform to the social standards at work
or school. It includes the ability to learn new knowledge, skills, and abilities. Furthermore,
people must apply this information in a practical, adaptive manner; without excessive direction
or guidance.)

C. Onset of intellectual and adaptive deficits during the developmental period.

(These limitations occur during the developmental period. This means problems with intellectual
or adaptive functioning were evident during childhood or adolescence. If these problems began
after this developmental period, the correct diagnosis would be neuro-cognitive disorder. For
instance, a traumatic brain injury from a car accident could cause similar symptoms.)

Specifiers

According to American Psychiatric Association (APA)

The various levels of severity are defined on the basis of adaptive functioning, and not IQ scores,
because it is adaptive functioning that determines the level of supports required. Moreover, IQ
measures are less valid in the lower end of the IQ range.
The DSM-5 (APA, 2013) severity codes indicate the diagnosing clinician's impression of the
severity of adaptive functioning. Severity is assessed across three domains. These are conceptual,
social, and practical life skill.

Mild Intellectual Disability includes about 85 percent of people with intellectual disabilities.
Many individuals within this group can achieve some academic success. They usually meet
elementary academic levels or beyond with sufficient supports. People with this degree of
severity are mostly self-sufficient with sufficient supports. In many cases, they can live
independently within their communities with a minimal level of additional supports. These
supports might include assistance with life decisions. Additional time, instructions, and
reminders may be needed for other life skills such as finances, nutrition, shopping, and
transportation.

Moderate Intellectual Disability includes around 10 percent of the individuals with intellectual
disabilities. People in this range have adequate communication skills but complexity is more
limited. Social cues, social judgment, and social decisions (particularly romantic decisions)
regularly need support. Most self-care activities can be performed but may require extended
instruction and support. Independent employment can be achieved in positions that require
limited conceptual or social skills. However, additional supports may be required. Likewise,
independent living may be achieved with moderate supports such as those available in group
homes.

Severe Intellectual Disability describes 3 to 4 percent of this population. Communication skills

are very basic. Self-care activities require daily assistance. Many individuals in this category will
require safety supervision and supportive assistance. Residence in supported housing is usually
necessary.

Profound Intellectual Disability describes a very small portion of the persons with intellectual
disabilities. Only 1 to 2 percent falls into this category. This person is dependent upon others for
all aspects of daily care. Usually 24-hour care and support are needed. Communication skills are
quite limited. People with profound intellectual disability usually have co-occurring sensory or
physical limitations.
According to American Association on Intellectual and Developmental Disabilities
(AAIDD)

Like the DSM-5 (APA, 2013) the AAIDD has a categorical system for classifying intellectual
disabilities. However, instead of classifying by the severity of functional limitations, the AAIDD
assesses severity based on the intensity of supports that are needed. These needs are typically
identified using a standardized support need instrument such as the Supports Intensity Scale
(AAIDD, 2004). The AAIDD system evaluates a person's strengths and abilities, not just their
limitations. It categorizes each person's level of functioning based on the level of support that
person needs to function reasonably well in his or her preferred environment:

Intermittent Support: Many people with intellectual disabilities do not require regular support
or assistance. Instead, they may only require additional supports during times of transition,
uncertainty, or stress. Usually people requiring this level of support would be categorized under
the APA standards as mild intellectual disability.

Limited Support: Some people with intellectual disabilities can learn to improve their adaptive
behavior. With additional training, they can increase their conceptual skills, social skills, and
practical skills. However, they may still require additional support to navigate everyday
situations. People in this group would often be categorized by APA standards as moderate
intellectual disability.

Extensive Support: Other people with intellectual disability require support that is more
intensive. These individuals have some basic communication skills and can complete some self-
care tasks. However, they will usually require daily support. This level of support is usually
associated with severe intellectual disability by APA criteria.

Pervasive Support: Pervasive support describes the most intense level of support. Daily
interventions are necessary to help the individual function. Supervision is necessary to ensure
their health and safety. This lifelong support applies to nearly every aspect of the individual's
routine. This classification is associated with those who have profound intellectual disability.
 Differential Diagnosis

The diagnosis of intellectual disability should be made whenever Criteria A, B, and C are met. A
diagnosis of intellectual disability should not be assumed because of a particular genetic or
medical condition. A genetic syndrome linked to intellectual disability should be noted as a
concurrent diagnosis with the intellectual disability.

Major and Mild Neurocognitive Disorders: Intellectual disability is categorized as a

neurodevelopmental disorder and is distinct from the neurocognitive disorders, which are
characterized by a loss of cognitive functioning. Major neuro-cognitive disorder may co-occur
with intellectual disability (e.g., an individual with Down syndrome who develops Alzheimer's
disease, or an individual with intellectual disability who loses further cognitive capacity
following a head injury). In such cases, the diagnoses of intellectual disability and
neurocognitive disorder may both be given.

Communication Disorders and Specific Learning Disorder: These neurodevelopmental

disorders are specific to the communication and learning domains and do not show deficits in
intellectual and adaptive behavior. They may co-occur with intellectual disability. Both
diagnoses are made if full criteria are met for intellectual disability and a communication
disorder or specific learning disorder.

Autism Spectrum Disorder: Intellectual disability is common among individuals with autism
spectrum disorder. Assessment of intellectual ability may be complicated by social-
communication and behavior deficits inherent to autism spectrum disorder, which may interfere
with understanding and complying with test procedures. Appropriate assessment of intellectual
functioning in autism spectrum disorder is essential, with reassessment across the developmental
period, because IQ scores in autism spectrum disorder may be unstable, particularly in early
childhood.

Comorbidity

Co-occurring mental, neurodevelopmental, medical, and physical conditions are frequent in

intellectual disability, with rates of some conditions (e.g., mental disorders, cerebral palsy, and
epilepsy) three to four times higher than in the general population. The prognosis and outcome of
co-occurring diagnoses may be influenced by the presence of intellectual disability. The most
common co-occurring mental and neurodevelopmental disorders are attention-
deficit/hyperactivity disorder; depressive and bipolar disorders; anxiety disorders; autism
spectrum disorder; stereotypic movement disorder (with or without self-injurious behavior);
impulse-control disorders; and major neurocognitive disorder. Major depressive disorder may
occur throughout the range of severity of intellectual disability. Self injurious behavior requires
prompt diagnostic attention and may warrant a separate diagnosis of stereotypic movement
disorder. Individuals with intellectual disability, particularly those with more severe intellectual
disability, may also exhibit aggression and disruptive behaviors, including harm of others or
property destruction.

Historical Background

Intellectual disabilities of all kinds have been documented under a variety of names in the
history. Throughout much of human history, society was unkind to those with any type of
disability, and people with intellectual disabilities were commonly viewed as burdens on their
families.

Greek and Roman philosophers, who valued reasoning

abilities, disparaged people with intellectual disabilities as
barely human. The oldest physiological view of intellectual
disability is in the writings of Hippocrates in the late fifth
century BC, who believed that it was caused by an imbalance
in the four humors in the brain.

Until the Enlightenment in Europe, care and asylum was

provided by families and the church (in monasteries and other
religious communities), focusing on the provision of basic physical needs such as food, shelter
and clothing. Negative stereotypes were prominent in social attitudes of the time.

In the 13th century, England declared people with intellectual disabilities to be incapable of
making decisions or managing their affairs. Guardianships were created to take over their
financial affairs.
In the 17th century, Thomas Willis provided the first description of intellectual disabilities as
a disease. He believed that it was caused by structural problems in the brain. According to Willis,
the anatomical problems could be either an inborn condition or acquired later in life.

In the 18th and 19th centuries, housing and care moved away from families and towards
an asylum model. People were placed by, or
removed from, their families (usually in
infancy) and housed in large professional
institutions, many of which were self-sufficient
through the labor of the residents. Some of
these institutions provided a very basic level of
education (such as differentiation between
colors and basic word recognition and
numeracy), but most continued to focus solely
on the provision of basic needs of food, clothing, and shelter. Conditions in such institutions
varied widely, but the support provided was generally non-individualized, with aberrant behavior
and low levels of economic productivity regarded as a burden to society. Individuals of higher
wealth were often able to afford higher degrees of care such as home care or private asylums.
Heavy tranquilization and assembly line methods of support were the norm, and the medical
model of disability prevailed. Services were provided based on the relative ease to the provider,
not based on the needs of the individual. A survey taken in 1891 in Cape Town, South Africa
shows the distribution between different facilities. Out of 2046 persons surveyed, 1,281 were in
private dwellings, 120 in jails, and 645 in asylums,
with men representing nearly two thirds of the
number surveyed. In situations of scarcity of
accommodation, preference was given to white men
and black men (whose insanity threatened white
society by disrupting employment relations and the
tabooed sexual contact with white women).

In the late 19th century, in response to Charles Darwin's On the Origin of Species, Francis
Galton proposed selective breeding of humans to reduce intellectual disabilities. Early in the 20th
century the eugenics movement became popular throughout the world. This led to forced
sterilization and prohibition of marriage in most of the developed world and was later used
by Hitler as rationale for the mass murder of intellectually challenged individuals during
the holocaust. Eugenics was later abandoned as an evil violation of human rights, and the
practice of forced sterilization and prohibition from marriage was discontinued by most of the
developed world by the mid-20th century.

In 1905, Alfred Binet produced the first standardized test for measuring intelligence in children.

Although ancient Roman law had declared people with intellectual disability to be incapable of
the deliberate intent to harm that was necessary for a person to commit a crime, during the
1920s, Western society believed they were morally degenerate.

Ignoring the prevailing attitude, Civitans adopted service to the developmentally disabled as a
major organizational emphasis in 1952. Their earliest efforts included workshops for special
education teachers and day camps for disabled children, all at a time when such training and
programs were almost nonexistent. The segregation
of people with developmental disabilities wasn't
widely questioned by academics or policy-makers
until the 1969 publication of Wolf Wolfensberger's
seminal work "The Origin and Nature of Our
Institutional Models". This book posited that society
characterizes people with disabilities as deviant,
sub-human and burdens of charity, resulting in the
adoption of that "deviant" role. Wolfensberger
argued that this dehumanization, and the segregated institutions that result from it, ignored the
potential productive contributions that all people can make to society. He pushed for a shift in
policy and practice that recognized the human needs of those with intellectual disability and
provided the same basic human rights as for the rest of the population.

The publication of this book may be regarded as the first move towards the widespread adoption
of the social model of disability in regard to these types of disabilities, and was the impetus for
the development of government strategies for desegregation. Successful lawsuits against
governments and an increasing awareness of human rights and self-advocacy also contributed to
this process, resulting in the passing in the U.S. of the Civil Rights of Institutionalized Persons
Act in 1980.

From the 1960s to the present, most states have moved towards the elimination of segregated
institutions. Normalization and deinstitutionalization were dominant. Along with the work of
Wolfensberger and others including Gunnar and
Rosemary Dybwad, a number of scandalous
revelations around the horrific conditions within
state institutions created public outrage that led to
change to a more community-based method of
providing services.

By the mid-1970s, most governments had committed to de-institutionalization, and had started
preparing for the wholesale movement of people into the general community, in line with the
principles of normalization. In most countries, this was essentially complete by the late 1990s.

Terminologies Used for Intellectual Disability

Negative connotations associated with these numerous terms for intellectual disability reflect
society's attitude about the condition. Terms that denote mental deficiency have been subjected
to the euphemism treadmill. This means that whatever term is chosen for this condition, it
eventually becomes perceived as an insult. The several traditional terms that long
predate psychiatry are simple forms of abuse in common usage today; they are often encountered
in such old documents as books, academic papers, and census forms (for example, the British
census of 1901 has a column heading including the terms imbecile and feeble-minded). With the
passage of time, new words like special or challenged replaced the older terms like retarded.
The term developmental delay is popular among caretakers and parents of individuals with
intellectual disability because delay suggests that a person is slowly reaching his or her full
potential rather than being disabled. Some of the terms used over the histories are as follows

 Cretin is the oldest and comes from a dialectal French word for Christian. The
implication was that people with significant intellectual or developmental disabilities
 were "still human" (or "still Christian") and deserved to be treated with basic human
dignity. Individuals with the condition were considered to be incapable of sinning, thus
"christ-like" in their disposition. This term is not used in scientific endeavors since the
middle of the 20th century and is generally considered a term of abuse.

 Amentia has a long history, mostly associated with dementia. The difference between
amentia and dementia was originally defined by time of onset. Amentia was the term used
to denote an individual who developed deficits in mental functioning early in life,
while dementia included individuals who develop mental deficiencies as adults. During
the 1890s, amentia meant someone who was born with mental deficiencies. By 1912,
ament was a classification lumping "idiots, imbeciles, and feeble minded" individuals in a
category separate from a dement classification, in which the onset is later in life.

 Idiot indicated the greatest degree of intellectual disability, where the mental age is two
years or less, and the person cannot guard himself or herself against common physical
dangers. The term was gradually replaced by the term profound intellectual disability.

 Imbecile indicated an intellectual disability less extreme than idiocy and not necessarily
inherited. It is now usually subdivided into two categories, known as severe intellectual
disability and moderate intellectual disability.

 Moron was defined by the American Association for the Study of the Feeble-minded in
1910, following work by Henry H. Goddard, as the term for an adult with a mental
age between eight and twelve; mild intellectual disability is now the term for this
condition.

 Mongolism was a medical term used to identify someone with Down syndrome.
The Mongolian People's Republic requested that the medical community cease use of the
term as a referent to intellectual disability. Their request was granted in the 1960s, when
the World Health Organization agreed that the term should cease being used within the
medical community.

 In the field of special education, educable (or "educable intellectual disability ") refers to
ID students with IQs of approximately 50–75 who can progress academically to a late
 elementary level. Trainable (or "trainable intellectual disability") refers to students
whose IQs fall below 50 but who are still capable of learning personal hygiene and other
living skills in a sheltered setting, such as a group home. In many areas, these terms have
been replaced by use of "moderate" and "severe" intellectual disability. While the names
change, the meaning stays roughly the same in practice.

 Retarded comes from the Latin retardare, "to make slow, delay, keep back, or hinder,"
so mental retardation meant the same as mentally delayed. The term was recorded in
1426 as a "fact or action of making slower in movement or time." The first record of
retarded in relation to being mentally slow was in 1895. The term retarded was used to
replace terms like idiot, moron, and imbecile because retarded was not then a derogatory
term. By the 1960s, however, the term had taken on a partially derogatory meaning as
well.

 The term 'mental retardation' was introduced by the American Association on Mental
Retardation in 1961 and soon afterwards was adopted by the American Psychiatric
Association (APA) in its Diagnostic and Statistical Manual for Mental Disorders. It was a
diagnostic term denoting the group of disconnected categories of mental functioning such
as idiot, imbecile, and moron derived from early intelligence tests, which
acquired pejorative connotations in popular discourse. The term mental
retardation acquired negative and shameful connotations over the last few decades due to
the use of the words retarded and retard as insults. This may have contributed to its
replacement with euphemisms such as mentally challenged or intellectually disabled.

 As of 2013, the term "mental retardation" is still used by the World Health
Organization in the ICD-10 codes, which have a section titled "Mental Retardation". In
the next revision, the ICD-11 is expected to replace the term "mental retardation" with
"intellectual disability," and the DSM-5 (2013) has replaced it with "intellectual
disability (intellectual developmental disorder).

Along with the changes in terminology, and the downward drift in acceptability of the old terms,
institutions of all kinds have had to repeatedly change their names. This affects the names of
schools, hospitals, societies, government departments, and academic journals. For example, the
Midlands Institute of Mental Subnormality became the British Institute of Mental Handicap and
is now the British Institute of Learning Disability (Wikipedia, 2013).
C hapter 2 ASSESSMENT OF INTELLECTUAL DISABILITY
 Chapter 2

Assessment

Tests of IQ and adaptive functioning form the basis for making a diagnosis of intellectual
disability. Other tests (e.g., neuropsychological tests) may provide further detail. However, these
additional tests are not needed for diagnosis. All relevant information into account before a
diagnosis is made. This includes

 interviews,
 observations
 medical history

Diagnosticians have some discretion. The test scores are weighted heavily. However, test scores
are not the sole basis for diagnosis. For instance, some children appear to be smarter or higher
functioning than the testing indicates. These observations are also taken into account along with
all the other data. The diagnostician then compares all the data to the diagnostic criteria for
intellectual disabilities.

Assessment for Intellectual Functioning

Some of the more commonly used IQ tests are described below:

Wechsler Intelligence Scale for Children (WISC): This is an IQ test for children ages 6 to 16.
The test has several subtests. The subtests provide insight into two distinct areas of intelligence.
These are verbal skills and performance skills. The verbal tests include: vocabulary, similarities,
comprehension, math, and informational knowledge. The performance tests include: picture
completion and arrangement; block design; object assembly; and coding.

Wechsler Preschool and Primary Scale of Intelligence: This is an IQ test for children 3 to 7
years old. This test is organized like the WISC. It measures two key aspects of intelligence:
verbal skills and performance skills. It has multiple subtests measuring different aspects of each
major area. This test is not appropriate for individuals with severe intellectual disability.
Wechsler Adult Intelligence Scale (WAIS): This is an IQ test for people over sixteen years of
age. This test is also similar to the WISC. However, the questions are more difficult since it tests
adults. Like the WISC, it is comprised of multiple subtests. These subtests measure different
aspects of the two major areas of intelligence.

Stanford-Binet Intelligence Scale: This is an IQ test for people between 2 to 23 years of age.
There are fifteen subtests for older groups. Six subtests are administered to all age groups. These
are vocabulary, comprehension, pattern analysis, quantitative, bead memory, and memory for
sentences.

McCarthy Scales of Children's Abilities: This test measures the cognitive and motor abilities
of children between the ages of 2.5 to 8.5 years old. There are six sections to this test. These are:
Verbal Scale; Perceptual-Performance Scale; Quantitative Scale; Memory Scale; Motor Scale;
and General Cognitive Scale. The results do not provide an IQ score. Instead, the test yields a
General Cognitive Index (GCI). This is similar but broader than a simple IQ. The McCarthy
Scales also provide individual ability scores. These are: verbal; non verbal reasoning; number
aptitude; short-term memory; and coordination. These scores help diagnosticians evaluate
learning problems in younger children.

Bayley Scales of Infant Development: These tests are used to assess the development of infants
and toddlers ages 1-42 months. This test is also used with older children who are unable to take
age-appropriate tests. There are three sections. The first is mental abilities. This includes tests of
recognition memory; object permanence; shape discrimination; attention; nonverbal
communication and vocalization; receptive and expressive language. The second is motor
abilities. This includes tests of gross and fine motor skills. The third is behavioral abilities. This
includes tests of social and emotional behavior.

Assessment for Adaptive Functioning

As mentioned, intellectual disabilities (ID, formerly mental retardation) have two key diagnostic
criteria. These are intellectual functioning (IQ) and adaptive functioning. Tests of adaptive
functioning evaluate the social and emotional maturity of a child, relative to his or her peers.
They also help to evaluate life skills and abilities. Commonly used tests of adaptive functioning
are described below:

Woodcock-Johnson Scales of Independent Behavior: This test measures independent behavior

in children.

Vineland Adaptive Behavior Scale (VABS): This test measures the social skills of people from
birth to 19 years of age. This test is not administered directly to the child. Instead, questions are
directed to primary caregivers and other people familiar with the child. The test contains four
sections. These are communication; daily living skills; socialization; and motor skills. This test is
also used for children with behavioral disorders, and physical handicaps.

The Diagnostic Adaptive Behavior Scale (AAIDD, 2013): This test measures adaptive
behavioral skills. There are three main categories of these skills. This includes conceptual, social,
and practical life skills. This test is very helpful for determining the intensity and types of
supports needed to maximize independent functioning and quality of life.
C hapter 3 ETIOLOGY OF INTELLECTUAL DISABILITY
 Chapter 3

Etiology

Intellectual disabilities have many causes. Some of these causes are preventable. Others are not.
These causes can be grouped into four categories.

 Medical Conditions;
 Brain Damage;
 Genetic Conditions;
 Psychiatric Conditions.

Four conditions are the most common causes of intellectual disabilities. First, there is autism.
This is a psychiatric cause. Next are two genetic conditions. These are Down syndrome and
Fragile X syndrome. Lastly, Fetal Alcohol Syndrome (FAS) is a medical condition. However,
among these common causes, only FAS is completely preventable.

Medical Causes of Intellectual Disabilities

Pre- and post-natal exposure to alcohol, drugs, toxins, and certain infections can have a
devastating effect on brain development. This exposure can result in physical and mental defects,
and even death of an infant.

Prenatal Exposure to Alcohol and Other Drugs

Fetal Alcohol Syndrome (FAS) is one of the leading causes of preventable birth defects and
intellectual disabilities. Alcohol
passes directly from the blood stream
of a pregnant woman, through the
placenta, to the developing fetus'
brain. It is not clear how much
alcohol is safe. Therefore, most
doctors recommend pregnant women
avoid alcohol. Even drinking three
drinks a day during pregnancy can cause fetal alcohol syndrome (FAS). Other drugs also harm a
developing fetus. This includes nicotine, cocaine, and heroin. A pregnant woman should tell her
doctor to reduce the risks to her unborn child.

Environmental Exposure to Toxins

Pre- and post-natal exposure to toxins can cause intellectual disabilities. Of particular concern
are lead, mercury, and radiation. Avoiding exposure to these toxins reduces the risk of
developing an intellectual disability.

Mercury is found in polluted waters. Fish that swim in these waters contain mercury. Large fish
such as shark, mackerel, and swordfish contain higher amounts of mercury. Because large fish
live longer, the mercury builds up to higher levels. When women consume these large fish, the
mercury can pass through the placenta, and to the fetus. Women can reduce this risk by
switching to low mercury fish. Low mercury fish are smaller. This includes shrimp, salmon, and
Pollack. Some farm-raised fish are also safer than ocean dwelling fish.

Lead based paints are present in pre-1970s homes and in the soil surrounding older homes. High
radiation exposure is associated with intellectual disabilities. Fortunately, modern radiation
equipment has drastically reduced the amount of radiation exposure. However, it is uncertain
what a safe level of exposure is. For this reason, women who may be pregnant should take
preventive measures before receiving any radiation procedures.

Infections

Certain types of infections can lead to intellectual disabilities. Pregnant women can take simple
steps to reduce these risks. These infections are represented by the acronym TORCH. Each letter
of TORCH stands for a different infection:

 T- Toxoplasma infection (toxoplasmosis) is caused by a parasite. This parasite can be

found throughout the world in warm-blooded animals. It can also be introduced through
undercooked meats that are infected with the parasite. The parasite can live in the ground.
People may ingest the parasite by getting dirt in their mouths. This can occur during
simple activities like gardening. Pregnant women should not garden, particularly in
 places where cats may defecate. Toxoplasmosis is insidious in that there are no symptoms
during the pregnancy. Once the child is born, the symptoms emerge. These include
jaundice, rashes, and an enlarged liver and spleen. Toxoplasmosis has a profound effect
on the baby's central nervous system. Unfortunately, these effects may not be recognized
for months or even years. Usually this is when signs of learning disabilities or intellectual
disability surface.
 O- Other infections, including Hepatitis B, syphilis, and the virus herpes zoster, that
causes chicken pox. Pregnant women should practice safe sex and use condoms to reduce
the risk of exposure. Women planning to become pregnant should talk to their doctor
about testing for these infections.
 R- Rubella, the contagion that causes German measles. It is commonly associated with
intellectual disabilities in infants. This insidious
condition is passed from mother to baby during
pregnancy. The mother's symptoms are mild,
including rash and a low-grade fever. The symptoms
present after birth and include intellectual disability
or even death.
 C- Another virus, cytomegalovirus, is so common
that nearly everyone has contracted it before
reaching adulthood. If the virus is contracted during teenage and young adult years, it is
commonly known as mononucleosis. Cytomegalovirus may be passed from mother to
fetus if she has contracted the condition for the very first time while pregnant. Five
percent of babies who contract the virus have significant developmental problems
including blindness and brain damage.
 H- Herpes simplex II is a sexually transmitted
disease. Once contracted, there is no cure. The
signs are very tender blisters. The virus may
remain dormant in the carrier's body until some
stressor activates the virus. In this dormant state, it
is not contagious. However, when blisters appear
and open, it is highly contagious. An infant can contract this virus from the mother during
 pregnancy if the mother contracts herpes simplex virus during pregnancy. It can also be
transmitted if the mother has an active outbreak during birth. The condition can be
detrimental to a newborn, resulting in significant brain damage and possibly death.

Brain Damage and Intellectual Disabilities

Several types of brain damage can lead to an intellectual disability. These include traumatic brain
injury, congenital brain damage (present before birth), and progressive brain damage. One
progressive brain diseases is spinal muscular atrophy. This is an inherited neuromuscular
disorder. Another is Batten disease. This is an inherited metabolic disease. It leads to the
progressive decline of brain functioning.

Traumatic Brain Injuries (TBI) are injuries to the brain that occur after birth (but before age 18).
Many brain injuries are preventable. These injuries may be caused by an auto accident, a blow to
the head, or a fall. Brain injury also occurs when infants are shaken or dropped. This unfortunate
situation often occurs when caregivers are frustrated. Caring for infants can be extremely
stressful but it should be done with caution to avoid long term health consequences.

Genetic Causes of Intellectual Disabilities

Many intellectual disabilities (ID, formerly mental retardation) are caused by genetic
abnormalities. The two most common genetic causes of intellectual disabilities are Down
syndrome and Fragile X syndrome.

Down Syndrome

Diagnostic Feature: Down syndrome is the most common genetic origin of intellectual
disabilities. Down syndrome occurs in 1 out of every 800 births. Down syndrome derives its
name from John Langdon Down. He was the one who first pinpointed the disorder. The
condition caused by an extra chromosome. An error in cell division during prenatal growth
results in an extra third chromosome 21. The extra chromosome is called Trisomy 21.
Brain Structure: The total brain volume is generally smaller than average. The shape of the
brain is also different.

Physical Features: The physical features of Down

syndrome can be quickly recognized at birth. The
child's eyes usually have an upward slant. They are
also white spots on the iris called Brush field spots.
The child's ears have an unusual shape. The neck is
shorter than usual. The shape of the face is full. The
profile of the face tends to be flat. The palm of the
hand may have a profound crease running crossways.
A person who has Down syndrome may not have all of
these physical features. Moreover, these traits are also
found in children without the disorder. So, only on the basis of physical features, diagnosis
cannot be made.

Behavioral Features: Each person with Down syndrome is unique. Some function quite well
with good social skills. Others have significant challenges. The Down syndrome population is
reputed to have friendly and loving temperaments. They often express affection openly. Many
people find their loving and sweet natures endearing.

Diagnosis: The definitive diagnosis of Down syndrome requires a blood test. Blood tests reveal
the abnormal Trisomy 21. The procedure is called a chromosomal karyotype. The procedure
takes about two weeks. During this time, blood cells are grown. Then, they are sorted and tested
for the extra chromosome.

General Trend in Population: People with Down syndrome have shorter lives than the general
population. The average life expectancy is about 55 years. This relatively short life span is 20
years longer than it was two decades ago. The syndrome is not associated with a particular
gender or race. Nor is it limited to certain socioeconomic groups. The risk for Down syndrome
increases with the mother's age.
Fragile X Syndrome

Diagnostic Feature: Fragile X syndrome is the second leading genetic cause of intellectual
disabilities. It involves a genetic anomaly of a gene. This is located on the X (sex-determining)
chromosome. This gene normally occurs as multiple
copies. However, with Fragile X, the code is
repeated in excess. Mutations in the FMR1 gene
cause fragile X syndrome.

Physical Features: There are several physical

features of Fragile X. The face is elongated and the
ears are large. The forehead tends to be larger than
normal. The jaw has a pronounced shape. People
with Fragile X are generally large in stature, but
with poor muscle tone. Males tend to have
abnormally large testicles. This becomes evident
during adolescence.

Behavioral Features: Behavioral features include a reluctance to make eye contact. They may
engage in odd, stereotyped movements. Other behavioral traits include hyperactivity, tremors,
and poor coordination. Their social and communication skills are not well developed. They tend
to be withdrawn and shy. Similar behavioral symptoms are characteristic of autism. People can
receive a diagnosis of both intellectual disability and autism.

Types of Fragile X Syndrome: There are three subtypes of Fragile X. The first is easily
detected. It is expressed at birth. The cognitive deficits are more severe. This type is shares many
symptoms of autism. This includes social avoidance, repetitive movements, and severe delays in
speech and language. A second type of Fragile X affects a person's sense of balance. They also
have tremors and memory deficits. The third type is Fragile X-related Premature Ovarian Failure
(POF). It is limited to females. The ovaries do not function correctly. This leads to infertility and
early menopause.

Gender Trend in Population: It is more common in women than men.

There are also some other causes which are comparatively less prevalent. They are as follows

 Tay-Sachs Disease: This disease is named after Warren Tay and Bernard Sachs and it is
an inherited disorder. It involves the absence of an enzyme hexosaminidase A,
responsible for metabolizing a fatty acid/lipid. Genetic testing prior to pregnancy can
determine if prospective parents they carry the genetic marker. Babies appear normal for
the first several months of life. As the disorder progresses, babies begin to lose previously
mastered skills. This includes crawling, turning over, and reaching. After a time,
blindness ensues. Gradually, the child becomes unable to move and is unresponsive.
Ultimately, the infant becomes unable to breathe or swallow. The disorder is fatal in
children. Life expectancy does not surpass five years of age.
 Prader-Willi Syndrome (PWS): is also referred to as hypotonia-hypomentia-
hypogonadism-obesity syndrome (HHHO). It is a genetic disorder involving a
malfunction of chromosome 15. Hypotonia describes a condition where muscle tone is
weak. Hypomentia refers to intellectual disability or learning disabilities. Hypogonadism
describes a condition characterized by inefficient, weak secretion of male or female
hormones. Obesity pertains to excessive weight. Facial features include almond-shaped
eyes that may be crossed, full cheeks, and a narrow face. The mouth is small and the
corners of the mouth turn downwards. The small mouth is accentuated by a thin upper
lip. Behavioral problems include tantrums, obsessive/compulsive tendencies, and skin
picking. Prader-Willi syndrome is tied to milder forms of intellectual disability.
 Williams Syndrome: The cause of the disorder is a mutation of chromosome 7. The
facial features are subtle but distinct. They include a tiny upturned nose. The mouth is
wide and full, with a small chin. The skin around the eye is distended. If eyes are light-
colored, a white starburst design may be visible. The neck is longer than normal. The
shoulders are sloping. The spine tends to curve and stature is short. There is limited
mobility in the joints.
 Angelman Syndrome: This genetic disorder involves the absence or inactivity of a
certain group of genes. Physical traits of Angelman syndrome are not easy to spot. They
include a flat-shaped head and a protruding tongue. The circumference of the head is also
smaller than average. The condition is marked by several developmental problems. These
 include problems with communication, walking, and standing. Communication problems
are so severe that they may never speak. Many people with this disorder are hyperactive.
They have trouble controlling body movements. They often exhibit abrupt, jerking
motions, and a stiff posture. Excessive and inappropriate laughter is a telltale sign.
Seizures may be present.
 Bardet-Biedl Syndrome: Bardet-Biedl syndrome is linked to problems on chromosome
3. Mutations cause polydactyl limbs. Polydactyl means 'many fingers.' It refers to anyone
who has more than five fingers. Symptoms include incomplete development of
reproductive organs, kidney and eye abnormalities, and extra fingers or toes. The
characteristic most commonly associated with the syndrome is obesity. Fatal cases are
marked by renal failure.
 Laurence-Moon Syndrome: Symptoms include hypogondadism and retinitis
pigmentosa. Retinitis pigmentosa is an eye disorder. Eyesight is gradually lost.
Hypogondadism means the testes and ovaries do not produce enough sex hormones. In
males, this results in the underdevelopment of sexual organs. Females may have defective
egg development and early menopause. Physical traits are not obvious except some
people have paralysis in the lower body. The condition is often accompanied by
involuntary muscle spasms known as spastic paraplegia.

Psychiatric Causes of Mental Retardation

Autism Spectrum Disorder (ASD)

A leading cause of intellectual disabilities is autism spectrum disorder (ASD). A person may be
diagnosed with both. ASD has two primary
symptoms. First, people with ASD have trouble
with communication and social interaction.
Second, they demonstrate repetitive patterns of
behaviors, interests, or activities. Some examples
are repetitive speech, ritualized patterns of
behavior, or fixation upon certain objects.
Approximately 40% of people with intellectual
disabilities will also have ASD. However, nearly 70% of people with ASD also have intellectual
disabilities (La Malfa, Lassi, Bertelli, & Placidi, 2004).
C hapter 4 MANAGEMENT OF INTELLECTUAL DISABILITIES
 Chapter 4

Management

As intellectual disabilities are not illnesses, there are no treatments per se. Instead, interventions
focus on identifying abilities and limitations. The goal is to provide sufficient supports that
maximize each person's functioning. In this respect, we may speak of rehabilitation, rather than
of treatment. Early intervention is crucial. This ensures the optimal development of children with
intellectual disabilities. Some early intervention programs begin at birth. These early intervention
programs serve multiple functions. First, they inform caregivers about early child development.
Second, they help children grow and learn by working with their strengths and limitations. Third,
families learn specialized techniques to help children function to the best of their abilities.
Settings for these programs may include home, school, and community. Some of the strategies
used in supportive rehabilitation are as follows

Individualized Support Plan (ISP)

When someone is ill, health care professionals develop an individualized treatment plan. The
treatment plan is designed to correct, or limit, the harmful symptoms. However, intellectual
disability is not an illness. Therefore, a different type of plan is developed. This plan is called an
individualized support plan (ISP). The ISP evaluates the abilities and limitations of the person.
Based on this evaluation, the ISP identifies what additional supports are needed to ensure
optimal functioning. Furthermore, the ISP determines the best method to provide these supports.

Goals

 The first goal of the ISP is to assess the individual needs and abilities of each person.
 The second goal is to identify a strategic approach that maximizes functioning. This is
accomplished by using strengths to offset limitations.
 Ultimately, the primary objective of the ISP is to optimize functioning and life
satisfaction. This is achieved by creating a match between a person's environment, and
their abilities.
ISPs are developed and executed by a team of professionals. However, the success of the ISP
rests upon a collaborative alliance between the team, the person with the disability, and
caregivers. Accordingly, psychologists, social workers, nurses, doctors, speech and occupational
therapists, teachers, and service coordinators are just a few of the professionals who develop and
execute the ISP.

Individualized Education Plan

Children with IQ scores above or below the mean (average) by two standard deviations usually
receive an Individualized Educational Plan (IEP). The IEP establishes individualized,
educational goals for each child. Children who score two standard deviations above the mean
(roughly 2.5% of children) have exceptionally high IQ scores. Children who score two standard
deviations below the mean (roughly 2.5% of children) have exceptionally low IQ scores. Both
groups of children are eligible for specialized educational services. It is generally agreed that the
educational needs of these unusual children cannot be met with traditional methods alone. Thus,
children with intellectual disabilities will receive an IEP.

The IEP is developed collaboratively. It includes input from many sources. These sources
include teachers, psychologists, the student, and the student's family. Each IEP outlines specific
goals. Special educational curriculums are then adapted to help each child achieve their IEP
goals. The curriculum is designed around each child's needs and abilities. The focus is to help the
child develop age appropriate functional skills.

The Choice of Educational Settings: The Pros and Cons of Mainstreaming Children with
Intellectual Disabilities

Many families and educators strongly advocate mainstreaming students with intellectual
disabilities. Mainstreaming refers to placing children with disabilities into regular classrooms.
They usually have additional supports as well. Mainstreaming allows children with intellectual
disabilities to receive education alongside their non-disabled peers. However, the majority of
students with intellectual disabilities are not mainstreamed. Most attend schools for children with
special needs.
Advantages: Mainstreaming is an appealing, inclusive approach. It’s advantages are as follows:

 First, mainstreaming offers many rewarding opportunities for socialization. Many

children with intellectual disabilities have inadequate social skills. These social
limitations ultimately hinder their success in life. Quite logically, social skills can only be
learned and acquired in a social environment. A regular classroom provides the ideal
social climate. These students truly benefit by observing and imitating their peers in a
regular classroom.
 Second, mainstreaming exposes all children to diversity. Such diversity is naturally
encountered in the real world. Whether or not a child has an intellectual disability,
children will eventually encounter many different people throughout their lives. Some
people will be from similar cultures and backgrounds. Other people will not. A school
setting is the ideal environment to notice and adjust to these differences. This real-world
preparation is advantageous. It promotes the ability to embrace human diversity. These
skills are critical for getting along with co-workers and neighbors.
 Third, mainstreaming in a regular classroom may inspire and challenge students with
intellectual disabilities to excel. Without sufficient challenge, people do not develop and
strengthen their abilities. A traditional classroom provides more opportunities for these
challenging experiences.

Disadvantages: There are certain disadvantages of mainstreaming as well which are as follows.

 It is unrealistic to expect that students with intellectual disabilities will receive the
attention they need and deserve within a regular classroom.
 Moreover, many teachers in regular classrooms have not received training in specialized
educational techniques.
 Some people also argue that mainstreaming is unfair to average students. This is because
the teachers' time and attention is spent with the children who require more
individualized instruction.

Perhaps, the best educational setting is the one that best helps a child to achieve the goals of their
IEP. Each child has different goals, abilities, and needs. There is no one best setting for all
children. Parents and educators must realistically appraise the learning environments and
resources available in their communities. Then, they can make a wise selection that best matches
the child's needs and circumstances. Placement decisions should be reevaluated periodically.
Children's needs and circumstances change over time.

Effective Teaching Methods for People with Intellectual Disabilities

Individuals with intellectual disabilities benefit from the same teaching strategies used to teach
people with other learning challenges. This includes learning disabilities, attention
deficit/hyperactivity disorder, and autism.

Breaking Task into Smaller Steps: One such strategy is to break down learning tasks into small
steps. Each learning task is introduced, one step at a time. This avoids overwhelming the student.
Once the student has mastered one step, the next step is introduced. This is a progressive, step-
wise, learning approach. It is characteristic of many learning models.

Learning through Practical Experiences: A second strategy is to modify the teaching

approach. Lengthy verbal directions and abstract lectures are ineffective teaching methods for
most audiences. Most people are kinesthetic learners. This means they learn best by performing a
task "hands-on." This is in contrast to thinking about performing it in the abstract. A hands-on
approach is particularly helpful for students with intellectual disabilities. They learn best when
information is concrete and observed. For example, there are several ways to teach the concept
of gravity. Teachers can talks about gravity in the abstract. They can describe the force of
gravitational pull. Second, teachers could demonstrate how gravity works by dropping
something. Third, teachers can ask students directly experience gravity by performing an
exercise. The students might be asked to jump up (and subsequently down), or to drop a pen.
Most students retain more information from experiencing gravity firsthand. This concrete
experience of gravity is easier to understand than abstract explanations.

Visual Aids: Third, people with ID do best in learning environments where visual aids are used.
This might include charts, pictures, and graphs. These visual tools are also useful for helping
students to understand what behaviors are expected of them. For instance, using charts to map
students' progress is very effective. Charts can also be used as a means of providing positive
reinforcement for appropriate, on-task behavior.
Provision of Feedback: A fourth teaching strategy is to provide direct and immediate feedback.
Individuals with ID require immediate feedback. This enables them to make a connection
between their behavior and the teacher's response. A delay in providing feedback makes it
difficult to form connection between cause and effect. As a result, the learning point may be
missed.

Applied Behavioral Analysis (ABA) and Intellectual Disabilities

The ABA approach utilizes two, well-researched learning theories. These are: 1) classical
conditioning and 2) operant conditioning. The ABA does not require great intellectual ability in
order for learning to be successful. Thus, ABA is ideally suited for people with mental
challenges. This includes people with intellectual disabilities.

Reinforcement: ABA's emphasis on providing immediate rewards for correct behavior is crucial
to motivation. However, the reward must be valuable or desired. Each student will find different
things rewarding. Only rewards that are intrinsically rewarding have a motivational effect.
Rewards that are not gratifying will not reward or motivate someone. For instance, if you dislike
chocolate candy, eclairs would not be rewarding. Therefore, they would not serve to motivate
and teach a new behavior. When the ABA is initially introduced, rewards must be immediate and
concrete. Snacks and food rewards work well for this purpose. For behaviors that require more
sustained effort, such as remaining on task for 30 minutes, a more sustained reward may be
appropriate. This might be permission to watch a favorite TV show, or to play an exciting game.

Punishment: ABA's modern emphasis provides rewards for correct behavior and ignoring
incorrect behavior. However, this was not always so. In the early days of ABA, incorrect choices
were not merely ignored. Rewards were balanced with punishments for undesired behavior.
Today, negative or undesired behaviors are usually ignored or redirected, rather than punished.
The only exceptions are "non-negotiable" circumstances.

Time Out/ Response Costs: Dangerous behaviors are considered "non-negotiable." These types
of behavior may require immediate negative consequences. For obvious reasons, dangerous
behavior cannot be ignored. Dangerous behaviors include any behaviors that threaten, or cause
significant harm to anyone. Some examples are banging one's head against the wall, or biting
other children. The other non-negotiable behaviors are ones that cause significant damage to
property. This might include setting fires or throwing computer equipment off a desk. Common
consequences include time-outs, or loss of preferred play items and activities. These behaviors
and consequences are outlined in the safety crisis management plan. An individualized safety
crisis management plan is routinely developed for at-risk children. It spells out what the negative
consequences are for dangerous behaviors.

Token Economy: As students become familiar with the instruction and reward process, a more
abstract "token" reward system can be introduced. Token reward systems use visual
representations. Common examples are stickers placed on a chart, or beads placed on a bracelet.
These represent a student's progress towards an ultimate, concrete reward. For example, once the
child earns five stickers he can play a game or watch a program. The token reward system is a
little more complex and abstract than immediate and concrete rewards. However, it is very
effective for increasing on-task behavior. Furthermore, it teaches students to delay their
gratification.

Extinction: In its most basic form, ABA is very simple and common sense. It rewards a person
for making a correct choice. Incorrect choices are ignored, or not rewarded. Therefore, students
learn by making simple associations between cause and effect. With repetition, a student learns
to associate a correct action with a reward. As such, this correct choice will be repeated. An
incorrect action does not earn a reward. When not rewarded, behaviors begin to slowly fade
away. This process is known as extinction,

Chaining: In another approach to ABA, complex tasks or behaviors are broken down into
smaller steps. For instance, suppose a student needs to learn to raise his hand before speaking in
a classroom. This might be broken down into five steps: 1) Raise the hand. 2) Raise the hand
while remaining silent. 3) Keep the hand raised, remaining silent, until the teacher acknowledges
you. 4) Once the teacher acknowledges you, put the hand down. 5) After the hand is down,
speak. Skills are systematically introduced in small steps. As one small skill is mastered, the next
step is introduced. Students learn by making simple associations between cause and effect. If
they respond correctly for that step, they are immediately rewarded. If they respond incorrectly,
nothing happens. Once a step is consistently mastered, the next step is rewarded, not the
previously mastered step. This process is known as chaining.

Let's illustrate these concepts. Suppose Billy has learned the first step. The first step is simply to
raise his hand. He talks while his hand is raised because he hasn't learned step two yet. Now step
two is introduced. Billy will not receive a reward when he raises his hand and is talking. At first,
he will be puzzled by this. He previously earned a reward for raising his hand. He may be
instructed to stop talking and will receive a reward when he does. Alternatively, he might raise
his hand without talking by sheer coincidence. He would immediately receive a reward. Step two
is learned because once Billy discontinues speaking and chattering while his hand is raised, he
will immediately receive a reward. This step is repeated until Billy can consistently raise his
hand while remaining silent. Then he will begin practicing the next step and so on. This
continues until the entire behavioral chain is mastered.

Physical Therapy and Sensory Skills Training

Sometimes the individualized education plan (IEP) specifies certain therapies. Physical therapy
is one such therapy. Intellectual capacity is highly influenced by the ability to receive and
correctly interpret sensory data. We receive this data from our five senses: sight, sound, touch,
taste, smell. Sensory integration is a natural process used by the body to interpret sensory
information. Normally, the various senses work together in unison. This helps people navigate
their surroundings. However, some children with intellectual disabilities have difficulty
interpreting, integrating, and coordinating sensory input. Sensory integration activities help these
children strengthen these abilities.

There are two different sorts of sensory problems. Some children have hyperactive (overactive)
systems. These children have difficulty blocking out signals that should be ignored. In response
to this overactive system, they avoid motion activities like climbing stairs. They may also be
very prone to motion sickness. They may seek support from others while walking.

Other children have hypoactive (underactive) systems. These children have difficulty attending
to signals that should be heeded. Children with hypoactive sensory systems may actively seek
out motion. They may enjoy swinging and climbing activities, and do not become dizzy after
spinning.

Sensory integration activities address children's sensory needs by either lessening or amplifying
the intensity of the sensory stimulation they receive. Most sensory integration activities work
with children's vestibular, proprioceptive, and tactile sensory systems. These are described
below.

 The vestibular sensory system enables us to stand and coordinate movement. It involves
sensory input from vision and from sensory organs in the inner ear. Activities that
stimulate the vestibular system involve movement. Swinging, jumping, and spinning are
good examples. A physical therapist working with hypoactive children might engage
them in structured movement exercises. This meets their sensory needs within socially
acceptable boundaries.
 The proprioceptive sensory system provides information about the body's positioning.
Proprioceptive feedback helps people coordinate fine motor activities. Examples include
coloring within lines or buttoning a shirt. It also helps with motor planning. This refers to
the ability to coordinate different motor tasks to complete an activity. Activities that
stimulate the proprioceptive system include deep pressure, hugging, and climbing.
Physical therapy promotes the development of gross motor skills required for everyday
activities. It also increases flexibility and stimulates learning abilities through sensory
integration activities.

Social Skills Training

Many people with intellectual disabilities have underdeveloped social skills. This is because the
development of social skills relies heavily on certain intellectual abilities. Social skills enable
people to function well in any social situation. This includes work, school, and interpersonal
relationships. Some examples of good social skills include:

 Understanding and honoring the standards of dress and decorum at different social
occasions;
 The acceptable forms of social interaction for different social occasions;
  Knowing when to make eye contact and when to avert the eyes;
 Determining when physical contact is acceptable and what type (e.g. a handshake versus
a hug);
 Being able to politely start and stop conversations;
 Being able to make small talk;
 Understanding how to notice and respond to non-verbal body language;
 Appreciating social nuance such as sarcasm and humor;
 Understanding the differences between literal and figurative speech;
 Being able to express feelings and respond to the feelings of others.

Social skills are closely linked with language and communications skills. Effective
communication involves the accurate use and interpretation of both verbal and nonverbal
communication. It includes the ability to understand non-literal, figurative speech. For example,
the weather is a popular way to make small talk. Suppose someone steps into an elevator and
says, "It's raining cats and dogs out there." People might begin to nod or laugh with amusement.
However, someone with an intellectual disability might become horrified. They might begin
crying imagining cats and dogs dropping from the sky. They do not understand this non-literal
figure of speech.

Good social skills also require behavioral management skills. For example, impulses must be
kept under control across a wide variety of social situations. Self-care and grooming skills must
be demonstrated. People with intellectual disabilities often need to be explicitly taught
behavioral management skills. For instance, they must learn to refrain from talking out of turn.
They also need to speak at the appropriate volume when conversing. When provided direction,
they learn to follow rules and social conventions. For example, with proper coaching, they know
it is correct to wait in line to purchase a ticket.

Social skills are taught in a kinesthetic manner. This means that individuals learn by doing or
engaging in role plays. They repeatedly practice proper social interactions in a step-by-step
manner. The process of repetition helps solidify social skills.
First, instructors and coaches introduce a social skill. Then, they demonstrate the skill through a
role-play activity. Students are provided familiar examples. This helps students connect the
learning to their own everyday experiences. It provides a reference point.

When skills are first introduced, they are practiced in a classroom. The classroom provides a safe
learning environment. Here, they can make mistakes and receive corrective feedback. They are
rewarded for correct responses. Role-played interactions are similar to real-life. Usually the
learning experience is generalized to real-life situations.

Students are given homework assignments. They are asked to note and record real-life
experiences that required the skills they learned. They may be asked to demonstrate how they
handled the situation. Students are also encouraged to discuss real-life experiences that
challenged them. The instructors use these experiences as teaching points. They guide the class
to practice solutions to these problematic social interactions.

After students demonstrate some mastery of the skill, they begin to practice the skill in the real
world. For example, the instructors may demonstrate getting into an elevator with a stranger. The
stranger is standing near the buttons that select the floors. The stranger turns and asks, "Where
are you going?" Obviously, this does not literally mean, "What is your ultimate destination?" It
means, "What floor do you want?" However, many people with intellectual disabilities interpret
questions literally. They might blurt out, "I'm going to the doctor because I have diarrhea." With
training, they learn the stranger isn't interested in those details.

After mastering the basic elevator scenario, the instructors increase the complexity. They may
demonstrate the same scenario with a twist. What if someone asks the same question but isn't
standing by the floor selection buttons? Students learn environmental cues serve to determine the
meaning of a communication.

The role-playing and rehearsal process is usually the most difficult part. It requires students to
demonstrate the skills that the instructors have modeled. The instructors guide the students
during rehearsal. Students are provided immediate feedback. This helps students to gain
confidence in their abilities.
Instructor feedback is typically positive in nature. They praise and reward the students' efforts.
The instructors do not criticize students who have difficulty with a skill. Instead, they correctly
model the desired skill again. With repetition, practice, and support the students' gain mastery
and confidence.

Supported Employment and Integrated Work Sites

Most people with intellectual disabilities are able to work. This may be part-time or full-time
employment. With additional supports, many people with intellectual disabilities can work
alongside people without disabilities. They also can successfully compete for these jobs.

There are different levels of support for employment. Some people with intellectual disabilities
may require occupational, physical, social or speech therapies along with job training programs.
Voc-rehab programs teach important job skills. These training programs may be offered in a
variety of locations. Some may be conducted at a regular job site. Others may be offered in a
classroom. The classroom simulates an employment setting, such as a factory. Vocational
programs also include job-seeking skills. Students learn how to complete an employment
application. They practice employment interviews.

Recently, a new support strategy had gained acceptance. It is called supported employment.
Supported employment is an evidence-based practice. An evidence-based practice means there is
a large body of research that demonstrates its effectiveness. Supported employment has three key
features. These features distinguish it from traditional vocational rehabilitation programs:

 Employment is paid, competitive employment. This means the same work performance is
expected of disabled and non-disabled workers. Therefore, work is compensated in the
same manner. This includes all forms of compensation such as pay, healthcare, vacation,
etc.
 Work sites are integrated. Workers with disabilities work alongside workers without
disabilities. They perform the same tasks. They eat lunch together and take breaks
together.
  Workers with disabilities are provided ongoing support. This enables them to achieve
success and satisfaction. This support includes natural supports such as supervisors and
co-workers. It also includes the provision of a job coach.

Therapies for Intellectual Disabilities

Various therapeutic services can improve a person's adaptive behavioral skills. These therapies
are helpful for many people with intellectual disabilities.

Occupational Therapy:

 Meaningful and purposeful activities;

 Self-care (e.g., grooming, dressing, feeding, bathing);
 Employment activities and skills;
 Leisure activities (e.g., knitting, playing games);
 Domestic activities (e.g., cooking, cleaning, laundry).

Speech Therapy:

 Improves communication skills;

 Improves receptive and expressive languages skills;
 Improves speech articulation;
 Improves vocabulary.

Physical Therapy:

 Enhances quality of life by maximizing mobility and self-locomotion;

 Provides adaptive solutions to mobility problems;
 Increases sensory integration

Genetic Manipulations

Someday it may be possible to use genetic manipulations. This area of research attempts to
correct the genetic causes of intellectual disabilities. However, this promising area of research is
still in its infancy.
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