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2/4/2017 IntellectualDisability

IntellectualDisability
Overview
Thescopeofthispageiscentralizedcontentaboutindividualswithanintellectualdisability(ID)and
associatedcommunicationdifficultiesacrossthelifespan.

SeeASHAsIntellectualDisabilityevidencemapforsummariesoftheavailableresearchonthistopic.

IntellectualDisability
Thedefinitionsofintellectualdisability(ID)andrelatedterminologyhaveevolvedovertimetoreflectthe
legalandsocialgainsmadebyindividualswithsuchadisabilityandtheirfamilies.SeeChangesinServices
forPersonsWithDevelopmentalDisabilities:FederalLawsandPhilosophicalandPerspectivesandFederal
ProgramsSupportingResearchandTraininginIntellectualDisability.Thesechangesreflectthemovement
frominstitutionalizationtoinclusivepractices,selfadvocacy,andselfdetermination.Therehasalsobeenthe
movementtowardrecognizingfundamentalcommunicationrightsofpeoplewithseveredisabilities.A
CommunicationBillofRightsoriginallydevelopedbytheNationalJointCommitteeforthe
CommunicationNeedsofPersonswithSevereDisabilities(NJC)in1992andupdatedin2016recognizes
therightofallpeopletoeffectivecommunication(NJC,1992Bradyetal.,2016).

Oneofthemajorshiftsintheearly1980swasamovetowardpersonfirstlanguage,reflectingtheideathat
thedisabilitydoesnotdefinetheperson.Termslikeindividualswithintellectualdisabilityhavereplaced
theoldertermsofmentallyretardedpersonsorthementallyretarded,anddefinitionsofIDhavechanged
frombeingstrictlyintelligencequotient(IQ)basedtoincludingstrengthsinadaptivebehavior(Schalock,
Luckasson,&Shorgren,2007).

IDischaracterizedby

significantlimitationsinintellectualfunctioning(e.g.,reasoning,learning,andproblemsolving)
significantlimitationsinadaptivebehavior(i.e.,conceptual,social,andpracticalskillsineveryday
life)and
onsetinchildhood(beforetheageof18yearsAmericanAssociationonIntellecutaland
DevelopmentalDisabilities[AAIDD,2013]).

ThisdefinitionofIDbalanceslimitationswithanequalemphasisonskills.Consequently,languageand
philosophyconcerningIDnowfocusesonlevelsofsupportnecessarytomaximizeanindividual'sability,
ratherthanstrictlyondeficitsinfunctioning.

TheAAIDDdefinitionisconsistentwiththediagnosticcriteriaforIntellectualDisability(Intellectual
DevelopmentalDisorder)intheDiagnosticandStatisticalManualofMentalDisorders(DSM5American
PsychiatricAssociation[APA],2013).Severitylevels(mild,moderate,severe,andprofound),asdefinedin
DSM5,arebasedonadaptivefunctioningintheconceptual,social,andpracticaldomains.

Limitationsinadaptivefunctioninginspecificskillareasareanecessarycriterionfordiagnosisunderthe
AAIDDandDSM5definitions.TheWorldHealthOrganizations(WHO,2001)InternationalClassification
ofFunctioning,DisabilityandHealth(ICF)andtheICFChildrenandYouthVersion(WHO,2007)recognize
activityandparticipationlimitationsinadditiontoimpairmentsinbodyfunctionsandstructures.
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DevelopmentalDisability

IDisasubsetofdevelopmentaldisability(DD).DDisdefinedasfollows:

Asevere,chronicdisabilityinanindividual5yearsofageorolder
Onsetbefore22yearsofage
Resultsinsubstantialfunctionallimitationsinthreeormoreareasoflifeactivity(selfcare,receptive
andexpressivelanguage,learning,mobility,selfdirection,capacityforindependentlearning,
economicselfsufficiency
(DevelopmentalDisabilitiesAssistanceandBillofRightsAct,2000)

Lifelong,earlyonsetconditionsthatresultinsubstantialfunctionallimitationsbutnotnecessarily
concomitantintellectuallimitationsincludeautismspectrumdisorder(ASD)orcerebralpalsy(although
manyindividualswiththeseconditionsdo,infact,haveID).Individualswiththesediagnoseswhohaveage
levelcognitiveskillswouldbeconsideredtohaveDDwithoutID.

CooccurringConditionsandDisorders

IndividualswithIDareaheterogeneousgroup,andcommunicationskillscanvaryduetofactorssuchas
severity,cooccurringconditions,andotherbehavioral,emotional,andsocialfactors.

ConditionsthateithercommonlycooccurwithorarefullycomorbidwithIDincludebutarenotlimited
toASD,cerebralpalsy,Downsyndrome,fetalalcoholsyndrome,andFragileXsyndrome.Otherconditions
thatmayalsocooccurwithIDincludeanxietydisorder,attentiondeficit/hyperactivitydisorder,depressive
andbipolardisorder,impulsecontroldisorder,andmajordepressivedisorder(APA,2013).See
CommunicationCharacteristics:SelectedPopulationsWithanIntellectualDisabilityforgeneral
communicationcharacteristicsofindividualswiththesemostcommonconditionsassociatedwithID.

AssociatedHealthConditions

IndividualswithIDmayhavemorehealthproblemsthanothersinthegeneralpopulation,oftenasaresultof
inadequatehealthcare,limitedaccesstoqualityservices(Krahn,Hammond,&Turner,2006van
SchrojensteinLantmandeValk&NoonanWalsh,2008),andcommunicationlimitations(Gentile,Cowan,&
Smith,2015).

AssociatedhealthconditionswithahigherprevalenceinindividualswithIDinclude:

anxietydisorders(Oeseburg,Dijkstra,Groothoff,Reijneveld,&Jansen,2011)
hearingloss(Herer,2012)
heartconditions(Patja,Molska,&Iivanainen,2001)
obesityrelatedproblems(Rimmer,Yamaki,Lowry,Wang,&Vogel,2010)
seizureactivity(Oeseburgetal.,2011)and
visualimpairment(Warburg,2001).

Greaterattentioncouldbedevotedtospecialhealthneedsofindividualswithdisabilitiesasaregularpartof
medicaltraining(Sullivanetal.,2011).Addressinghealthinequalitiesaswellasprovidingadequatehealth
careandmedicaltrainingcanimprovequalityoflifeandincreaselongevityinindividualswithID.

IncidenceandPrevalence
IncidenceofIDreferstothenumberofnewcasesidentifiedinaspecifiedtimeperiod.PrevalenceofID
referstothenumberofpeoplewhoarelivingwiththeconditioninagiventimeperiod.The
incidence/prevalencedatainthissectionpertaintoU.S.basedpopulations.

ThedeterminationofincidenceandprevalenceofIDiscomplicatedbecauseresearchersofIDdonotusethe
sameoperationaldefinitionwhenselectingandidentifyingindividualswithID.Insomecases,anIQcutoff
scoreisused(e.g.,70)asacriterionfordiagnosis,whereasinothercases,thediagnosticcriteriaaremore
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qualitativeinnature(e.g.,onsetinchildhoodwithlimitationsinadaptivebehaviorandintellectual
functioning).Variationsinstudydesign,terminologydefinitions,samplesizeandcharacteristics,and
diagnostictoolscanalsoaffectincidenceandprevalencedata.Forexample,somestudyauthorsusethe
termsintellectualdisabilityanddevelopmentaldisabilityinterchangeably,thelatterofwhichcaninclude
conditionslikeASDanddevelopmentallanguagedisorder.Keepthesefactorsinmindwhenreviewingthe
incidenceandprevalencedatabelow.

OverallPopulation
A2011metaanalysisofinternationalstudiesfoundtheIDprevalenceofindividualsacrossthelife
spantobe10.37/1000or1.04%(Maulik,Mascarenhas,Mathers,Dua,&Saxena,2011).
Afollowupmetaanalysisofinternationalstudies,extendingtheworkofMauliketal.(2011),found
theIDprevalenceofchildren/adolescentsandadultstorangefrom.05to1.55%(McKenzie,Milton,
Smith&OuelletteKuntz,2016).

ChildrenandAdolescents:Overall

Datafromthe2011metaanalysisofinternationalstudiesfoundtheIDprevalenceofchildrenand
adolescentstobe18.3/1000or1.83%(Mauliketal.,2011).
Thefollowupmetaanalysisofinternationalstudiesreportedtheprevalencerangeforchildrenand
adolescentstobefrom0.22to1.55%(McKenzieetal.,2016).
Datafromthe20062010NationalHealthInterviewSurveyindicatedthatIDprevalenceinchildren
under18yearsofageintheUnitedStateswas0.5%(Schieveetal.,2012).
The2009/2010NationalSurveyofChildrenWithSpecialHealthCareNeedsrevealedthat
approximately5.8%ofchildrenaged217yearsintheUnitedStateshadanID.
Ina2010U.S.CensusBureaustudy,IDwasdiagnosedinapproximately154,000(0.4%)children
under15yearsofage(Brault,2012).
Duringthe20142015schoolyear,approximately0.12%of3to5yearoldchildrenand0.62%of6
to21yearoldstudentswhowereservedundertheIndividualswithDisabilitiesEducationAct,PartB,
hadadiagnosisofID(U.S.DepartmentofEducation,2015).

ChildrenandAdolescents:Gender
Basedondatafromthe2011metaanalysisofinternationalstudies,thefemaletomaleratioof
childrenandadolescentswithIDvariedbetween0.4and1.0(i.e.,fourto10femaleswithIDforevery
10maleswiththeconditionMauliketal.,2011Maulik,Mascarenhas,Mathers,Dua,&Saxena,
2013).

ChildrenandAdolescents:CoMorbidities

TheAutismandDevelopmentalDisabilitiesMonitoring(ADDM)NetworkoftheCentersforDisease
Control(CDC)notedaprevalenceof4per1,000childrenaged8yearswithASDwhoalsohadID
(Christensenetal.,2016).
TheADDMreportontheprevalenceofcooccurringASDandIDalsorevealedagreatermaleto
femaleprevalenceratioof3.7malesto1.0femaleinchildren8yearsold(Christensenetal.,2016).
Datafromthe20092010AnnualSurveyofDeafandHardofHearingChildrenandYouthrevealedan
IDprevalenceof15.5%inchildrenwhoaredeafwithASDand8.2%inchildrenwhoaredeafwithout
ASD(Szymanski,Brice,Lam,&Hotto,2012).

ChildrenandAdolescents:CoMorbidityAndRace/Ethnicity

ComorbidASDandIDwassignificantlylowerinnonHispanicWhitechildren(3.3per1,000)than
nonHispanicBlackchildren(5.8per1,000)whowere8yearsold(Christensenetal.,2016).

Adults:Overall

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Datafromthe2011metaanalysisofinternationalstudiesfoundtheIDprevalenceofadultstobe
4.94/1,000or.49%(Mauliketal.,2011).
ThefollowupmetaanalysisofinternationalstudiesfoundtheIDprevalenceofadultstorangefrom
.05to.08%(McKenzieetal.2016).
AstudybytheU.S.CensusBureaurevealedthatapproximately1.2million(0.5%)civilian,
noninstitutionalizedadultshadIDin2010(Brault,2012).

Adults:Gender
Basedondatafromthe2011metaanalysisofinternationalstudies,thefemaletomaleratioofadults
withIDvariedbetween0.7and0.9(i.e.,seventoninefemaleswithIDforevery10maleswiththe
conditionMauliketal.,2011Mauliketal.,2013).

SignsandSymptoms
DefiningCharacteristics

IndividualswithIDhaveintellectualdeficitsaswellasdeficitsinadaptivefunctioningintheconceptual,
social,andpracticaldomains(APA,2013).

DeficitsinIntellectualFunctions

Languagedevelopment
Reasoning
Problemsolving
Planning
Abstractthinking
Judgment
Academiclearning
Learningfromexperience

DeficitsinAdaptiveFunctioning

Failuretomeetdevelopmentalandsocioculturalstandardsforpersonalindependenceandsocial
responsibility
Limitedfunctioninginoneormoredailylifeactivities(e.g.,communication,socialparticipation,and
independentliving)acrosssettingsinthehome,school,work,andcommunity).

Thelevelofsupportneededforadaptivefunctioning(i.e.,performanceofbasiclifeskills)determinesthe
severitylevelforID.AccordingtotheDSM5(APA,2013),thesignsandsymptomsofadaptivefunctioning
deficitsacrossdomainsmayinclude:

ConceptualDomain

Slowlanguagedevelopment(childrenlearntotalklater,ifatall)
Slowdevelopmentofpreacademicskills
Difficultiesinacademiclearning(reading,writing,mathematics)
Difficultyunderstandingconceptsoftimeandmoney
Problemswithabstractthinking(concreteapproachtoproblemsolving)
Difficultiesinexecutivefunction(i.e.,planning,strategizing,prioritysetting,cognitiveflexibility)
Problemswithshorttermmemory
Difficultieswithfunctionaluseofacademicskillssuchasmoneymanagementandtimemanagement

SocialDomain

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Limitationsinlanguageandcommunicationskills
Moreconcreteandlesscomplexspokenlanguage(ifused),comparedwithpeers
Limitedvocabularyandgrammaticalskills
Receptivelanguagethatmaybelimitedtocomprehensionofsimplespeechandgestures
Communicationthatmayoccurthroughnonspokenmeansonlysuchasgestures,signs,facial
expressions,andotherformsofaugmentativeandalternativecommunication(AAC)
SocialSkills
Immaturesocialjudgmentanddecisionmaking
Difficultyunderstandingpeersocialcuesandsocialrules
Emotionalandbehavioralregulationdifficultiesthatmayadverselyaffectsocialinteractions

PracticalDomain

Requiringdifferentlevelsofsupportfordailylifeactivitiessuchas
Personalcare
Complextasks(e.g.,shopping,transportation,careorganization,meals,moneymanagement)
Employment
Healthcareandlegaldecisions
Householdtasks
Recreationalskills

CommunicationPatterns

IndividualswithIDandassociatedlanguageandcommunicationdisordersmaydemonstratesignsand
symptomsofspokenandwrittenlanguagedisordersacrossthedomainsofphonology,morphologyand
syntax,semantics,andpragmatics.Seespokenlanguagedisordersandwrittenlanguagedisorders(currently
underdevelopment)forinformationrelatedtolanguagecomprehensionandproduction,multiplemodesof
communication(e.g.,AAC),andbehavioraldifficultiesaswellassocialandemotionalproblems
experiencedbyindividualswithlanguagedisorders.

IndividualswithIDareaheterogeneousgroupcommunicationabilitiesvaryandmaybenonsymbolic(e.g.,
gestures,vocalizations,problembehaviors)and/orsymbolic(e.g.,words,signs,pictures).See
CommunicationCharacteristics:SelectedPopulationsWithanIntellectualDisabilityforexamplesoftypical
communicationpatternsofindividualswithASD,cerebralpalsy,Downsyndrome,fetalalcoholsyndrome,
andFragileXsyndrome,allofwhichmostcommonlycooccurwithID.

Causes
Thereareprenatal,perinatal,andpostnatalcausesofID.Someprenatalcauses(e.g.,environmental
influences)arepreventable.Geneticcausesaccountfor45%ofID(Batshaw,Roizen,&Lotrecchiano,2013).
DownsyndromeisthelargestgeneticcauseofID,andFragileXsyndromeisthelargestinheritedcauseof
ID.FetalalcoholsyndromeisthelargestenvironmentalcauseofID.

Prenatal

Geneticsyndromes(e.g.,DownsyndromeandFragileXsyndrome)
Inbornerrorsofmetabolism
Brainmalformation(e.g.,microcephaly)
Maternaldisease(e.g.,placentaldisease)
Environmentalinfluences(e.g.,alcohol,otherdrugs,toxins,teratogens)

Perinatal
Laboranddeliveryrelatedevents(leadingtoneonatalencephalopathy)
Anoxiaatbirth

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Postnatal

Hypoxicischemicinjury
Traumaticbraininjury
Infections
Demyelinatingdisorders
Seizuredisorders(e.g.,infantilespasms)
Severeandchronicsocialdeprivation
Toxicmetabolicsyndromesandintoxications(e.g.,lead,mercury)

CrossculturalattitudesandbeliefsmayinfluencesomeindividualsperceptionsaboutIDanditscauses
(Allison&Strydom,2009Scior,2011).

RolesandResponsibilities
Althoughspeechlanguagepathologists(SLPs)donotdiagnoseIDthemselves,theyplayakeyrolein
assessingthecommunicationskillsofindividualswithID,andtheymaybepartofateammakinga
differentialdiagnosisbetweenIDandASDorotherconditions.

SLPsalsoplayaroleinenhancingadaptivecommunicationfunctioning,asmanyoftheadaptiveskillareas
relyoncommunicationabilities.Forexample,conceptualskillsincludereceptiveandexpressivelanguage,
reading,andwritingsocialskillsincludeinterpersonalskills,followinglaws,andproblemsolvingand
practicalskillsincludefollowingroutines,usingthetelephone,andusingsocialmedia.

Theprofessionalrolesandactivitiesinspeechlanguagepathologyincludeclinical/educationalservices
(assessment,planning,andtreatment)preventionandadvocacyandeducation,administration,andresearch.
SeeASHA'sScopeofPracticeinSpeechLanguagePathology(ASHA,2016b).

AppropriaterolesforSLPsincludethefollowing:

ProvideinformationtoindividualsandgroupsknowntobeatriskforID,totheirfamilymembers,and
toindividualsworkingwiththoseatrisk
Screenindividualswhomayhavehearing,speech,language,communication,and/orswallowing
difficultiesanddeterminetheneedforfurtherassessmentand/orreferralforotherservices
Conductaculturallyandlinguisticallyrelevantandageappropriateassessmentofspeech,language,
communication,andswallowing,usingformalandinformaltools
AssesstheneedforAACservicesandsupports
Determineeligibilityforspeechandlanguageservices
Refertootherprofessionalstoruleoutotherconditions,determineetiology,andfacilitateaccessto
comprehensiveservices
PromoteearlyidentificationofDDsandhelptoimplementservicestomaximizethepotentialof
youngchildren
PartnerwithfamiliesinassessmentandinterventionwithindividualswithID
Participateasamemberoftheschoolplanningteam(e.g.,whosemembersincludeparents,teachers,
specialeducators,counselors,andpsychologists)todetermineappropriateeducationalservices
MakedecisionsaboutthemanagementofcommunicationdeficitsinpersonswithID
Developtreatmentplansforspeechandlanguageservices,includingsociallanguagegoalsandgoals
forassistingwithselfregulatoryandsocialinteractivefunctionstoenableparticipationindaily
activitiesandcurriculumtoasgreatanextentaspossible
Providetreatment,documentprogress,anddetermineappropriatedismissalcriteria
CounselpersonswithIDandtheirfamiliesregardingcommunicationrelatedissuesandprovide
educationaimedatenhancingcommunicationdevelopmentandpreventingfurthercomplications
relatedtoID
EducateotherprofessionalsontheneedsofpersonswithIDandtheroleofSLPsindiagnosingand
managingcommunicationdeficitsofthosewithID
Collaboratewithparents,teachers,caregivers,jobcoaches,peers,andotherstopromote
communicationdevelopmentanduseinindividualswithID
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ServeasanintegralmemberofateamworkingwithindividualswithIDandtheirfamilies/caregivers
and,whenappropriate,consideringtransitionplanning
SupportstudentswithIDthroughouttheirschoolyearsandinpostsecondaryeducationsettings
SupportindividualswithIDinvocationalandcommunitysettings
Consultandcollaboratewithotherprofessionals,familymembers,caregivers,andotherstofacilitate
programdevelopmentandtoprovidesupervision,evaluation,and/orexperttestimony,asappropriate
RemaininformedofresearchintheareaofIDandhelpingadvancetheknowledgebaserelatedtothe
natureandtreatmentofID
AdvocateforindividualswithIDandtheirfamiliesatthelocal,state,andnationallevelsand
providequalitycontrolandriskmanagement.

AsindicatedintheCodeofEthics(ASHA,2016a),SLPswhoserveindividualswithIDshouldbe
specificallyeducatedandappropriatelytrainedtodoso.

Assessment
SeetheAssessmentsectionoftheIntellectualDisabilityevidencemapforpertinentscientificevidence,
expertopinion,andclient/caregiverperspective.

Screening
SLPsscreenforhearing,speech,language,communication,andswallowingproblems.Screeningdoesnot
resultinadiagnosisofadisorderbut,rather,determinestheneedforfurtherassessmentand/orreferralfor
otherservices.ScreeningmaynotbeaneededstepforindividualswithID,particularlythosewithmore
severelimitationsinintellectualoradaptivefunctioning.Fortheseindividuals,acomprehensiveassessment
islikelytobethefirststep.

Screeningtypicallyincludes

gatheringinformationfromparents,teachers,andcoworkersregardingconcernsaboutanindividuals
language(s)andskillsineachlanguage
conductingahearingscreeningtoruleouthearinglossasapossiblecontributingfactortolanguage
difficulties
administeringformalscreeningassessmentsthathavenormativedataand/orcutoffscoresandthat
havedemonstratedevidenceofadequatesensitivityandspecificity
usinginformalmeasures,suchasthosedesignedbytheclinicianandtailoredtothepopulationbeing
screened(e.g.,preschool,schoolage/adolescence,adult)
observingspeechproduction,languagecomprehensionandproduction,socialcommunication,and
literacyskillsinnaturalenvironmentsand
conductingascreeningofswallowingfunction.

Screeningmayresultinrecommendationsfor

completeaudiologicassessment
comprehensivelanguageassessment
comprehensivespeechsoundassessment,ifthespeechsoundsystemisnotappropriateforthe
individualsageand/orlinguisticcommunity
comprehensiveliteracyassessmentand
referralforotherassessmentsorservices.

ComprehensiveAssessment

CollaborationandTeaming

AssessmentforindividualswithIDinvolvesmultipleprofessionalsduetothevaryingandfarreachingneeds
acrossdevelopmentaldomains.Teammodelsmaybemultidisciplinary,interdisciplinary,ortransdisciplinary

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(seecollaborationandteaming).

TheparticularcollaborativeteammodelthatisselecteddependsontheneedsoftheindividualwithID.
Teammembersdeterminestrengthsandlimitationsinadaptivefunctioningandcollaborativelydeterminethe
levelsofsupportsneededacrossconceptual,social,andpracticaldomains.

TheroleofSLPsandaudiologistsistoassesstheindividualsspeech,language,andhearingskills.
AssessmentsaresensitivetoculturalandlinguisticdiversityandaddresscomponentswithintheICF(WHO,
2001)framework,includingbodystructures/functions,activities/participation,andcontextualfactors.
Findingsfromthecommunicationandhearingassessmentsshouldbeanalyzedinthecontextoffindings
fromotherprofessionals(e.g.,psychologist)forwhomanIDdiagnosisiswithintheirpurview.

ComponentsofaComprehensiveAssessment

Bothformalandinformalassessmentapproachescanbeused.Formaltestingmayberequiredifdiagnosisor
eligibilityhaveyettobedeterminedforachildatriskfor,orsuspectedof,aDD.Informaltestingmaybe
mostusefultodeterminethechildsachievementofspecificdevelopmentalmilestones.Seeassessmenttools,
techniques,anddatasourcesthatmaybeusedinacomprehensivecommunicationassessment.Dynamic
assessmentmaybeusedtoidentifynonsymbolicandsymboliccommunicationbehaviorsandtoevaluate
individuallearningpotential(Pea,1996Snell,2002).

Thecomprehensiveassessmentmayincludethefollowing,dependingontheageandfunctioningofan
individualwithIDandhisorherneeds:

Casehistory,includingmedical,educational,andvocationalstatusaswellasteacher,caregiver,
employer,andclient/patientperspectivesontheproblem.
Interviewwithfamilymembersaboutcommunicationduringdailyroutines.
Reviewofauditory,visual,motor,andcognitivestatus,includinghearingscreening.
Assessmentof
nonsymbolic(e.g.,gestures,vocalizations,problembehaviors)and/orsymbolic(e.g.,words,
signs,pictures)communication
play
socialinteractionandsocialcommunication
spokenlanguage(listeningandspeaking)
writtenlanguage(readingandwriting)
speechproduction
oralmotorskills
swallowingand
fluency.
AssessmentforAACand/orotherassistivetechnology.
Identificationofthepotentialforeffectiveinterventionstrategiesandcompensations.

DetailsregardingthecomponentsofacomprehensiveassessmentareavailableonthefollowingPractice
Portalpages:

Childhoodhearingscreening
Spokenlanguagedisorders
Speechsounddisorders:Articulationandphonology
Childhoodapraxiaofspeech
Childhoodfluencydisorders
Writtenlanguagedisorders(currentlyunderdevelopment)
Augmentativeandalternativecommunication(AAC)(currentlyunderdevelopment)
Pediatricdysphagia
Adultdysphagia(currentlyunderdevelopment)

ForindividualswithASDandID,alsoseeautismspectrumdisorderandsocialcommunicationdisordersin
schoolagechildrenforrelevantassessmentconsiderationsbasedonindividualneeds.

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InformationprovidedinCommunicationCharacteristics:SelectedPopulationsWithanIntellectualDisability
maybeusefulinputtingtogetheranassessmentprotocoltodocumentanindividualperformanceprofile.For
example:

ChildrenwithDownsyndromeoftenhaveaspecificdeficitinexpressivesyntaxrelativetosemantics.
Theyalsohavedifficultywithspeechproductionduetolowmuscletoneandcharacteristicfacial
dysmorphlogy(Berglund,Eriksson,&Johansson,2001Roberts,Price,&Malkin,2007).Therefore,
childrenwithDownsyndromemayrequireadetailedevaluationofsyntacticproductionrelativeto
comprehensionalongwithaspeechintelligibilityinventory.
IndividualswithFragileXsyndromeoftenhavepragmaticlanguagedifficulties(Abbeduto&Sterling,
2011).Theywouldbenefitfromadetailedevaluationofsocialcommunicationrelativetolanguage
structureandfunction.

Assessmentmayresultin

diagnosisofacommunicationdisorderordelay,secondarytoID
descriptionofthecharacteristicsandseverityofthecommunicationdisorderordelay
determinationofperformancevariabilityasafunctionofcommunicativesituations/contexts
identificationofpossiblehearingproblems
recommendationsforinterventionandsupport
recommendationofacommunicationsystem(e.g.,lowtechorspeechgeneratingdevice[SGD])
referraltootherprofessionalsasneeded(e.g.,physician,physicaltherapist,occupationaltherapist,
psychologist,orcounselor)
recommendationsforsupportforparents,caregivers,teachers,andemployersand
recommendationsforsupportfortransitions(e.g.,earlyinterventionintoschoolageschoolageinto
workplace).

FamilyCenteredPractices

PersonswithIDandtheirfamiliesareintegraltotheassessmentprocessandarepivotaldecisionmakersin
determiningspecificgoalsandobjectivesandhowclinicalservicesshouldbeprovidedfollowingthe
assessment.

Familiesofferanimportantanduniqueknowledgebaseaboutthestrengths,challenges,andneedsforthe
individualwithID.Theyprovideusefulinformationaboutcommunicationskillsduringdailyroutines.They
alsoidentifyvaluedlifeoutcomesfortheirchildren(e.g.,beingsafeandhealthy,havingahome,establishing
meaningfulrelationships,havingchoicesandcontrol,andcreatingopportunitiesformeaningfulactivities
acrossenvironmentsGiangreco,1990).Ultimately,thedecisionaboutspecificgoalsandobjectivesrests
withthefamilyandthepersonwithID,recognizingthattheindividualfamilycircumstancesandvaluesare
centraltothedecisionmakingprocess.

Seefamilycenteredpracticeforgeneralguidelines.

CulturalandLinguisticFactors

IndividualswithIDcommonlyexperiencestigmatization,discrimination,andhealthinequalitiesacross
cultures(Allison&Strydom,2009).Becauseofthis,somefamilymembersmaynotbewillingtoseek
services,evenwhensuchservicesarereadilyavailable.

Linguisticfactorsmayinfluenceanassessmentprotocolwhenworkingwithindividualswhoare
multilingual.Carefulconsiderationoflanguagehistory(e.g.,qualityanddurationofexposuretodifferent
languages)andlinguisticabilitiesinalllanguagesisnecessaryintheevaluation.Seebilingualservice
delivery,culturalcompetence,andcollaboratingwithinterpretersforadditionalinformation.

EligibilityforServices

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IndividualswithIDofallagesareeligibleforSLPservicesbecauseenhancementofcommunicationskillsis
neededtofunctioneffectively,regardlessofageorcognitivelevelrelativetocommunicationabilities.
EligibilityisanareathathascontinuedtoevolveastherightsofindividualswithIDhavebeenincreasingly
wellrecognized.Infact,theNJCemphasizesthattherearenoprerequisitesforcommunication(NJC,2002,
2003).

BeginningwiththeDevelopmentalDisabilitiesServicesandFacilitiesActof1970(PL91517),eligibility
rulesforservicedeliveryforIDhaveundergonewidespreadchange(e.g.,Hauber,1984Kohlenberg,Mack,
&Brown,1996WhitneyThomas,Timmons,Gilmore,&Thomas,1999).

Categoricallyapplyingaprioricriteriainmakingdecisionsoneligibilityforservicesisnotconsistentwith
thelawandIDEAregulations(IDEA,2004).Theseaprioricriteriacauseconcernwhenappliedwithout
regardtoindividualneeds.Theyincludediscrepanciesbetweencognitiveandcommunicationfunctioning
(cognitivereferencing)diagnosisabsenceofprerequisitecognitiveorotherskillsandfailuretobenefit
frompreviouscommunicationservicesandsupports.SeeNJC(2002,2003)forinformationrelatedtoa
prioricriteria.AlsoseeASHAsresourcepageoncognitivereferencing.

Cognitivereferencingisaparticularconcernwhenappliedtoindividualswithdisabilitiesingeneralandto
individualswithIDinparticular(Casby,1992Cole,Dale,&Mills,1990Cole&Fey,1996Notari,Cole,&
Mills,1992).Cognitivereferencingrestsontheassumptionthatlanguageskillscannotimprovebeyond
cognitiveability.RelevantresearchindicatesthatlanguageinterventionbenefitschildrenwithIDevenwhen
nolanguagecognitiondiscrepancyexists(D.Carr&Felice,2000Coleetal.,1990Warren,Gazdag,
Bambara,&Jones,1994).

Theabsenceofprerequisitecognitiveorotherskillsfordeterminingeligibilityisalsoofconcernfor
individualswithID.Therearenoprerequisitesforcommunicationsupportsandservices,includingtheuseof
AAC(Romski&Sevcik,2005).Forexample,someindividualswithIDmaybegoodcandidatesfor
immediateintroductionofsymboliccommunicationgoalsthattargetacquisitionanduseofwordsorAAC
symbols.Forindividualswithextremelylimitedfunctionalcommunication,othershorttermgoalsmaybe
equallyappropriate(e.g.,broadercommunicationgoalssuchasturntakingandsocialparticipation,bothof
whichinvolvenonsymbolicmodessuchasgesturing).

Forinformationabouteligibilityforservicesintheschools,seeeligibilityanddismissalinschools,IDEA
PartBIssueBrief:IndividualizedEducationProgramsandEligibilityforServices,and2011IDEAPartC
FinalRegulations.

AdolescentsandAdultsWithID

IndividualswithIDcontinuetodevelopcommunicationskillsbeyondtheschoolyears(e.g.,Cheslock,
BartonHulsey,Romski,&Sevcik,2008).AsthepersonwithIDreachesadolescenceandadulthood,hisor
hercommunicationandfunctionalneedschange.Forexample,theteenyearsplaceapremiumonpeer
interactions,useofsocialmedia,andcommunicationskillsneededtooptimizeacceptanceandrelationship
development.

Individualstransitioningfromschooltovocationalsettingswillneedcommunicationskillsspecifictothe
worksetting(e.g.,talkingwithcoworkersandsupervisors,interactingwithcustomers).

SLPsworktomaximizetheparticipationandindependenceofindividualswithIDastheyexperiencelife
transitionsthatplacenewdemandsoncommunication.Thespeechlanguageassessmentwillneedto
incorporateanevaluationofskillsneededtosupporttheindividualschangingcommunicationneeds.

IDandHearingLoss

AnincreasedprevalenceofhearinglosshasbeenreportedinindividualswithIDascomparedwiththe
generalpopulation.Forexample,considerableratesofconductivehearinglosshavebeenreportedin
childrenwithDownsyndrome(e.g.,Hess,Rosanowski,Eysholdt,&Shuster,2006Park,Wilson,Stevens,
Harward,&Hohler,2012),andHerer(2012)foundthattheprevalenceofhearinglossinnoninstitutionalized

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adultswithIDwashigherthanforindividualsinthegeneralpopulationandthatthehearinglossoccurredat
amuchyoungerage.

Therefore,earlydetectionofhearinglossandroutinemonitoringareessentialforensuringpositive
communicationoutcomes.Thecomprehensiveassessmentincludesahearingscreeningandreferralfora
completeaudiologicalassessment,ifhearingconcernsareindicated.

Seepermanentchildhoodhearinglossandhearinglossbeyondearlychildhoodformoreinformation.

ChallengingBehaviors

ComprehensiveassessmentofindividualswithIDinvolvesassessmentofthefunctionofchallenging
behaviors,alsoknownasproblembehaviors.Commonchallengingbehaviorsincludeaggressive,
disruptive,selfinjurious,andstereotypicbehaviors.

Challengingbehaviorscanfunctionasameanstogainattention(socialreinforcement),expresswantsor
needs(tangiblereinforcement),indicatefrustrationoradesiretoavoidanonpreferredactivityorevent
(escapeavoidance),orgainsensoryinput(sensoryreinforcement).

Understandingthesebroadfunctionsofnonspeechmodescanleadtogreaterunderstandingofthepotential
communicationfunctionsofchallengingbehaviors(e.g.,Reichle&Wacker,1993)anddevelopmentof
responsiveinterventions.Thisknowledgeservesasthebasisforreplacingproblembehaviorswithmore
appropriatecommunicationskills,includingAAC,thatwouldservethesamefunctions(seefunctional
communicationtraining[FCT]intheTreatmentsection).

DifferentialDiagnosis

SLPsneedtodifferentiatebetweenIDandotherdisordersandconditions(e.g.,spokenlanguagedisorders
andhearingloss)whosecommunicationproblemsparticularlywhenseverecanbemistakenlyattributed
toID(e.g.,latelanguageemergenceandASD).

DevelopmentalDelay

Developmentaldelay(DD)iscommonlyusedasatemporarydiagnosisinyoungchildrenatriskforID.It
indicatesafailuretoachieveageappropriatedevelopmentalmilestones(Petersen,Kube,&Palmer,1998).
MoresevereimpairmentsaremorelikelytoresultinearlyidentificationofID(Daily,Ardinger,&Holmes,
2000).

Often,thefirstsignofadevelopmentalproblemincludinginmilderformsofIDisdelayedlanguage
development.Therefore,SLPsmayneedtohelpmakeadifferentialdiagnosisbetween(a)latelanguage
emergenceand(b)IDoranotherDD.

ASD

SLPsmayreceivereferralsforchildrenwithcommunicationdelaysordeficitsandlimitationsinsocial
functioning.ThesebehaviorsmaysignalASD,ID,orotherconditions.TheSLPmaybepartofateam
makingadifferentialdiagnosisbetweenIDandASDoradiagnosisofcomorbidity.DiagnosisofIDorASD
maybedifficultbecauseofthesimilaritiesandcomorbiditybetweenthetwoconditions.

CommonalitiesbetweenASDandIDinclude:

onsetduringthedevelopmentalperiod
deficitsinnonspokenandverbalcommunicationskills
limitationsinsocialparticipationand
attentionandacademicdifficulties.

DifferencesbetweenASDandIDincludethefollowing:
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IndividualswithIDhavedeficitsinintellectualfunctioning,bydefinitionhowever,individualswith
ASDhavearangeofintellectualabilities,fromhavinganIQwithinnormallimitstohavingsevereIQ
limitations.
IndividualswithIDusuallydevelopskillsslowerthandotheirtypicallydevelopingpeers,butsome
followpatternsoftypicaldevelopmentthosewithASDmaynotfollowthetypicaldevelopmental
progressionofskillsacrossdomains(e.g.,communicationandsocialinteraction).
ResearchshowsthatindividualswithASDhavedifficultywiththeoryofmind(i.e.,understandingthe
perspectiveofothers),regardlessoftheirlevelofcognitivefunctioningthesedifficultiesaremore
severeinindividualswithASDthaninindividualswithIDalone(Yirmiya,Erel,Shaked,&
SolomonicaLevi,1998).

Treatment
SeetheTreatmentsectionoftheIntellectualDisabilityevidencemapforpertinentscientificevidence,expert
opinion,andclient/caregiverperspective.

EachindividualwithIDhasauniqueprofile,basedonhisorherleveloflanguagefunctioningaswellas
functioninginareasrelatedtolanguageandcommunication,includinghearing,cognitivelevel,speech
productionskills,andemotionalstatus.Interventionconsiderscoexistingstrengthsandneedsinallareasto
ensureindividualizedtreatmentandsupports.

ResearchsupportstheprovisionofcommunicationinterventionforindividualswithID(Sevcik&Romski,
2016Snelletal.,2010).AsindicatedbyAAIDD(2013),apersonsleveloflifefunctioningwillimproveif
appropriatepersonalizedsupportsareprovidedoverasustainedperiod(AdditionalConsiderationssection,
para.2).Thegoaloftreatmentistominimizethepotentialdebilitatingeffectsofdisabilitiesonclientsand
theirfamiliesandtomaximizethelikelihoodofdesirableoutcomes.

TreatmentPrinciples
Communicationinterventionfocusesonthecontextofinteractionsandincludesindividualsthatpersonswith
IDencounterintheirnaturalenvironments.SLPsensurethatinterventionprovidesampleopportunitiesfor
communicationandincorporatesavarietyoflanguagefunctions(e.g.,greeting,commenting,requesting)
multiplepartnersdifferentformsandmodalities[e.g.,speech,AAC]andvariedcommunicationcontexts
[e.g.,home,educational,recreational,vocational,andcommunitysettings]).Treatmentapproachestypically
encompassavarietyoftechniquesandapproaches(Goldstein,2006).

SLPshelpensurethatcommunicationpartnersrecognizeandrespondtocommunicationattemptsandbuild
ontheinterests,initiations,andrequestsofpersonswithID.Wheninvolvingothersininterventionactivities,
SLPsfosteranappreciationfortheimportanceoflanguageinfuturelearningandfunctioning.

SeeTreatmentPrinciplesforIndividualsWithanIntellectualDisability.

TreatmentTargetsandContexts

Communicationinterventionissensitivetoculturalandlinguisticdiversityandaddressescomponentswithin
theICF(WHO,2001)framework,includingbodystructures/functions,activities/participation,and
contextualfactors(personalandenvironmental).

Dependingonassessmentresults,age,severity,etiology,andcommunicationandrelatedneeds,intervention
forindividualswithIDmayaddresstheareasof

earlycommunicationskills(e.g.,pointing,turntaking,jointattention)
socialinteractionandplay
pragmaticconventions(spokenandnonspoken)forcommunicatingappropriatelyinvariedsituations
speechproduction
spokenandwrittenlanguageforsocial,educational,andvocationalfunctions,withanemphasison
participationinspecificactivitiesidentifiedasproblematicfortheindividual
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literacy
increasedcomplexityofspokenandwrittenlanguageformoreeffectivecommunication
contextualfactorsthatinfluencetheindividualsrelativesuccessordifficultyinthoseactivities
compensatorycommunicationtechniquesandstrategies,includingtheuseofAACorotherassistive
technologyand
feedingandswallowing.

SLPsprioritizetreatmenttargetsonanindividualbasis,focusingonthosethathavethegreatestpotentialfor
improvingcommunication.

Treatmentprogramsoftenincorporatetrainingofcommunicationpartnerstosupporttheindividuals
languagecomprehensionandexpression.Trainingcanincludeuseofcommunicationstrategies,cuing
techniques,and/orassistivetechnology.

Interprofessionalcollaborationalsohasthepotentialtoimprovecommunicationskills.Forexample,an
exercisephysiologistandanSLPmayworktogethertoimproverespiratorysupport,whichcaninturn
enhancespeechproductionandintelligibility.

SeeASHA'sPreferredPracticePatternsforamoredetailedoutlineofthemajorcomponentsof
communicationinterventionforindividualsacrossthelifespan(ASHA,2004).

TreatmentModes/Modalities
Treatmentmodesandmodalitiesaretechnologiesorothersupportsystemsthatcanbeusedinconjunction
withorintheimplementationofvarioustreatmentoptions.Forexample,videobasedinstructioncanbeused
inpeermediatedinterventionstoaddresssocialskillsandothertargetbehaviors.

Augmentativeandalternativecommunication(AAC)supplementing,orusingintheabsenceof,natural
speechand/orwritingwithaided(e.g.,picturecommunicationsymbols,linedrawings,Blissymbols,and
tangibleobjects)and/orunaided(e.g.,manualsigns,gestures,andfingerspelling)symbols.Aidedsymbols
requiresometypeoftransmissiondeviceunaidedsymbolsrequireonlythebodytoproduce.AidedAAC
includesspeechgeneratingcommunicationdevices(Beukelman&Mirenda,2013).

Activityschedules/visualsupportsactivityschedules/visualsupportsincludeobjects,photographs,
drawings,orwrittenwordsthatactascuesorpromptstohelpindividualscompleteasequenceof
tasks/activities,attendtotasks,transitionfromonetasktoanother,orbehaveappropriatelyinvarious
settings.Writtenand/orvisualpromptsthatinitiateorsustaininteractionarecalledscripts.Scriptsareoften
usedtopromotesocialinteractionbutcanalsobeusedinaclassroomsettingtofacilitateacademic
interactionsandpromoteacademicengagement(Hart&Whalon,2008).

Computerbasedinstructiontheuseofcomputertechnology(e.g.,iPad)and/orcomputerizedprograms
toteachcommunicationandsocialskills(e.g.,BernardOpitz,Sriram,&NakhodaSapuan,2001Neely,
Rispoli,Camargo,Davis,&Boles,2013).

Videobasedinstruction(alsocalledvideomodeling)anobservationalmodeofteachingthatusesvideo
recordingstoprovideamodelofthetargetbehaviororskill.Videorecordingsofdesiredbehaviorsare
observedandthenimitatedbytheindividual(DardenBrunson,Green,&Goldstein,2008).Thelearnersself
modelingcanbevideotapedforlaterreview.

TreatmentOptions

Belowarebriefdescriptionsoftreatmentoptionscommonlyusedtoaddresscommunicationproblems
associatedwithID.Thetreatmentmodes/modalitiesdescribedabove(e.g.,AAC)maybeusedtoimplement
thesetreatmentoptions.InterventionforindividualswithIDtypicallyincorporatesavarietyofoptionsand
techniquesincombination.Thislistisnotexhaustive,andtheinclusionofanyspecifictreatmentapproach
doesnotimplyendorsementfromASHA.

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SLPsdeterminewhichoptionsareappropriatebytakingintoconsiderationtheindividualsageandlanguage
profileandcommunicationneeds,factorsrelatedtolanguagefunctioning,thepresenceofcoexisting
conditions,culturalbackgroundandvalues,andavailableresearchevidence.

Otherportalpagescanserveasusefulresourcesfortreatmentoptions,dependingontheetiologyfortheID.
OntheASHAPracticePortal,seethetreatmentsectionsofautismspectrumdisorder,spokenlanguage
disorders,andsocialcommunicationdisordersinschoolagechildren.

BehavioralInterventions

Behavioralinterventionsandtechniques(e.g.,differentreinforcement,prompting,fading,andmodeling)are
designedtoreduceproblembehaviorsandteachfunctionalalternativebehaviorsusingthebasicprinciplesof
behaviorchange.Thesemethodsarebasedonbehavioral/operantprinciplesoflearningtheyinvolve
examiningtheantecedentsthatelicitacertainbehavior,alongwiththeconsequencesthatfollowthat
behavior,andthenmakingadjustmentsinthischaintoincreasedesiredbehaviorsand/ordecrease
inappropriateones.Behavioralinterventionsrangefromonetoone,discretetrialinstructiontonaturalistic
approaches.

Appliedbehavioranalysis(ABA)atreatmentapproachthatusesprinciplesoflearningtheorytobring
aboutmeaningfulandpositivechangeinbehavior.ABAtechniqueshavebeenusedtohelpbuildavarietyof
skills(e.g.,communication,socialskills,selfcontrol,andselfmonitoring)andhelpgeneralizetheseskillsto
othersituations.Thetechniquescanbeusedinbothstructured(e.g.,classroom)andeveryday(e.g.,family
dinnertime)settingsandinoneononeorgroupinstruction.ABAhasbeenusedforindividualswithID,
particularlythosewhoalsohaveASD(e.g.,Spreckley&Boyd,2009).

Interventioniscustomizedbasedontheindividualsneeds,interests,andfamilysituation.ABAtechniques
areoftenusedinintensive,earlyintervention(beforeage4years)programstoaddressafullrangeoflife
skills(e.g.,Frea&McNerney,2008).Intensiveprogramstotalfrom25to40hoursperweekfor1to3years.
QualificationsforprovidingABAtherapymayvarybystatecheckwithyourstate,asthismayaffect
reimbursement.

Environmentalarrangementatechniquethatinvolvesarrangingtheenvironmenttoencourage
communication(Halle,1988McCormick,FromeLoeb,&Schiefelbusch,2003).Theideaistoincrease
interestintheenvironmentandsettheoccasionforcommunication.TheSLPcanbuildontheindividuals
desiretorequestandcommentonaspectsoftheenvironmentusingstrategiessuchasputtinginteresting
materialsinsightbutoutofreachsabotagingthesituationwithmissingelementsorprovidinginadequate
portionsandsettingupchoicemaking,unexpected,orsillysituations.

Functionalcommunicationtraining(FCT)abehavioralinterventionprogramthatcombinesthe
assessmentofthecommunicativefunctionsofproblembehaviorwithABAprocedurestoteachalternative
responses.Problembehaviorscanbeeliminatedthroughextinctionandreplacedwithalternate,more
appropriateformsofcommunicatingneedsorwants.FCTcanbeusedacrossarangeofagesandregardless
ofcognitivelevelorexpressivecommunicationabilities(E.G.Carr&Durand,1985).

AnFCTapproachhasbeenusedwithstudentswithIDtoreplacechallengingbehaviorswithappropriate
communicationalternatives(Brady&Halle,1997Martin,Drasgow,Halle,&Brucker,2005Schmidt,
Drasgow,Halle,Martin,&Bliss,2014).Thefirststepisthedefinitionofthechallengingbehaviorandthe
antecedentandconsequentvariableshypothesizedtomotivatethem(Dunlap&Fox,1999Lucyshyn,
Kayser,Irvin,&Blumberg,2002Schwartz,Boulware,McBride,&Sandall,2001).Second,theSLPuses
thisinformationtoidentifyandteachsimpleandpotentiallymoreefficientcommunicationskillsthatserve
thesamefunctions.Finally,onemayexpandonthoseskillsandensurethatappropriatecommunicationskills
areusedeffectivelyindifferentcontextsandthatthechallengingbehaviorisextinguished.

Incidentalteachingateachingtechniquethatusesbehavioralprocedurestoteachelaboratedlanguage
naturallyoccurringteachingopportunitiesareprovidedbasedontheindividualsinterests.Followingthe
individualslead,attemptstocommunicatearereinforcedastheseattemptsgetclosertothedesired
communicationbehavior(McGee,Morrier,&Daly,1999).Incidentalteachingrequiresinitiationbythe
individual,whichservestobeginalanguageteachingepisode.Ifthepersondoesnotinitiate,anexpectant
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lookandatimedelaymightbesufficienttopromptlanguageuse.Thecliniciancanpromptwithaquestion
(e.g.,Whatdoyouwant?)ormodelarequest(e.g.,Say:Ineedpaint.).

Milieutherapyarangeofmethods(includingincidentalteaching,timedelay,andmandmodel
procedures)thatareintegratedintoachildsnaturalenvironment.Itincludestrainingineveryday
environmentsandduringactivitiesthattakeplacethroughouttheday,ratherthanonlyattherapytime.
Milieulanguageteachingandotherrelatedproceduresoffersystematicapproachesforpromptingchildrento
expandtheirrepertoireofcommunicationfunctionsandtouseincreasinglycomplexlanguageskills(Kaiser,
Yoder,&Keetz,1992Kasarietal.,2014).

Timedelayabehavioralmethodofteachingthatfadestheuseofpromptsduringinstruction.Forexample,
thetimedelaybetweeninitialinstructionandanyadditionalinstructionorpromptingisgraduallyincreased
astheindividualbecomesmoreproficientattheskillbeingtaught.Timedelaycanbeusedwithindividuals
regardlessofcognitivelevelorexpressivecommunicationabilities(e.g.,Liber,Frea,&Symon,2008).

PeerMediated/ImplementedTreatment

Peermediated/implementedtreatmentapproachesincorporatepeersascommunicationpartnersforchildren
withdisabilitiesinanefforttominimizeisolation,provideeffectiverolemodels,andboostcommunication
competence.Typicallydevelopingpeersaretaughtstrategiestofacilitateplayandsocialinteractions
interventionsarecommonlycarriedoutininclusivesettingswhereplaywithtypicallydevelopingpeers
naturallyoccurs(e.g.,preschoolsetting).ThefollowingexamplesmaybeusedforchildrenwithID,based
onindividualcommunicationneeds.

LearningExperiencesandAlternativeProgram(LEAP)amultifacetedprogramforpreschoolchildren
withASDandtheirparents(Hoyson,Jamieson,&Strain,1984Strain&Hoyson,2000).LEAPusesa
varietyofstrategiesandmethods,includingABA,peermediatedinstruction,selfmanagementtraining,
prompting,andparenttraining.LEAPisimplementedinaclassroomsettingconsistingofchildrenwithASD
andtypicallydevelopingpeersandisdesignedtosupportchilddirectedplay.

CircleofFriendsatreatmentapproachthatusestheclassroompeergrouptoimprovethesocial
acceptanceofaclassmatewithspecialneedsbysettingupaspecialgrouporcircleoffriends.Thefocusis
onbuildingbehaviorsthatarevaluedineverydaysettings.Theapplicationofskillstonewandappropriate
situationsisreinforcedasnaturallyaspossibleassuchsituationsoccur(Whitaker,Barratt,Joy,Potter,&
Thomas,1998).

Integratedplaygroupsatreatmentmodeldesignedtosupportchildrenofdifferentagesandabilitieswith
ASDinmutuallyenjoyedplayexperienceswithtypicalpeersandsiblings.Smallgroupsofchildrenplay
togetherundertheguidanceofanadultfacilitator.Thefocusisonmaximizingthechildspotentialand
his/herintrinsicdesiretosocializewithpeers(Wolfberg&Schuler,1993).

TreatmentConsiderations

TargetBehaviorsforSpecificPopulations

SelectionoftargetbehaviorsforindividualswithIDhasbenefitedfromanincreasedunderstandingofthe
specificcommunicationdeficitsassociatedwithvariousdiagnoses,especiallythemoststudiedpopulations
DownsyndromeandASD.Avarietyofapproachesmaybeselectedbasedonindividualstrengthsandneeds.

Considerthefollowingexamples:

ForchildrenwithDownsyndrome,interventionshavetendedtofocusonimprovingintelligibility
throughspeechandalternativemodesofcommunications(Girolametto,Weitzman,&Clements
Baartman,1998KayRainingBird,Gaskell,Babineau,&MacDonald,2000Kumin,Council,&
Goodman,1999Layton&Savino,1990Warren&Yoder,1998Yoder&Warren,2001).

ForchildrenwithASD,interventionstypicallyfocusonsocialcommunicationskills(e.g.,Goldstein,
English,Shafer,&Kaczmarek,1997Kaiser,Hancock,&Nietfeld,2000Pierce&Schreibman,1995
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Smith&Camarata,1999Stevenson,Krantz,&McClannahan,2000Thiemann&Goldstein,2004).
Peermediatedinterventionapproacheshaveshownparticularsuccesswithyoungchildren.

TransitioningYouth

IndividualswithIDmayexperiencechallengesinacquiringtheskillsnecessaryforindependentlivingand
achievingsuccessinpostsecondaryeducation/trainingprograms,employmentsettings,andsocialsituations.
Theyneedcontinuedsupporttofacilitateasuccessfultransitiontoadulthood.SLPsareinvolvedintransition
planningandmaybeinvolvedtovaryingdegreesinothersupportservicesbeyondhighschool.

Seetransitionyouth.

AgingAdults

TheSLPhelpsmaximizeindependentfunctioninginagingadults.AdultswithIDexperiencethesameage
relatedhealthproblemsandfunctionaldeclineobservedinthegeneralelderlypopulation(LazenbyPaterson
&Crawford,2014).However,theagingprocessmaybeprematureinadultswithIDascomparedwiththe
generalpopulation(e.g.,Lin,Wu,Lin,Lin,&Chu,2011).

Forexample,individualswithDownsyndromemaybeathigherriskforearlieronsetofdementiawhen
comparedwiththegeneralpopulation(Burtetal.,2005Hawkins,Eklund,James,&Foose,2003).Even
whendementiaisnottakenintoaccount,speechandlanguageskillsmaybegintodeclineinadultswithID
fromabouttheageof50(Robertsetal.,2007).IfadultswithIDseekspeechandlanguageservicesbecause
ofnewcommunicationconcerns,SLPswillneedtoconsiderthepossibilitythattheindividualis
experiencingmildcognitiveimpairment,aconditioncharacterizedbysubtlecognitivedeficitsthatmaylead
todementia(seedementia).

Mosthealthyadultswillnotexperienceproblemswitheating,drinking,andswallowing,despiteagerelated
changesinthemusclesusedforfeedingandswallowing(Lazenby,2008).However,someadultswithID
particularlythosewithpsychomotorimpairmentsorothercomorbidconditionsthataffectfeedingand
swallowingmayexperiencedysphagiarelatedproblemsastheyage(LazenbyPaterson&Crawford,
2014).

IndividualsWithChallengingBehaviors

WhenindividualswithIDaretaughtcommunicationskillsthatserveefficientlyandeffectivelyasalternative
behaviors,reductionsinchallengingbehaviorsresult(Kurtz,Boelter,Jarmolowicz,Chin,&Hagopian,
2011).

Identifyingandtreatingbehaviorsearlyindevelopmentmaypromoteappropriatecommunicationusing
alternativemodesandpreventnegativelongtermconsequences.Replacingchallengingbehaviorswith
appropriateandincreasinglysophisticatedcommunicationskillshasthepotentialtofacilitategrowthin
academicachievementandimprovesocialrelationshipsandvocationaloutcomes.

Identifyingthefunctionofchallengingbehaviorscanbeacomplextaskinitself.Forexample,the
motivationforaspecificchallengingbehaviorcanvarybasedoncontext(taskvs.leisurecontextsHaring&
Kennedy,1990).SLPsareencouragedtoconsiderapotentiallypreventiveapproachbyteaching
communicationskillsthatservemultiplefunctions(Wacker,Berg,Harding,&Asmus,1996).

SLPshaveanessentialroleineducatingteammembersaboutthecommunicationfunctionsofsuch
behaviorsanddevelopingmethodsforreplacingthemwithotherformsofcommunicationbehavior.

CulturalandLinguisticFactors

Culturaldifferencesintheattitudes,beliefs,andperceptionsofindividualswithIDarewelldocumented
withintheUnitedStatesandinothercountries(Allison&Strydom,2009Scior,2011WHO,2010).This
informationisimportantbecauseitaffectsservicedeliveryandtheinteractionbetweentheSLPandthe
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family.Althoughtherehasbeenaglobalmovementtoencouragedeinstitutionalizationofindividualswith
IDandimproveaccesstoqualitycareandsocialintegration,thisisnotyetarealityinallcountries.

Culturalperspectivesaffectcommunicationandthewaycareisprovided.SLPsneedto(a)beawareof
culturallyassociatedbeliefsaboutthecauseofID,(b)providepersoncenteredcare,(c)buildworking
relationshipswithcaregivers,and(d)addresscommunicationbarriers(Allison&Strydom,2009).

ServiceDelivery
SeetheServiceDeliverysectionoftheIntellectualDisabilityevidencemapforpertinentscientificevidence,
expertopinion,andclient/caregiverperspective.

InadditiontodeterminingthetypeofspeechandlanguagetreatmentthatisoptimalforindividualswithID,
SLPsconsiderotherservicedeliveryvariablesincludingformat,provider,timing,andsettingthatmay
affecttreatmentoutcomes.Servicedeliverydecisionsaremadebasedontheindividualscommunication
needsrelativetohisorherfamily,community,school,orworksetting.

Format

Formatreferstothestructureofthetreatmentsession(e.g.,groupvs.individualdirectand/orconsultative)
provided.

Servicedeliveryoptionsincludehomebased,pullout,classroombased(e.g.,pushin),andcollaborative
consultation.ThepulloutmodelcontinuestobethepredominantservicedeliveryoptionforSLPpractice
acrosspopulationsandages.However,exclusiveuseofthismodelwithpersonswithIDisrarely
appropriate.Failuretogeneralizehasbeenacommonlyciteddrawbacktotraditionalpulloutmodelsof
servicedelivery(Cirrin&Penner,1995Nelson,1998).

Provider

Providerreferstothepersonofferingthetreatment(e.g.,SLP,trainedvolunteer,caregiver).

Recommendedpracticesfollowacollaborativeprocessthatinvolvesamultifacetedteamincludingfamilies,
caregivers,personswithdisabilities,andprofessionals.Theseteamsestablishandcoordinateservicesthat
arefamilycentered,culturallyappropriate,comprehensive,andcompassionate,andthatproducemeaningful
lifeoutcomes.Involvedpartnersmayincludeparents,siblings,grandparents,friends,andacquaintancesin
thehometeachers,classmates,paraprofessionals,andothersintheschoolemployers,jobcoaches,and
fellowworkersinvocationalsettingsandavarietyofconversationalpartnersincommunitysettings
(recreationalfacilities,churchesandsynagogues,stores,etc.).

Modelsofteamingrequirevaryingdegreesofcollaborationandengageparticipantsintheestablishmentofa
jointpurpose,sharedgoals,andanorganizedapproachtoimplementingthesegoals.Seecollaborationand
teaming.

Timing

Timingreferstotheschedulingofinterventionrelativetothediagnosis.

Theimportanceofearlyinterventionforchildrenwhoareathighriskforcommunicationdisorderscannotbe
overstated.ForchildrenwithIDandotherDDs,interventionthatfocusesonfactorsinfluencingdevelopment
mayimproveoutcomesinoverallcognitivedevelopmentandsocialcompetence(e.g.,Guralnick,2005
Ludlow&Allen,1979Mahoney&Perales,2005Ramey&Ramey,1998).

Setting

Settingreferstothelocationoftreatment(e.g.,home,communitybased,work).

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ThereareseveraladvantagestoprovidingservicesintheeverydaycontextsofpersonswithID.More
contextuallybasedmodelsareconsistentwiththenaturalenvironmentsphilosophyandthemovetoward
inclusiveeducationalprogramming(PaulBrown&Caperton,2001).Suchmodelshavebeenusedformany
yearstopreparepersonswithIDfortransitionstoindependentlivingandworking(Clees,1996Luce&
Dyer,1995Morris,2002Patton,Polloway,Smith,&Edgar,1996White,Edelman,&Schuyler,2001
White,Simpson,Gonda,Ravesloot,&Coble,2010).

Byfocusingonmultipleeverydaycontexts,thetimeavailableforteachingandtheopportunitiesforlearning
canbedispersedthroughoutthedaywithinfrequentlyoccurringactivities,events,androutines.Intervention
inmultiplecontextsimpliesaportableapproachtoservicedeliverythatallowsthepersonwithIDtopractice
functionalskillswheneverandwherevertheyareusefulandmeaningful.Italsoimpliesthatmultiple
communicationpartnersbesidestheSLPareinvolvedinservicedeliveryinvarioussettings.

Resources
ASHA

AugmentativeandAlternativeCommunication(AAC)
AutismSpectrumDisorder
ChangesinServicesforPersonsWithDevelopmentalDisabilities:FederalLawsandPhilosophical
Perspectives
ChildhoodApraxiaofSpeech
ChildhoodFluencyDisorders
CollaborationandTeaming
CommunicationCharacteristics:SelectedPopulationsWithanIntellectualDisability
FederalProgramsSupportingResearchandTraininginIntellectualDisability
HearingLoss:BeyondEarlyChildhood
LateLanguageEmergence
LiteracyinIndividualsWithSevereHearingLoss
NewbornHearingScreening
PediatricDysphagia
PermanentChildhoodHearingLoss
SocialCommunicationDisorders
SpeechSoundDisorders:ArticulationandPhonology
SpokenLanguageDisorders
TreatmentPrinciplesforIndividualsWithanIntellectualDisability

OrganizationsandRelatedContent

AmericanAssociationonIntellectualandDevelopmentalDisabilities(AAIDD)
AmericanOccupationalTherapyAssociation
AmericanPhysicalTherapyAssociation
AssociationofAssistiveTechnologyActPrograms
AutismSpeaks
CentersforDiseaseControlandPrevention(CDC):DevelopmentalDisabilities
CouncilforExceptionalChildren/DivisionforCommunicativeDisabilitiesandDeafness
EasterSeals
InternationalSocietyforAugmentativeandAlternativeCommunication
NationalDownSyndromeSociety
NationalFragileXFoundation
FRAXAResearchFoundation
NationalJointCommitteefortheCommunicationNeedsofPersonsWithSevereDisabilities
NationalOrganizationonFetalAlcoholSyndrome
RESNA:RehabilitationEngineeringandAssistiveTechnologySocietyofNorthAmerica
TASH:TheAssociationforPersonswithSevereHandicaps
TheArcforPeopleWithIntellectualandDevelopmentalDisabilities

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2/4/2017 IntellectualDisability

UCP:UnitedCerebralPalsy
UnitedStatesSocietyforAugmentativeandAlternativeCommunication

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