Reviewing the evidence for treating addiction among people with intellectual and developmental disabilities

(A version of this article was published in the National Association of Social Workers’ Specialty Practice Section’s ATOD newsletter in fall 2022)

Addiction disorders are noted in a small percentage of people with intellectual and developmental disability (I/DD). People with IDD who have addiction disorders face all of the same consequences as non-disabled people do. However, consequences of substance use in this population are postulated to be more severe due to higher levels of somatic and psychiatric co-morbidities, the frequent use of psychotropic medication, greater challenges accessing appropriate treatment. Access to addiction treatment is limited for this population. One barrier to treatment access is the lack of evidence-informed practices for treatment validated for use in the population.

Many individuals with mild intellectual disabilities use tobacco, alcohol, and drugs but rates of addiction are either the same or higher than non-disabled peers. National data on addiction in this population is limited, but the 2014 United States National Health Interview Survey (NHIS) revealed that 8% of adults with I/DD reported moderate to heavy drinking and of the 22.3% of the population reporting any drinking at all, only 1% reported feeling that they had a problem with alcohol. Seventy-seven percent of this population reported being a lifetime abstainer.

Historically, people with IDD were considered a population to be excluded from psychotherapy (Kouimtsidis, Scior, Baio, et al., 2017) due to cognitive deficits that impair their ability to learn new information or generalize new learning. Difficulties include articulating emotional states, limited understanding of abstract concepts, expressive or receptive speech difficulties, and delays in processing/retrieving information (Lindsay et al., 1997; McCabe et al., 2006). A person with IDD may be more suggestible, changing answers to questions when provided with negative feedback (Everington & Fuller, 1999). People with IDD may also try to mask their difficulties in understanding and following verbal communication by drawing on social skills or set phrases that they know are contextually appropriate (Hassiotis at al,, 2012).

Without evidence-informed treatments to draw on, addiction treatment providers are often at a loss for how to work with this population in their settings, which are often based on cognitive behavioral talk therapy techniques. Some researchers in other treatment arenas have begun to assess the applicability of cognitive behavioral therapy (CBT) to populations with IDD (Azam, Serfaty, King, et al. 2012), noting that heterogeneity in people with IDD is a challenge to implementing manual-based interventions (McQueen, Blinkhorn, Broad, et al., 2018). Of CBT as it relates to people with IDD, Copersino, Slayter, McHugh, et al. (2022) write: that despite little research on this topic, elements of CBT that focus on knowledge and skill attainment ‘in the here and now’ do seem to provide developmentally-appropriate instructional techniques for this population. The authors draw on other studies of experiential training approaches, such as role-play, which are often used to support this population’s capacity to practice assertiveness and to build social competency as well as self-efficacy (Burke et al., 2018; Keser and Barlas, 2016; Lalli et al., 1991). Additionally, such instructional techniques can reinforce target behaviors in people with ID for whom social adaptive functioning deficits are associated with increased risk of AOD problems.

Building on these ideas about the application of CBT to this population, two empirical studies have explored implementation of addiction treatment for this population. Studies are limited due to the challenges associated with research in this population. Copersino, Slayter, McHugh, et al. (2022) examined the clinical utility of an alcohol and other drug (AOD) refusal skills intervention designed to be cognitively accessible to adults with IDD aged 18-65. This was a 2-week, 10 session program, 45 minutes each. This study explored the benefits of a ten-session therapy group focused on building confidence, developing assertiveness and demonstrating measurable skills around refusing alcohol and other drugs. Refusal skills are “an adaptive skill set aimed at providing individuals with well-rehearsed and assertive responses to people who pressure them to use, hold, or obtain alcohol and other drugs” (Copersino, Slayter, McHugh, et al., 2022, p. 15). Teaching this common skill set is seen as promoting the disability policy and practice goals of greater independence, self-determination and community inclusion. The approach balances “standards of reasonable care with autonomy, to increase feasibility of implementation… providing services on a voluntary basis not only increases the acceptability to consumers, but also to family members, care providers and other stakeholders who advocate for individualized and self-determination-oriented case management approaches” (Copersino, Slayter, McHugh, et al., 2022, p. 17). Refusal skills education in standard CBT approaches is intended to provide clinical tools for people feeling ambivalent about recovery who may find themselves in high-risk situations where their resolve is tested. Curriculum content was drawn from source material on general education about alcohol and drugs, motivational strategies for addiction recovery in IDD, assertiveness training for people with IDD, and coping strategies of individuals with IDD (for stressful social interactions). The intervention started with a module on identifying visual images of alcohol and other drugs. This was accompanied by learning and practicing assertiveness (such as talking about body language, gaze, tone of voice). In the second module, core refusal skills strategies were introduced. The final module teaches about ‘checking ahead’ to both recognize and avoid risk in situations that are new. This comes with an acknowledgement that the situation might involve asking who will be at a party before joining in, with preparation to use refusal skills.

Study findings suggest that there was a strong, statistically significant effect for refusal skill acquisition between pre-test and post-test. The magnitude of skill acquisition was predicted by group attendance as opposed to individual differences in verbal learning ability or efficiency. While only 17-27% of the group’s clients were able to suggest an alternate activity in the ‘trusted person scenario,’ between 67-90% were still able to assert refusal in those same circumstances. 60-73% were able to break off an interaction to leave a trusted person continuing to pressure them around substance use. Attendance rates in a voluntary group such as this was a better indicator of motivation than self-report measures for people with IDD (Copersino, Slayter, McHugh, et al., 2022).

Now, we review a formal clinical trial of an intervention targeting hazardous and harmful binge drinking among community-based people with IDD (Kouimtsidis, Scior, Baio, et al., 2017). Five weekly sessions were 30 minutes each (10 minute sections) The 6th session (week 8, booster) was 1 hour Their intervention drew on motivational interviewing and an unspecified form of modified form of CBT in a group format was tested against a treatment as usual model and found to reduce harmful drinking. The treatment manual used in this study adapted existing manuals for both Motivational Enhancement and CBT. First, the intervention focused on developing therapeutic rapport, explaining the intervention, discussing the role of the client’s ‘support person’ and other logistics. The second and third sessions were focused on enhancing motivation using techniques adapted from the Motivational Enhancement Therapy (MET) approach published in the UKATT MET Manual (UKATT research team, 2011). MET is rooted in the transtheoretical model of behavior change, also known as the ‘Stages of Change’ model (Prochaska, DiClemente & Norcross, 1992). Themes explored in these sessions related to clients’ current lifestyle linked to personalized advice about their drinking. Here the therapist uses additional motivational strategies to address resistance. These strategies include ‘simple reflection’ or ‘reflection with amplification’ or ‘double-sided reflections,’ as well as shifting the focus of discussion and rolling with resistance rather than confrontation with the client. Themes addressed in the third session included motivation enhancement, increasing willingness to change, developing treatment goals, exploring the discrepancy between one’s intentions and one’s drinking behavior as well as exploring and resolving ambivalence about drinking. Finally, treatment aims and promoting freedom of choice are addressed. Sessions 4 and 5, focused on new skill development, and used the United Kingdom Cognitive Behaviour Therapy Study in Methadone Maintenance Treatment Manual (Kouimtsidis et al, 2007). The last session focuses on changes in drinking and general lifestyle achieved, for discussion and celebration. The clinician defines and identifies each client’s hierarchy of high risk situations. A review of both current and past coping strategies to be used in the future is done. A personal coping plan that can be adapted in any situation is constructed. The goal of the work in this session is to bring together the clients’ motivation to change their behavior, review changes that are successful, and to promote further actions.

In conclusion, these two existing empirical treatment intervention studies provide nascent guidance to clinicians working with populations with IDD facing addiction challenges.

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