Intellectual Disability

See the Treatment section of the Intellectual Disability evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Each individual with ID has a unique profile, based on his or her level of language functioning as well as functioning in areas related to language and communication, including hearing, cognitive level, speech production skills, and emotional status. Intervention considers coexisting strengths and needs in all areas to ensure individualized treatment and supports.

Research supports the provision of communication intervention for individuals with ID (Sevcik & Romski, 2016; Snell et al., 2010). As indicated by AAIDD (2013), a persons level of life functioning will improve if appropriate personalized supports are provided over a sustained period (Additional Considerations section, para. 2). The goal of treatment is to minimize the potential debilitating effects of disabilities on clients and their families and to maximize the likelihood of desirable outcomes.

Treatment Principles

Communication intervention focuses on the context of interactions and includes individuals that persons with ID encounter in their natural environments. SLPs ensure that intervention provides ample opportunities for communication and incorporates a variety of language functions (e.g., greeting, commenting, requesting); multiple partners; different forms and modalities [e.g., speech, AAC]; and varied communication contexts [e.g., home, educational, recreational, vocational, and community settings]). Treatment approaches typically encompass a variety of techniques and approaches (Goldstein, 2006).

SLPs help ensure that communication partners recognize and respond to communication attempts and build on the interests, initiations, and requests of persons with ID. When involving others in intervention activities, SLPs foster an appreciation for the importance of language in future learning and functioning.

See Treatment Principles for Individuals With an Intellectual Disability.

Treatment Targets and Contexts

Communication intervention is sensitive to cultural and linguistic diversity and addresses components within the ICF (WHO, 2001) framework, including body structures/functions, activities/participation, and contextual factors (personal and environmental).

Depending on assessment results, age, severity, etiology, and communication and related needs, intervention for individuals with ID may address the areas of

  • early communication skills (e.g., pointing, turn-taking, joint attention);
  • social interaction and play;
  • pragmatic conventions (spoken and nonspoken) for communicating appropriately in varied situations;
  • speech production;
  • spoken and written language for social, educational, and vocational functions, with an emphasis on participation in specific activities identified as problematic for the individual;
  • literacy;
  • increased complexity of spoken and written language for more effective communication;
  • contextual factors that influence the individuals relative success or difficulty in those activities;
  • compensatory communication techniques and strategies, including the use of AAC or other assistive technology; and
  • feeding and swallowing.

SLPs prioritize treatment targets on an individual basis, focusing on those that have the greatest potential for improving communication.

Treatment programs often incorporate training of communication partners to support the individuals language comprehension and expression. Training can include use of communication strategies, cuing techniques, and/or assistive technology.

Interprofessional collaboration also has the potential to improve communication skills. For example, an exercise physiologist and an SLP may work together to improve respiratory support, which can in turn enhance speech production and intelligibility.

See ASHA's Preferred Practice Patterns for a more detailed outline of the major components of communication intervention for individuals across the life span (ASHA, 2004).

Treatment Modes/Modalities

Treatment modes and modalities are technologies or other support systems that can be used in conjunction with or in the implementation of various treatment options. For example, video-based instruction can be used in peer-mediated interventions to address social skills and other target behaviors.

Augmentative and alternative communication (AAC)—supplementing, or using in the absence of, natural speech and/or writing with aided (e.g., picture communication symbols, line drawings, Blissymbols, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. Aided symbols require some type of transmission device; unaided symbols require only the body to produce. Aided AAC includes speech-generating communication devices (Beukelman & Mirenda, 2013).  See ASHA's Practice Portal page on Augmentative and Alternative Communication.

Activity schedules/visual supports—activity schedules/visual supports include objects, photographs, drawings, or written words that act as cues or prompts to help individuals complete a sequence of tasks/activities, attend to tasks, transition from one task to another, or behave appropriately in various settings. Written and/or visual prompts that initiate or sustain interaction are called scripts. Scripts are often used to promote social interaction but can also be used in a classroom setting to facilitate academic interactions and promote academic engagement (Hart & Whalon, 2008).

Computer-based instruction—the use of computer technology (e.g., iPad) and/or computerized programs to teach communication and social skills (e.g., Bernard-Opitz, Sriram, & Nakhoda-Sapuan, 2001; Neely, Rispoli, Camargo, Davis, & Boles, 2013).

Video-based instruction (also called video modeling)—an observational mode of teaching that uses video recordings to provide a model of the target behavior or skill. Video recordings of desired behaviors are observed and then imitated by the individual (Darden-Brunson, Green, & Goldstein, 2008). The learners self-modeling can be videotaped for later review.

Treatment Options

Below are brief descriptions of treatment options commonly used to address communication problems associated with ID. The treatment modes/modalities described above (e.g., AAC) may be used to implement these treatment options. Intervention for individuals with ID typically incorporates a variety of options and techniques in combination. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA.

SLPs determine which options are appropriate by taking into consideration the individuals age and language profile and communication needs, factors related to language functioning, the presence of co-existing conditions, cultural background and values, and available research evidence.

Other portal pages can serve as useful resources for treatment options, depending on the etiology for the ID. On the ASHA Practice Portal, see the treatment sections of autism spectrum disorderspoken language disorders, and social communication disorder.

Behavioral Interventions

Behavioral interventions and techniques (e.g., different reinforcement, prompting, fading, and modeling) are designed to reduce problem behaviors and teach functional alternative behaviors using the basic principles of behavior change. These methods are based on behavioral/operant principles of learning; they involve examining the antecedents that elicit a certain behavior, along with the consequences that follow that behavior, and then making adjustments in this chain to increase desired behaviors and/or decrease inappropriate ones. Behavioral interventions range from one-to-one, discrete trial instruction to naturalistic approaches.

Applied behavior analysis (ABA)—a treatment approach that uses principles of learning theory to bring about meaningful and positive change in behavior. ABA techniques have been used to help build a variety of skills (e.g., communication, social skills, self-control, and self-monitoring) and help generalize these skills to other situations. The techniques can be used in both structured (e.g., classroom) and everyday (e.g., family dinnertime) settings and in one-on-one or group instruction. ABA has been used for individuals with ID, particularly those who also have ASD (e.g., Spreckley & Boyd, 2009).

Intervention is customized based on the individuals needs, interests, and family situation. ABA techniques are often used in intensive, early intervention (before age 4 years) programs to address a full range of life skills (e.g., Frea & McNerney, 2008). Intensive programs total from 25 to 40 hours per week for 1 to 3 years. Qualifications for providing ABA therapy may vary by state; check with your state, as this may affect reimbursement.

Environmental arrangement—a technique that involves arranging the environment to encourage communication (Halle, 1988; McCormick, Frome Loeb, & Schiefelbusch, 2003). The idea is to increase interest in the environment and set the occasion for communication. The SLP can build on the individuals desire to request and comment on aspects of the environment using strategies such as putting interesting materials in sight but out of reach; sabotaging the situation with missing elements or providing inadequate portions; and setting up choice-making, unexpected, or silly situations.

Functional communication training (FCT)—a behavioral intervention program that combines the assessment of the communicative functions of problem behavior with ABA procedures to teach alternative responses. Problem behaviors can be eliminated through extinction and replaced with alternate, more appropriate forms of communicating needs or wants. FCT can be used across a range of ages and regardless of cognitive level or expressive communication abilities (E. G. Carr & Durand, 1985).

An FCT approach has been used with students with ID to replace challenging behaviors with appropriate communication alternatives (Brady & Halle, 1997; Martin, Drasgow, Halle, & Brucker, 2005; Schmidt, Drasgow, Halle, Martin, & Bliss, 2014). The first step is the definition of the challenging behavior and the antecedent and consequent variables hypothesized to motivate them (Dunlap & Fox, 1999 ; Lucyshyn, Kayser, Irvin, & Blumberg, 2002; Schwartz, Boulware, McBride, & Sandall, 2001). Second, the SLP uses this information to identify and teach simple and potentially more efficient communication skills that serve the same functions. Finally, one may expand on those skills and ensure that appropriate communication skills are used effectively in different contexts and that the challenging behavior is extinguished.

Incidental teaching—a teaching technique that uses behavioral procedures to teach elaborated language; naturally occurring teaching opportunities are provided based on the individuals interests. Following the individuals lead, attempts to communicate are reinforced as these attempts get closer to the desired communication behavior (McGee, Morrier, & Daly, 1999). Incidental teaching requires initiation by the individual, which serves to begin a language teaching episode. If the person does not initiate, an expectant look and a time delay might be sufficient to prompt language use. The clinician can prompt with a question (e.g., What do you want?) or model a request (e.g., Say: I need paint.).

Milieu therapy—a range of methods (including incidental teaching, time delay, and mand-model procedures) that are integrated into a childs natural environment. It includes training in everyday environments and during activities that take place throughout the day, rather than only at therapy time. Milieu language teaching and other related procedures offer systematic approaches for prompting children to expand their repertoire of communication functions and to use increasingly complex language skills (Kaiser, Yoder, & Keetz, 1992; Kasari et al., 2014).

Time delay—a behavioral method of teaching that fades the use of prompts during instruction. For example, the time delay between initial instruction and any additional instruction or prompting is gradually increased as the individual becomes more proficient at the skill being taught. Time delay can be used with individuals regardless of cognitive level or expressive communication abilities (e.g., Liber, Frea, & Symon, 2008).

Peer-Mediated/Implemented Treatment

Peer-mediated/implemented treatment approaches incorporate peers as communication partners for children with disabilities in an effort to minimize isolation, provide effective role models, and boost communication competence. Typically developing peers are taught strategies to facilitate play and social interactions; interventions are commonly carried out in inclusive settings where play with typically developing peers naturally occurs (e.g., preschool setting). The following examples may be used for children with ID, based on individual communication needs.

Learning Experiences and Alternative Program (LEAP)—a multifaceted program for preschool children with ASD and their parents (Hoyson, Jamieson, & Strain, 1984; Strain & Hoyson, 2000). LEAP uses a variety of strategies and methods, including ABA, peer-mediated instruction, self-management training, prompting, and parent training. LEAP is implemented in a classroom setting consisting of children with ASD and typically developing peers and is designed to support child-directed play.

Circle of Friends—a treatment approach that uses the classroom peer group to improve the social acceptance of a classmate with special needs by setting up a special group or circle of friends. The focus is on building behaviors that are valued in everyday settings. The application of skills to new and appropriate situations is reinforced as naturally as possible as such situations occur (Whitaker, Barratt, Joy, Potter, & Thomas, 1998).

Integrated play groups—a treatment model designed to support children of different ages and abilities with ASD in mutually enjoyed play experiences with typical peers and siblings. Small groups of children play together under the guidance of an adult facilitator. The focus is on maximizing the childs potential and his/her intrinsic desire to socialize with peers (Wolfberg & Schuler, 1993).

Treatment Considerations

Target Behaviors for Specific Populations

Selection of target behaviors for individuals with ID has benefited from an increased understanding of the specific communication deficits associated with various diagnoses, especially the most studied populations—Down syndrome and ASD. A variety of approaches may be selected based on individual strengths and needs.

Consider the following examples:

  • For children with Down syndrome, interventions have tended to focus on improving intelligibility through speech and alternative modes of communications (Girolametto, Weitzman, & Clements-Baartman, 1998; Kay-Raining Bird, Gaskell, Babineau, & MacDonald, 2000; Kumin, Council, & Goodman, 1999; Layton & Savino, 1990; Warren & Yoder, 1998; Yoder & Warren, 2001).
  • For children with ASD, interventions typically focus on social communication skills (e.g., Goldstein, English, Shafer, & Kaczmarek, 1997; Kaiser, Hancock, & Nietfeld, 2000; Pierce & Schreibman, 1995; Smith & Camarata, 1999; Stevenson, Krantz, & McClannahan, 2000; Thiemann & Goldstein, 2004). Peer-mediated intervention approaches have shown particular success with young children.
Transitioning Youth

Individuals with ID may experience challenges in acquiring the skills necessary for independent living and achieving success in postsecondary education/training programs, employment settings, and social situations. They need continued support to facilitate a successful transition to adulthood. SLPs are involved in transition planning and may be involved to varying degrees in other support services beyond high school.

See transition youth.

Aging Adults

The SLP helps maximize independent functioning in aging adults. Adults with ID experience the same age-related health problems and functional decline observed in the general elderly population (Lazenby-Paterson & Crawford, 2014). However, the aging process may be premature in adults with ID as compared with the general population (e.g., Lin, Wu, Lin, Lin, & Chu, 2011).

For example, individuals with Down syndrome may be at higher risk for earlier onset of dementia when compared with the general population (Burt et al., 2005; Hawkins, Eklund, James, & Foose, 2003). Even when dementia is not taken into account, speech and language skills may begin to decline in adults with ID from about the age of 50 (Roberts et al., 2007). If adults with ID seek speech and language services because of new communication concerns, SLPs will need to consider the possibility that the individual is experiencing mild cognitive impairment, a condition characterized by subtle cognitive deficits that may lead to dementia (see dementia).

Most healthy adults will not experience problems with eating, drinking, and swallowing, despite age-related changes in the muscles used for feeding and swallowing (Lazenby, 2008). However, some adults with ID—particularly those with psychomotor impairments or other comorbid conditions that affect feeding and swallowing—may experience dysphagia-related problems as they age (Lazenby-Paterson & Crawford, 2014).

Individuals With Challenging Behaviors

When individuals with ID are taught communication skills that serve efficiently and effectively as alternative behaviors, reductions in challenging behaviors result (Kurtz, Boelter, Jarmolowicz, Chin, & Hagopian, 2011).

Identifying and treating behaviors early in development may promote appropriate communication using alternative modes and prevent negative long-term consequences. Replacing challenging behaviors with appropriate and increasingly sophisticated communication skills has the potential to facilitate growth in academic achievement and improve social relationships and vocational outcomes.

Identifying the function of challenging behaviors can be a complex task in itself. For example, the motivation for a specific challenging behavior can vary based on context (task vs. leisure contexts; Haring & Kennedy, 1990). SLPs are encouraged to consider a potentially preventive approach by teaching communication skills that serve multiple functions (Wacker, Berg, Harding, & Asmus, 1996).

SLPs have an essential role in educating team members about the communication functions of such behaviors and developing methods for replacing them with other forms of communication behavior.

Cultural and Linguistic Factors

Cultural differences in the attitudes, beliefs, and perceptions of individuals with ID are well documented within the United States and in other countries (Allison & Strydom, 2009; Scior, 2011; WHO, 2010). This information is important because it affects service delivery and the interaction between the SLP and the family. Although there has been a global movement to encourage deinstitutionalization of individuals with ID and improve access to quality care and social integration, this is not yet a reality in all countries.

Cultural perspectives affect communication and the way care is provided. SLPs need to (a) be aware of culturally associated beliefs about the cause of ID, (b) provide person-centered care, (c) build working relationships with caregivers, and (d) address communication barriers (Allison & Strydom, 2009).

Service Delivery

See the Service Delivery section of the Intellectual Disability evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

In addition to determining the type of speech and language treatment that is optimal for individuals with ID, SLPs consider other service delivery variables—including format, provider, timing, and setting—that may affect treatment outcomes. Service delivery decisions are made based on the individuals communication needs relative to his or her family, community, school, or work setting.

Format

Format refers to the structure of the treatment session (e.g., group vs. individual; direct and/or consultative) provided.

Service delivery options include home-based, pull-out, classroom-based (e.g., push-in), and collaborative consultation. The pull-out model continues to be the predominant service delivery option for SLP practice across populations and ages. However, exclusive use of this model with persons with ID is rarely appropriate. Failure to generalize has been a commonly cited drawback to traditional pull-out models of service delivery (Cirrin & Penner, 1995; Nelson, 1998).

Provider

Provider refers to the person offering the treatment (e.g., SLP, trained volunteer, caregiver).

Recommended practices follow a collaborative process that involves a multifaceted team including families, caregivers, persons with disabilities, and professionals. These teams establish and coordinate services that are family centered, culturally appropriate, comprehensive, and compassionate, and that produce meaningful life outcomes. Involved partners may include parents, siblings, grandparents, friends, and acquaintances in the home; teachers, classmates, paraprofessionals, and others in the school; employers, job coaches, and fellow workers in vocational settings; and a variety of conversational partners in community settings (recreational facilities, churches and synagogues, stores, etc.).

Models of teaming require varying degrees of collaboration and engage participants in the establishment of a joint purpose, shared goals, and an organized approach to implementing these goals. See collaboration and teaming.

Timing

Timing refers to the scheduling of intervention relative to the diagnosis.

The importance of early intervention for children who are at high risk for communication disorders cannot be overstated. For children with ID and other DDs, intervention that focuses on factors influencing development may improve outcomes in overall cognitive development and social competence (e.g., Guralnick, 2005; Ludlow & Allen, 1979; Mahoney & Perales, 2005; Ramey & Ramey, 1998).

Setting

Setting refers to the location of treatment (e.g., home, community-based, work).

There are several advantages to providing services in the everyday contexts of persons with ID. More contextually based models are consistent with the natural environments philosophy and the move toward inclusive educational programming (Paul-Brown & Caperton, 2001). Such models have been used for many years to prepare persons with ID for transitions to independent living and working (Clees, 1996; Luce & Dyer, 1995; Morris, 2002; Patton, Polloway, Smith, & Edgar, 1996; White, Edelman, & Schuyler, 2001; White, Simpson, Gonda, Ravesloot, & Coble, 2010).

By focusing on multiple everyday contexts, the time available for teaching and the opportunities for learning can be dispersed throughout the day within frequently occurring activities, events, and routines. Intervention in multiple contexts implies a portable approach to service delivery that allows the person with ID to practice functional skills whenever and wherever they are useful and meaningful. It also implies that multiple communication partners besides the SLP are involved in service delivery in various settings.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.