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Improving Treatment 
for People with Physical and Cognitive Disabilities
Dr. Dawn-Elise Snipes
~	Define the impact of disabilities on the 7 categories of functional capacity
~	Explore unique challenges for people with disabilities
~	Identify attitudinal, procedural and treatment barriers and methods to mitigate them
~	Review other identified behavioral targets
~	People with physical and cognitive disabilities have unique issues in treatment
~	People may have the same disability without having the same functional capacities and limitations
7 Categories of Functional Capacity
~	Self-Care
~	Mobility and Transportation
~	Communication (expressive and receptive) 
~	Learning (attention, comprehension, retention, application)
~	Problem Solving and Abstraction
~	Social Skills
~	Executive Functioning
~	Persons with mental illness often have impairments in memory and executive function that impede learning and behavior change.

Disabilities and Addiction
~	20 percent or more of all persons qualifying for state vocational rehabilitation services qualify for a diagnosis of substance abuse or substance dependence
~	Consumers with disabilities other than SAB reported patterns of illicit drug use that were more frequent and heavier for every drug compared with the general population 
~	Respondents with a disability were more likely to be "heavy“ (35%) or "moderate" drinkers (25%)
~	People with mental illnesses are more likely than people with other disabilities to have a substance use disorder
Unique Life Stressors Contributing to MI/SAB
~	Conditions more prevalent in people with DDs than the general population
~	Social Isolation
~	Families' efforts to protect them
~	Physical difficulty of getting out to social settings
~	Lack of opportunities to practice social skills
~	Lack of physical stamina potentially due to obesity
~	Lack of energy due to meds (opioids, antipsychotics)
~	Trouble finding  getting to recreational activities
~	Poverty
~	Nondisabled people's discomfort with people with disabilities
~	Altered body image in those with a recent disability (wheelchair, insulin pump, ostomy bag)
~	Low self esteem

Unique Life Stressors Contributing to MI/SAB
~	Conditions more prevalent in people with DDs than the general population
~	Unemployment/poverty (30% live below poverty line)
~	People with disabilities at all income levels generally spend a large proportion of their income to meet their disability-related needs
~	Lack of employment skills
~	Homelessness
~	Victimization
~	Caregiver exploitation (financial abuse)
~	Abuse

Obvious vs. Hidden Disabilities
~	Identifying hidden disabilities is the key to successful treatment. 
~	A patient who repeatedly fails at treatment may not understand what he is told, or may not be able to read or remember materials. 
~	Many people who have disabilities (e.g., multiple sclerosis, seizure disorders, cardiac problems, autoimmune disorders) look healthy much of the time, but these conditions often cause significant fatigue or limitations on walking, driving, or other physical activities.
~	People with FASDs, ASDs, ADHD, PTSD etc. may not have gotten effective differential diagnoses in the past
Don’t Forget Physio
~	Vitamin D
~	Iron levels
~	Thyroid
~	Gonadal Hormones (including PMDD, menopause, PCOS, low T)
~	A1C levels (diabetes or prediabetes)
~	34.5% of all US adults had prediabetes, based on their fasting glucose or A1C level 

Commonly Held Beliefs That Pose Barriers

~	People with disabilities do not abuse substances.
~	Mainstreaming means people with disabilities should receive exactly the same treatment protocol 
~	A person is noncompliant when her disability prevents her from responding to treatment.
~	A person with a disability will make other clients uncomfortable.
~	People with disabilities will sue the program regardless of the services offered.
~	Serving people with disabilities requires going to extremes.
Identified Behavioral Targets
~	People with both a substance use disorder and a coexisting disability may need assistance with:
•	Escape from abusive situations
•	Learn to protect themselves from victimization
•	Find volunteer work or other means of gaining a sense of productivity 
•	Develop prevocational skills such as ADLs and using public transportation
•	Learn social skills (FASD, Autism, lack of enrichment opportunities)
•	Learn to engage in healthy recreation
Identified Behavioral Targets
~	People with both a substance use disorder and a coexisting disability may need assistance with:
•	Become educated about their legal rights to accessible environments and services as well as employment
•	VR Services
•	Obtain financial benefits to which they are entitled
•	Build new peer networks
Commonly Held Beliefs That Pose Barriers

~	People with cognitive disabilities are not capable of learning new behaviors
~	People with disabilities use their disability to avoid fully participating 
~	People with disabilities deserve pity and latitude
~	People with disabilities want to be “normal”
Discriminatory Policies and Procedures

~	We do not serve clients who are taking medication (even if the medication is for a medical condition, such as epilepsy)
~	Fire and safety regulations require all clients be able to walk out of the building independently (wheelchair, ASDs…)
~	All clients must participate in house chores
~	Every person must read two chapters of a book per day.
~	Clients must be able to bathe and put themselves to bed
~	Discharge or fines due to factors beyond the client’s control
~	Inability to sit still or stay awake
~	Missing appointments because accessible bus is on a random schedule
~	OCD/agoraphobia 
~	Intoxication?

Barriers to Communication
~	Slow speech
~	Cognitive slowing (TBI, medications, dementia)
~	Thiamine deficiency can cause dementia/intoxication like symptoms… (anorexia, bypass, alcoholism)
~	Difficulty with extended attention
~	Differences between expressiveness and receptivity
~	Difficulty reading / literacy issues (audio recordings)
~	Stuttering and expressive communication issues
~	Writing
~	Drawing
Barriers to Communication
~	Hearing or visual impairment (including dyslexia and color blindness)
~	Depression can contribute to blurred vision, headaches, physical and cognitive slowing
~	Poor acoustics can make it extra difficult for people with hearing loss
Other Issues
~	Sensory hypersensitivity
~	Smells
~	Sights/lighting
~	Sounds
~	Touch / Temperature
~	Assuming people with disabilities want to be “normal”

~	Clinicians may inadvertently overlook some confounding issues for people with cognitive or physical disabilities, focusing only on the “presenting issue”
~	Assisting people in achieving their highest quality of life means ensuring they are able to be safe and meet their biopsychosocial needs by screening for obstacles and providing resources and linkages.
~	For more resources and information see TIP 29 Treatment for People with Physical and Cognitive Disabilities