In this next section we will be discussing Intellectual & Developmental Disability and how their mind and emotional brain develop.

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General intellectual functioning is measured by an individually administered standardized test of intelligence that results in an overall intelligence quotient (IQ) for the individual. Significantly sub average functioning is defined as an IQ score of 70 or below. (Ref. NADD)

NOTE: There are many reasons for neurodevelopmental disorders. Do not dwell on these. If questions arise, transfer them to a Parking Lot.

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People with neurodevelopmental disorders (ND) have generalized lagging skills and capability within the area of executive functioning.Ask for examples of when the DSP experienced the lack of executive functioning when trying to support a person with IDD and a Co-Occurring Disorder.

Inefficient attention – inability to focus on specific tasks or to maintain focus of thoughts and emotions for extended periods of time, this may also be exhibited in over focusing or perseverationLittle or no concept of time – Reflected in time of day or night, seasons, or a generalized concept of how long something takes Limited understanding of Cause and Effect – Lack of skills to discern how events are correlated, what causes whatConfusion regarding abstract communication – Inability to process abstract or complex words, phrases, ideas and concepts, including context. Example of sarcasm and words having dual meanings or like pronunciation.Inability to inhibit behavioral responses –Lack of impulse control, the need to process thoughts verbally

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ACTIVITY

Divide class in to 4 groups. (For a smaller class split into 2 groups)Ask them to describe how someone with IDD connects with others? Think communication, participation, independence, integration, etc.After 5 minutes, have each group summarize their thoughts.

Then present that we all connect through ATTACHMENT STYLES.

Everyone connects with others through relationship. From Proximal (Space and time) to Intimate (Fully Connected) Relate back to the personal space exercise in the main curriculum.

Relationship is achieved through developed attachment styles.

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Attachment becomes the basis for development of trust or mistrust and shapes how a person will relate to the world, learn, and form relationships throughout life. (Ref. Accepted Definitions, www.ATTACH.org)

Note that much of the research on Attachments is focused on a primary caregiver, usually a parent.

The role of a Direct Support Professional is sometimes viewed as being a substitute for the primary caregiver.

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Attachment theory is based on the joint work of J. Bowlby (1907–1991) and M. S. Ainsworth (1913– ).

Its developmental history begins in the 1930s, with Bowlby's growing interest in the link between maternal loss or deprivation and later personality development and with Ainsworth's interest in security theory.

NOTE:After touching on the Bullet points remind the participants of the guiding question –How do people with IDD connect with others.

Watch the video – STOP AT THE 4:54 mark as the extensive information later in the video is not as applicable the Individuals supported by the Oregon Intervention System.

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Research has identified 4 main Attachment styles.

Secure attachment is when the Caregiver is quick to respond in a kind and compassionate manner with consistency and children feel they can rely on their caregivers to attend to their needs of proximity, emotional support and protection. It is considered to be the best attachment style. Insecure Attachments (3 Types)1) Anxious-avoidant attachment is when Caregiver is distant or disengaged, uninvolved with the child, or noticeably preoccupied with their own agenda. The child simply avoids seeking the caregiver. 2) Anxious-ambivalent attachment is when the Caregiver demonstrates inconsistency and shows a variety of emotion and the infant responds with feeling separation anxiety when separated from the caregiver and does not feel reassured when the caregiver returns to the child. 3) Disorganized attachment is when the Caregiver manifest extreme emotions of fear, anger, uncertainty, passivity and lack of urgency, and there is a lack of attachment behavior. The child in turn responds with fear, anger, passivity and avoidance, showing drastic emotional instability.

How might each of these be interpreted when a DSP is providing daily support for a person with IDD and Dual Diagnosis?

Instructor will separate the class into 4 groups and assign each group an attachment style to discuss. They will then come up with an example of that attachment style as demonstrated in the group home setting. Share with the entire class.

To save time – The following examples may be shared.Secure attachment – An individual is beginning to show some signs of distress or discomfort and they seek out help from their DSP or someone else without further challenging behavior. (ie. “I just pinched my figure in my closet door. Can you take a look at it?”)Avoidant attachment – An individual subconsciously believes that their needs won’t be met and avoids interaction with the caregiver. (ie. “ I need to talk to the Manager”, going to someone they think can give them what the perceive is what they need.)Ambivalent attachment – An individual is pacing and then blows up for no apparent reason. The Caregiver responds differently each time and enables the attachment style.Disorganized attachment – An individual may isolate themselves in their room for the entire day, refusing to work with the assigned Caregiver. Any attempts to interact with them leads to more frustration, anger and perhaps verbal or physical aggression.

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The Caregiver/Direct Support ProfessionalMay feel that you can get along with anyone…but the person you are supporting is very likeable but extremely demanding.May think that you can handle emotional mood swings…but these drastic and immediate mood swings include feeling like you are in the midst of a battle for your life.May find themselves supporting someone who is verbally aggressive and explosive the majority of the day.

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TYPICAL DEVELOPMENTIn the typical development of the human brain, Theory of Mind may be described how the person develops; gaining Insight and Empathy through Integration with those around them. As described by Dr. Daniel Siegel in the upcoming video.

When there is a NEURODEVELOPMENTAL DISORDERFor people with IDD their developing Theory of Mind; Insight, Empathy and Integration are disrupted because of the lack of executive functioning and the ability to conceptualize and put events and interaction into proper context is very difficult. They often lack the secure attachments to develop as others. This is partially due to the disability but also effected by environment, trauma, etc.

Part of our daily function as Direct Support Professionals is to help the people we support in developing their ‘Theory of Mind’, helping them develop the skills to relate to others.

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Dr Daniel Siegel on Mindsight; the ability to see what’s going on in the connections that we have each day.

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Some of the terminology of Attachment Theory includes the thoughts around Caregivers becoming a Secure Base and a Safe Haven for those being supported.

• SAFE HAVEN – describes a relationship in which the individual has the sense that the Caregiver (DSP) supports them in all they do; protecting them from harm but allowing for their independence, comforting them when they fail or experience loss, delighting in them as a person and helping them organize their thoughts and feelings.

• SECURE BASE - is provided through a relationship with one or more sensitive and responsive attachment figures who meet the individual's needs and to whom the child can turn as a SAFE HAVEN, when upset or anxious.

Being present in a person’s daily life assists with building a secure attachment where there may have been years of neglect and abandonment.

Additional References:https://www.circleofsecurityinternational.com

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General interactions of a Caregiver.

Note that these are general interactions and that specific person-centered interactions will be described in an individual’s PBSP.

Always – Be Kind, Be Wise (not functioning impulsively), Be Confident in the situation at hand, Be Consistent emotionally (The Calm in the Storm)Whenever Possible – Follow the person’s specific needs (let them lead), Instruct rather than Direct (interact through appropriate discussions).When Necessary –Be the Safe Haven (provide safety in a crisis), Be the Secure Base (the constant for someone to return to, a source of peace and rest), Be Stable (not easily upset or disturbed by crisis).

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An Attachment Disorder may be diagnosed in childhood and over time, as the person’s individual personality is formed, a Personality Disorder is a common diagnosis. CAUTION: It can be very harmful to an individual to label them with the symptoms of an Attachment Disorder or Personality Disorder. The DM-ID 2 recommends that Clinicians NOT diagnose an individual with intellectual disabilities with a Personality Disorder until after the age of 22.

An Attachment Disorder is a treatable condition in which there is a significant dysfunction in an individual’s ability to trust or engage in reciprocal loving, lasting relationships. An attachment disorder occurs due to traumatic disruption or other interferences with the caregiver-child bond during the first years of life. It can distort future stages of development and impact a person’s cognitive, neurological, social and emotional functioning. It may also increase risk of other serious emotional and behavioral problems. Note: for a medical definition of Reactive Attachment Disorder of Infancy or Early Childhood 313.89, see the Diagnostic and Statistical Manual 5 (DSM 5).

Classified as Trauma- and Stressor- Related Disorders in the DSM-5

Attachment Disorders may develop as a result of abuse and neglect.

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Clinicians may be hesitant to diagnose an Attachment Disorder for Individuals with Intellectual and Developmental Disability due to the complex nature of the person’s psychological presentation and behavioral concerns that may be equally explained by other Trauma related disorders or Mood Disorders.

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Provide a brief summary of the module