Evaluation of activities of daily living accommodations for adults with intellectual and developmental disabilities

The goal of this communication is to provide clinicians and behavioral scientists with a scoping perspective on the diverse array of impacts of the COVID-19 pandemic on individuals with intellectual and developmental disabilities (IDD) in the U.S. It is our hope that this will stimulate subsequent scientific and advocacy efforts to ameliorate the disproportionate burden of the pandemic on people with IDD.We begin with the assertion that among non-infected persons in the U.S. few are more adversely affected by COVID-19 than individuals with IDD, given that a vast proportion require in-person care or critical therapeutic support within their living environments, with little back-up or systematic coverage for prolonged interruption of services.Many have temporarily lost access to trained caregivers or community service providers, and now face evolving threats to the return of baseline service, given uncertainties in State and agency budgets.Therefore, a first priority relates to restoration of in-person support services or comparable alternatives.There have been emerging guidelines on the safe care and support of individuals with IDD during the COVID pandemic-see Supplementary Table (ST) 1 which lists resources and documentation of early success of such strategies, however guidance is still evolving, has not permeated all reaches of the community where the information is desperately needed, and is not always presented in ways that can be fully comprehended by those with IDD.It must be

On behalf of the Conference Planning Committee, it is my sincere pleasure to welcome you to the "Queen City," Charlotte, North Carolina, and the American Association on Intellectual and Developmental Disabilities (AAIDD) 136th Annual Meeting. The theme of this year's conference is research, practice, policy—and there's no better setting for such a conference than the Carolinas! This year's AAIDD annual conference promises to be a forum where researchers, clinicians, practitioners, educators, policymakers, and advocates will be able to share cutting-edge research, effective practices, and valuable information on important policy initiatives.I want to start my presidential address by thanking all the attendees for joining us for the AAIDD 136th Annual Meeting. This conference could not be the success it is without your presence and participation. I also want to thank all our colleagues from across the United States and the world who traveled to Charlotte to present their work and share their ideas and findings with us. I'll come back to this point in a minute. I would be remise if I did not acknowledge the important contribution to the success of this meeting of all those who provided their time and wisdom on the Conference Planning Committee and the Local Arrangements Committee as well as the large group of volunteers, and of course none of this could happen without the diligent work of the AAIDD staff and Dr. Maggie Nygren, AAIDD executive director and CEO. Please join me in thanking all these individuals in making this annual meeting the success that it is.This year's annual meeting was preceded by a series of exciting and stimulating preconference workshops on topics ranging from findings from the AAIDD Cuba Delegation, the National Task Group on Dementia, DirectCourse's Comprehensive Competency-Based Training Approach, Supports Intensity Scale and Individual Support Planning, and Ethical Issues for Psychologists.We opened our conference with a blue-ribbon plenary panel on research, practice, and policy in the area of autism spectrum disorders. We heard three fantastic presentations from Drs. Joe Piven (University of North Carolina), Connie Kasari (University of California–Los Angeles), and Susan L. Parish (Brandeis University). The opening plenary was an excellent example of the richness and importance of research, intervention, and policy issues and their interplay in the area of autism spectrum disorders. Our other panel presentation had a distinguished group of federal partners, including Drs. Melissa Parisi (Eunice Kennedy Shriver National Institute of Child Health and Human Development; NICHD), Gloria Krahn (National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention; NCBDD CDC), and George Jesien (Association of University Centers on Disabilities). This illustrious federal panel discussed the importance and role played by these agencies in supporting research and practice as well as the importance of policy matters in continued funding of these programs in the area of intellectual and developmental disabilities.Our biggest challenge this year in organizing the conference was reviewing and evaluating the great number of high-quality proposals submitted. We received almost 300 proposal submissions from across the United States and more than a dozen countries around the world. The conference was rich with 24 break-out panel presentations on topics including aging, health, employment, quality of life, transition, cross-cultural issues, end-of-life, forensic, supports, direct support workforce, inclusion, systems change, self-advocacy, spirituality, parenting, funding issues, and postsecondary education. In addition to these rich break-out sessions, we had more than 150 stimulating poster presentations from students, recent graduates, early careers professionals, established professionals, and researchers from around the world.Today and tomorrow, our conference wraps with a series of postconference workshops that will offer continuing education units on a variety of topics, including writing for publication, lessons learned from states using the Supports Intensity Scale, assessment of intellectual disability in capital cases, religion and spirituality, positive behavior supports, trauma-informed care, and dysphagia. These workshops offer some very practical hands-on training from highly respected and skills practitioners. I trust many of you will be taking advantage of these workshops before heading home.This year's conference theme was selected to highlight and remind us of the importance of interdisciplinary and interprofessional collaboration for the field of intellectual and developmental disabilities. Our field has had many accomplishments in research, intervention, and policy that have had significant impacts on improving the lives and outcome for persons with intellectual and developmental disabilities (IDD) and their families.Many years ago, a Norwegian physician by the name of Dr. Asbjorn Folling discovered that a group of individuals with intellectual disability had particular characteristics, and this led to his discovery that these individuals all had inherited a recessive gene that resulted in their bodies' inability to break down an amino acid called phenylalanine. The condition, called phenylketonuria (PKU), if undetected, would result in a build-up of phenylalanine to toxic levels in the individual's central nervous system, resulting in severe cognitive impairments. A relatively simple treatment consisting of a strict diet that eliminates all foods high in protein, which are rich in phenylananine, eliminated the devastating effects of PKU on infant brain development. Infant screening for PKU commenced as early as the 1960s, resulting in the identification and treatment of PKU and thus preventing thousands of children from developing intellectual disability.We should also not forget that the benefits yielded from the work done in our field reach beyond persons with IDD.Another important area of work stimulated by a practitioner in the field of intellectual disability is early childhood education. This was Dr. Maria Montessori, an Italian physician who worked with young children with intellectual disability. Maria Montessori had been influenced by the work of a couple of giants in the field of intellectual disability, including Jean Itard and Edouard Séguin. The Montessori Method stresses the development of initiative and self-reliance by permitting children to do by themselves the things that interest them—self-paced learning under the guidance of a teacher. Montessori's work led to significant gains in learning in children previously thought to have little potential because of their intellectual disability. The Montessori Method demonstrated that this structured learning method and environment can have important beneficial results in children with cognitive delays but also in typically developing children. Today, Maria Montessori's educational approach is used around the world and has become a highly coveted educational strategy used with children of all intellectual abilities.A final example of the richness of the work done in our field is in the area of applied behavior analysis and positive behavior supports. The science of using principles of behavior analysis to understand the function of behavior to promote learning and behavior change has been a critical part of intervention strategies in the field of intellectual and developmental disabilities for decades. We have used the science of applied behavior analysis and, more recently, positive behavior supports to teach new skills, promote pro-social behavior, and understand and reduce problem behavior. These approaches have been instrumental in our field of early intervention to promote inclusion, supported employment, and supported living, to name a few examples. These techniques are being used in all realms of daily life, including and increasingly with people without special needs. More and more preschool programs and school districts have adopted positive behavior support strategies to promote pro-social behaviors and the prevention of all forms of less desirable behaviors such as bullying, disrespectful behavior, aggression, and so forth.So we can see how research and practitioners play key interactive roles in promoting improved research and intervention for persons with IDD. And, at times, these methods also have applications for everyone. Public policy and legislation also play a key role in research and intervention for people with IDD. We, at times, did not appreciate the important role research and intervention findings play in crafting and influencing policies. Their interrelatedness cannot and should not be understated. I want to name but a few important policies that have played a key role in promoting services, programs, and research for persons with IDD. Early in the 1960s the Kennedy administration created important legislation now called the Developmental Disabilities and Bill of Rights Act (DD Act). The DD Act led to the creation of the University Centers for Excellence in Developmental Disabilities, DD planning Councils, and Protection and Advocacy Agencies in every state. During this same period we saw policy work that led to the creation of the National Institute on Child and Human Development (NICHD), which has been an important source of research funding for the field of intellectual and developmental disabilities, including the IDD research centers. Other important legislation for our field has included the Individual with Disabilities Education Act (IDEA), Combating Autism Act, and also Rose's Law. Rose's Law is an interesting piece of legislation but important because it resulted in the removal of stigmatizing language such as "mental retardation" from federal laws, replacing it with "intellectual disability." This aforementioned list is far from comprehensive. We have had a century of ground-breaking policy changes that have illustrated the work between policymakers, stakeholders, practitioners, and researchers. I selected these to make a point—not to identify them as more important than others not mentioned. Suffice it to say, policy, practice, and research are intertwined and interdependent, perhaps more than many really appreciate or admit.Founded in 1876, the American Association on Intellectual and Developmental Disabilities is the oldest professional association concerned with intellectual and developmental disabilities. I am truly honored to have the privilege to serve as president for 2012–2013. We have a great group of board members, a dedicated staff, and a very dynamic executive director/CEO. Despite these difficult economic times, our association is in good financial health. An exciting characteristic of our association that strikes me as indicative of the strength of our membership and leadership is the products that we continue to develop and deliver to the field. The credit for all this is a shared one. It is shared among our board members, our executive director/CEO, the staff in the national office, and especially you! All of our key products (e.g., the terminology and classification manual and user's guide, Positive Behavior Supports Training Curriculum, Supports Intensity Scale, annual meeting—yes, I include this as one of our key products—Good Blood, Bad Blood, online courses, and webinars) are largely the result of the hard work and brain power of our members.I have three basic priorities that I have set for my presidency. Following are my priorities—not necessarily in order of importance.The major functions of AAIDD are to:There are several factors that establish AAIDD as the best place for cutting-edge research, tools, and materials that inform IDD policy and practice. AAIDD has a long history in publishing some of the field's best journals, including Intellectual and Developmental Disabilities as one of the field's leading practice journals and the American Journal on Intellectual and Developmental Disabilities as the oldest and more respected research journal. This is the professional home for thousands of interdisciplinary practitioners, researchers, and leaders within the field of intellectual and developmental disabilities. Whether mentioned in legislation, the U.S. Supreme Court, or among stakeholders, families, or colleagues, AAIDD is seen as the authoritative organization on matters related to IDD. We must keep our focus on evidence-based and data-driven product development and ensure that we, as an organization, continue to deliver high-quality tools and materials that are needed to advance the quality of supports, services, and knowledge.Our association can only sustain its leadership through succession planning and grooming the next generation of educators, researchers, leaders, policymakers, practitioners, and so forth. We must make every effort to include students and early career professionals on our association task forces, committees, and work groups. The vitality of our association can only be ensured by the inclusion of senior leaders and more junior rising stars among our membership. This is a win–win proposal that will benefit all and promote high-quality work and outcome.I am committed to continuing the great work of the last several AAIDD presidents in supporting the students and early career professionals who have recently formed their own special interest group. Below are some suggestions of ways you and I can support AAIDD students or early career professionals:Please e-mail me any suggestions or ideas you have to increase the participation and meaningful involvement of students and early career professionals in our association life and annual meetings.This priority is to make certain that we educate and guide the American Psychiatric Association (APA) as it continues its work in crafting the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Of particular concern is that the DSM-5 revisions of the condition formerly called "mental retardation" currently include APA's proposal to rename the condition "intellectual developmental disorder." As you know, there is a national consensus in the United States, including federal legislation, to replace "mental retardation" with "intellectual disability."In addition to proposing a radically different terminology that lacks all support from the field of intellectual disability, the current version of the DSM-5 diagnostic criteria are the following: (a) significant deficits in intellectual functioning–profile of cognitive abilities; (b) significant deficits in adaptive behavior including daily life, communication, social participation, functioning at school and work, personal independence at home and in community where these limitations result in a need for ongoing support at school, work, or independent life; and (c) that these significant deficits originate during the developmental period.The adoption of a different terminology and the proposed DSM-5 diagnostic criteria are fraught with the potential to harm people with intellectual disability and their families. In a June 14 letter to the APA and the DSM-5 Neurodevelopmental Disorders work group cochairs, AAIDD wrote a detailed letter expressing our concerns and making clear suggested changes. AAIDD's concern regarding the DSM-5 proposal to adopt "intellectual developmental disorder" is that it is regressive and divergent with the currently accepted terminology of "intellectual disability." We have in the United States legislation called Rose's Law that was signed by President Obama that has replaced "mental retardation" with "intellectual disability" in federal law. All professional and disability organizations have adopted "intellectual disability." The DSM-5 adopting a different terminology will lead to confusion, inconsistency, and will hurt people with intellectual disability and their families. Adopting a different terminology, accepted by no one else, could affect federal and state determination of eligibility for benefits and services in schools, social security insurance, Home and Community Based Services (HCBS) waivers, as well as research communication and evaluations in the forensic arena, including capital cases.Other concerns include that the lack of an operational definition of the age of onset could potentially lead to different determinations of the age cutoff across states or even between state agencies. We also suggested the APA make more systematic their definition of adaptive behavior as being represented by conceptual, practical, and social skills. Finally, we cautioned the DSM-5 against deemphasizing individualized standardized testing in favor of clinical assessment and recommended APA strengthen the language regarding measurement error.I want to draw your attention to this important matter and encourage you to familiarize yourself with the AAIDD concerns with the DSM-5 proposal. We also applaud our colleagues in other national and international organizations who have endorsed the AAIDD position, including The Arc [of the United States], Special Olympics International, Inclusion International, American Psychological Association–Division 33, and American Academy of Developmental Medicine and Dentistry. We expect other groups to continue adopting our letter as a model in communicating their concerns to the DSM-5 work group. We should all be extremely concerned about the current direction being taken by the DSM-5.In closing my presidential address, I want to thank you again for joining us in Charlotte for the 136th AAIDD Annual Meeting and for choosing to be a member of AAIDD. I hope to see many of you next year in Pittsburgh, Pennsylvania. Do not hesitate to contact me should you have any questions, concerns, suggestions, and ideas how we can further advance the mission of our association, and let me know how you can become involved in strengthening AAIDD! Thank you.My thanks to the Conference Planning Committee: Lynn Ahlgrim-Delzell, Giulia Balboni, Britt Butler, Melissa DiSipio, Celia Feinstein, Judith Gross, Aaron Kaat, Yves Lachapelle, Laura Lee McIntyre, Loui Lord Nelson, Maggie Nygren, Joanna Pierson, Holly Riddle, Geronimo Robinson, David Rotholz, Peter Smith, Jim Thompson, and Miguel Verdugo; and the Local Arrangements Committee: Lynn Alhgrim-Delzell (co-chair), Holly Riddle (co-chair), Barbara Agnello, Greg Best, Kelly Bohlander, Davan Cloninger, Barton Cutter, Jody Deacon, Kira Fisher, Monica Foster, Melissa Hudson, Kelly Kazukauskas, Angela Lee, Judy Lewis, Mike Mayer, Andrea Misenheimer, Lauren Mullis Borchert, Greg Olley, Scott Paul, Pat Porter, Genny Pugh, Rod Realon, Ron Reeve, David Rotholz, and Deborah Whitfield.

Background People with intellectual and/or developmental disabilities are more likely to have lower levels of health literacy than people without intellectual and/or developmental disabilities. As low health literacy exacerbates poor health outcomes, occupational therapy practitioners should provide cognitively accessible materials to people with intellectual and/or developmental disabilities. While there is evidence that discharge materials may not be cognitively accessible to other populations with cognitive impairments, there is a lack of research examining cognitive accessibility of discharge materials for individuals with intellectual and/or developmental disabilities. Methodology We utilized the Patient Education Materials Assessment Tool, the Simple Measure of Gobbledygook, and a supplemental set of items designed specifically to evaluate cognitive accessibility for people with intellectual and/or developmental disabilities to examine the cognitive accessibility of acute care discharge materials for people with intellectual and/or developmental disabilities. 24 written discharge materials were collected from two acute care occupational therapy departments within a New England city. We assessed materials for cognitive accessibility from three perspectives, which include understandability, actionability, and readability. Results Findings suggest that current materials may not be cognitively accessible to people with intellectual and/or developmental disabilities. Cognitive accessibility was found to be the highest in picture-based materials and materials that included a tool to assist the user. Discussion Occupational therapy practitioners may use findings to adapt their discharge materials to enhance cognitive accessibility for clients with intellectual and/or developmental disabilities.

Editorial: Introduction to Special Section on Evidence-Based Practices for Persons With Intellectual and Developmental Disabilities

The first plenary session of 132nd Annual Meeting of the American Association on Intellectual and Developmental Disabilities (AAIDD) reflected its support for basic and applied research to prevent or minimize the effects of conditions causing developmental disabilities, with Dr. Alan Guttmacher (2008), currently the acting director of the National Human Genome Research Institute, discussing the realized and potential benefits of genomics research on health and quality of life. This presentation dealt with an incredibly complex topic with clarity and sensitivity, and it was carefully neutral in tone and content with respect to intellectual and developmental disabilities. Nevertheless, a major implication regarding disabilities in general and developmental disabilities more specifically was quite clear. Current research in genomics, as well as in many other areas, is intended to improve understanding of the fundamental causes of disability to reduce risk, thereby lowering incidence of impairments and minimizing their severity. Should these goals be realized, the proportion of the population with disability would decrease, perhaps dramatically, and in some distant future significant impairments might even be eliminated altogether. As unachievable as that ultimate goal might appear to be, an assumption supporting many of the programs and much of the research agenda in the field of developmental disabilities is that we, as a society and as individuals, would be better off if physical, mental, and cognitive impairments ceased to exist.Yet, prevention encompasses many things and can be viewed from many perspectives, some of which have continued to challenge the universality of this assumption. There is a need for serious and open discussion of the many aspects of prevention within our field (and the disabilities field more generally) that entails explicit consideration of risks and benefits of specific programs and approaches to implementation. Although important distinctions can and should be made among primary prevention (avoiding the occurrence of a causal condition), secondary prevention (avoiding or minimizing the consequences of a causal condition after it occurs), and tertiary prevention (minimizing or improving outcomes after the consequences of a causal condition are evident), this dialogue needs to begin with consideration of the overarching goal of lowering the incidence and prevalence of impairments and reducing disability.In many respects, prevention was embraced long ago as a valued societal benefit, and this has had significant impacts in the case of intellectual and developmental disabilities. Certainly, the history of prevention in our own field has included some policies and actions that had devastating consequences for people with intellectual and developmental disabilities, and careful and constant vigilance will always be required to ensure that the rights, privileges, and dignity of every individual are respected and preserved. Nevertheless, many other aspects of the past continue to be broadly viewed as enormously beneficial, and several examples seem particularly illustrative.Until the late 19th century, congenital hypothyroidism (cretinism) caused many individuals in western Europe to have intellectual disability. For some alpine regions, it was so common an occurrence that local physicians thought it unremarkable (Merke, 1984). We now know that this condition is caused by dietary iodine deficiency, and this discovery, along with the availability of iodized salt, has virtually eliminated it as a public health concern in industrialized countries. (Nevertheless, congenital hypothyroidism remains one of the most common preventable causes of intellectual impairment in many underdeveloped regions of the world; Jain, Agarwal, Deorari, & Paul, 2008.)Prior to the 1950s, babies born with phenylketonuria (PKU), a relatively rare genetic disorder, were unimpaired at birth but invariably developed severe intellectual disabilities. This was caused by their inability to metabolize phenylalanine, a nutrient present in many everyday foods (including breast milk). Over time, the build up of abnormally high levels of phenylalanine has neurotoxic effects (Jervis, 1939), and, thanks to this discovery, a highly specialized diet was developed that has been successfully preventing disability in affected babies ever since. (All newborns in the United States are currently screened for PKU plus a growing number of other conditions, providing the basis for early diagnosis and prevention.)In the 1960s, a vaccine was developed with the intention of eradicating rubella (German measles), largely because infants exposed in utero were at high risk for intellectual and developmental disabilities. This vaccine has reduced the incidence of congenital rubella syndrome from 20,000 cases during the epidemic of the 1960s to less than 25 annually in the United States (U.S. Centers for Disease Control and Prevention, 2005). Current programs to reduce alcohol consumption by pregnant women are strongly endorsed and broadly supported for much the same reason, in this case to prevent fetal alcohol syndrome and related disorders, as is the use of folate supplements during pregnancy to reduce the incidence of neural tube defects (Pitkin, 2007). Obstetric practices have improved to avoid brain injury due to perinatal hypoxia and mechanical injury, as well as transmission of maternal viral infections that might affect babies' development. Environmental exposure to lead and mercury is being reduced to avoid their potentially neurotoxic effects, and the list could go on.Although these examples might suggest that there is no down side to prevention, the lessons of history show otherwise. Eugenics movements have gained momentum periodically, and there will always be some people in favor of imposing their views on those they see as less worthy than themselves. We are fortunate that we live in relatively enlightened times, but no matter how enthusiastic supporters of prevention may be, they must always be mindful of potential abuses. Furthermore, it must be emphasized that one of the most pressing issues facing our field has been conspicuously avoided in these examples: elective pregnancy termination based on the results of prenatal screening and diagnosis. Consideration of this critically important subject, along with the negative biases of many clinicians toward developmental disability (see Bauer, 2008), must be a major part of any dialogue about prevention. Even leaving this issue of life and death aside, though, an outspoken segment of our community vehemently opposes prevention. As expressed by the final comment from the audience at Guttmacher's (2008) plenary presentation identifying "the elephant in the room," some among us would "not want to live" in a world without intellectual and developmental disabilities. The commitment of this gentleman and his like-minded colleagues is beyond question, as is their regard for individuals with disabilities. However, other people share this commitment yet endorse the concept of prevention (although not necessarily all the strategies for possible implementation). The real elephant in the room, then, seems to be the question of whether a high regard for individuals with developmental disability inherently conflicts with support for prevention of the impairments affecting those very same people. There are certainly many ways to explore the answer to this question, but all of them should consider the logical connection between the two values in apparent opposition.Capturing the essential spirit of why people with intellectual and developmental disabilities should be valued as highly as people without disability, begin by accepting that (a) every person should have the same basic human rights and be recognized as an autonomous and unique individual and (b) each of us is capable of contributing in important ways to the diversity that enriches the human experience. In addition, accept that for every individual, each with his or her own unique profile of strengths and weaknesses, maturation and development depend critically on growth and change throughout the lifespan. Achievement of individualized successful development involves complex interactions among nature and nurture (and good fortune, no doubt), but specifics are unimportant for this discussion. It is only important to recognize that change is a natural part of life that incorporates growth, learning, and maturation and that individual characteristics must be viewed as dynamic rather than static.Once this is accepted, impairments, when present, should be recognized as just one type of personal characteristic among many, and, having no special status, impairments should also be viewed as dynamic and changeable. All treatments are based explicitly or implicitly on this premise, which is the driving force behind a host of programs that include access to a full and appropriate public education for all children (e.g., Public Law 94–142) and virtually all habilitation, education, and training. Shifting back to prevention, if impairments are subject to change, including reduction in severity, the logical foundation for opposing avoidance of their occurrence in the first place seems to collapse.As Guttmacher (2008) emphasized by the title of his plenary talk, "We Are All Mutants…," each of us is imperfect and vulnerable in one way or another. Any one of us can cross that threshold of impairment at any time, and in promoting acceptance of diversity and the value of people with disabilities, advocates serve all members of our society. Particularly at this juncture, when amazing advances in biomedical sciences and engineering are having dramatic impacts on practice and policy, it seems more important than ever to engage in an explicit evaluation of prevention and treatment from the diverse perspectives that make up the field of intellectual and developmental disabilities. A consensus is needed before the risks and benefits of specific policies, positions, and actions can be evaluated, and although that consensus might already exist outside of a small but vocal antiprevention minority, it seems at least as likely that core beliefs about prevention and treatment vary substantially. The stakes are enormous, and it would be incredibly useful to know the reality of current thinking.We each need to determine where we stand as part of the process of either building that consensus or determining that it can not be reached, and the process could start with each of us posing fundamental questions to ourselves and to others, such as: If impairments do not devalue individuals, why would successful treatment of those very same impairments? Does it follow that if successful treatment would not devalue these individuals, then prevention of impairments in others would not? Would we treasure our children with intellectual and developmental disabilities as much without their cognitive impairments? If we ever discover how to cure intellectual disability, should treatment be universally available? Has virtual eradication of congenital hypothyroidism in industrialized countries been beneficial, or have we tragically lost an entire class of people? Perhaps the most fundamental question of all is: What would we really think of a world where people without sight could see, where people unable to stand could run, and where people with intellectual disability were without their "significant limitations both in intellectual function and adaptive behavior" (American Association on Mental Retardation, 2002, p. 1)?Support was provided by Grant P30 HD024061 (M. Cataldo, Principal Investigator) from the Intellectual and Developmental Disabilities Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. I thank Drs. Michael Guralnick, Steven F. Warren, and Warren Zigman for many thoughtful comments on an earlier draft of this article.

Black people with intellectual and developmental disabilities (IDD) report poor health and lower service use compared with their White counterparts. Structural racism, neighborhood segregation in particular, has been identified as a potential barrier to equitable service use, but empirical investigations remain limited. To examine the association between race/ethnicity and neighborhood-level segregation on the use of outpatient occupational therapy and physical therapy and home health services among people with IDD. A secondary data analysis, using weighted two-level logistic regression models, of the Medical Expenditure Panel Survey (2013-2020) and census tract data from the American Community Survey. Sixteen percent of individuals with IDD reported use of outpatient occupational therapy and physical therapy, and 23% reported use of home health services. Race and neighborhood segregation were not significantly associated with service use; however, age and Medicaid coverage showed significant associations with both occupational therapy and physical therapy and home health care use. Individuals ages 0 to 3 yr were more likely to receive services than older cohorts, highlighting age-related disparities. The findings suggest that although racial disparities were not evident in this data set, structural and age-related factors still shape service utilization. Occupational therapy scholars need larger and more nuanced data sets of people with IDD to better map associations between race and neighborhood segregation and its impact on service use along the health care pipeline. Plain-Language Summary: In this article, we introduce a novel application of neighborhood-level racial segregation measures to assess structural racism in health care access among people with intellectual and developmental disabilities (IDD). By integrating data from the Medical Expenditure Panel Survey and American Community Survey, we provide preliminary evidence on service utilization patterns for outpatient occupational therapy and physical therapy and home health care, highlighting age-related disparities and the need for more nuanced data sets. The findings underscore the importance of contextualizing service use within structural determinants and offer direction for occupational therapy practitioners and health services researchers to refine equity-driven methodologies and advocacy strategies, ensuring that all people with IDD can access the home and community-based supports they need to participate in daily life. Positionality Statement: The research team was led by Khalilah R. Johnson, an occupational scientist and occupational therapy practitioner who identifies as Black and female and has an extensive history working with Black people with IDD in participatory action research and practice. Izabela Annis, the team's statistician and programmer, uses European ethnic classification and identifies as Slavic. In her work, she uses rigorous and comprehensive statistical methods to measure and analyze the complex effects of structural racism on health and social outcomes. Kathleen C. Thomas is a White woman whose family experience of serious mental illness shapes her understanding of stigma and its structural impacts. This lens informs her commitment to research and mentoring that focuses on reducing disparities experienced by people with mental illness and by communities marginalized by disability, poverty, rurality, and racism.

Health care providers' knowledge of and comfort working with adults with developmental disabilities (DD) affect the quality of care this growing population receives. Previous research on this topic has not included occupational therapy practitioners. To determine occupational therapy practitioners' views about working with older adults with DD in traditional health care settings. Quantitative survey over 4 mo. A random sample of 310 practitioners from the American Occupational Therapy Association's Gerontology and Physical Disabilities Special Interest Sections working in traditional health care settings. A researcher-developed survey to assess occupational therapy practitioners' comfort, knowledge, challenge, and supports and barriers in regard to working with older adults with DD. In the 310 included surveys (31% response rate), most occupational therapy practitioners reported feeling comfortable (76.1%-80.0%) and knowledgeable (66.5%-68.4%) working with older adults with DD. Approximately 93% reported that work with older adults with DD was at least somewhat challenging. Key perceived barriers included clients' cognitive needs, lack of caregiver collaboration, and challenging behavior. Most occupational therapy practitioners in traditional health care settings found working with older adults with DD challenging, and many did not feel sufficiently knowledgeable to meet the needs of this population. Similar to other health professionals, occupational therapy practitioners may benefit from additional resources to provide services to this population. Older adults with DD receive occupational therapy services in hospitals, rehabilitation centers, nursing homes, and other medical settings. Because clients such as these are not common in these settings, occupational therapy practitioners who work there would like more tools to help provide good care.

Clean and Healthy Lifestyle Behavior (PHBS Program) for Children with Intellectual Disability

Academy of Nutrition and Dietetics: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities

Objective: This study describes perceived levels of involvement in school-based Response to Intervention (RtI) initiatives as reported by occupational therapy (OT) practitioners from different types of communities (i.e., rural, suburban, and urban). In addition, it identifies differences among practice patterns of rural OT practitioners, compared to those from different communities, and provides suggestions for future research and training.Method: A postal survey was sent to a random sample of 1,000 OT practitioners from the American Occupational Therapy Association’s Early Intervention and School Systems Special Interest Section.Results: The survey had a 29.5% response rate (n = 295 OT practitioners). Twenty surveys (6.8%) were excluded due to missing or incomplete data. Two hundred and seventy five surveys were analyzed. OT practitioners in rural communities (58.1%; n = 50) were more likely to report participation in early identification of students benefiting from RtI interventions than practitioners in other communities. Practitioners in rural settings were also more likely to participate in universal screenings (33.7%; n = 29) and to cite a lack of resources as a limiting factor to their work in RtI (77.9%; n = 67).Conclusion: OT Practitioners in rural communities may be involved in key RtI practices more often than OT practitioners in urban and suburban contexts. Rural practitioners report this increased level of involvement despite a perceived lack of resources. More research is needed to understand how rural OT practitioners are involved in universal screening and to identify the resources that they believe they are lacking.

Occupational therapy practitioners use a range of habilitative and compensatory approaches to teach new skills or modify tasks and environments to address occupational performance among adults with intellectual disability (ID); therefore, they must identify and use available evidence to guide intervention planning. To summarize the scope of evidence that can inform occupational therapy intervention with adults with primary or comorbid ID. Articles published in peer-reviewed journals between January 2002 and January 2018 and indexed in PubMed, CINAHL, PsycINFO, and Scopus. Study Selection and Data Collection: A total of 159 articles met inclusion criteria and contained information on occupational therapy intervention with adults ages 18 yr or older with primary or coexisting ID. Fifty-seven of the 159 articles focused on intervention to address occupational performance outcomes (i.e., employment, self-care, leisure and social interaction, community participation). A wide range of literature is available to support occupational therapy intervention with adults with ID. Occupational therapy practitioners may be less knowledgeable about this evidence because much of it is located in non-occupational therapy or international journals. What This Article Adds: This scoping review provides occupational therapy practitioners with evidence to support high-quality occupational therapy intervention with adults with ID.

Youth with intellectual disabilities (ID) have persistently poor work outcomes. Occupational therapy can support school-to-work transition but is underrepresented in transition practice. To identify and describe interventions within the scope of occupational therapy for youth with ID who are transitioning from school to work. MEDLINE, ERIC, PsycINFO, and CINAHL were searched, and hand searching was performed in relevant peer-reviewed journals. Included were peer-reviewed, English-language articles published from 2004 to 2017 describing studies focused on youth with ID with no significant co-occurring physical diagnoses who were transitioning from U.S.-based school settings to paid employment. Data extraction was managed using Google Drive. Data were organized on extraction sheets by trained reviewers. The quality of each study was assessed using questions adapted from the Critical Appraisal Skills Program checklist. A total of 35 articles were included, 7 of which used randomized controlled designs. All articles described interventions aligned with the Occupational Therapy Practice Framework: Domain and Process (3rd ed.), but specific mention of occupational therapy was notably absent from the literature. Interventions had little and generally low-level evidence supporting their use. Significant and concerning gaps exist in the literature on school-to-work transition for youth with ID, likely impeding evidence-based practice. No included article mentioned occupational therapy or had a contributor who was an occupational therapy practitioner. Practitioners should advocate for occupational therapy's role in transition and contribute reports of occupational therapy transition services for youth with ID to the literature. This study demonstrates that occupational therapy is poorly represented in literature describing transition services for youth with ID. Although the articles described interventions within the occupational therapy domain, these interventions were not provided by occupational therapy practitioners and did not have a strong evidence base.

This is the third in a series of perspective articles (Schalock et al., 2007; Wehmeyer et al., 2008) from the Terminology and Classification Committee of the American Association on Intellectual and Developmental Disabilities (AAIDD). The purpose of these articles is to share our thoughts on critical issues associated with terminology, definition, and classification in the field of intellectual disability and to seek input from the field as we prepare the 11th edition of AAIDD's Diagnosis, Classification, and System of Supports Manual (the working title). In the first article (Schalock et al., 2007), we explained the reasons for shifting from the term mental retardation to intellectual disability. Although the two terms cover the same population of individuals, we concluded that intellectual disability was the better term because itIn the second article (Wehmeyer et al., 2008), we distinguished between operational and constitutive definitions of intellectual disability and discussed their application to understanding the construct underlying the term intellectual disability. The primary function of an operational definition is to assure consistency among diagnosticians by setting parameters for observing and recording evidence of the disability (Wehmeyer et al., 2008). We supported the continued use of the operational definition of intellectual disability (formerly mental retardation) from the 2002 manual (Luckasson et al., p. 1): “[Intellectual disability is] characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. This disability originates before age 18.”The operational variables included in AAIDD definitions have not changed significantly in 50 years (Schalock et al., 2007). Operational criteria for diagnosis have been generally consistent for the past 35 years, when the IQ criterion was changed from one to two standard deviations (Grossman, 1973). However, the construct underlying the term intellectual disability (and, thus, the constitutive definition of intellectual disability) has changed significantly over the last 2 decades due to the impact of the social–ecological model of disability (Institute of Medicine, 1991; Luckasson et al., 1992, 2002; WHO, 2001). In this model, intellectual disability is understood as a multidimensional state of human functioning in relation to environmental demands.This article focuses on supports and support needs, as they pertain to persons with intellectual disability, and closely related developmental disabilities. Definitions of each are as follows:This article is organized into five sections: (a) distinguishing the concept of supports from the construct of support needs; (b) conceptualizing supports as the bridge between “what is” (i.e., a state of incongruence due to a mismatch between personal competency and environmental demands) and “what can be” (a life with meaningful activities and positive personal outcomes); (c) considering support needs within a model of human functioning; (d) recommending an assessment and planning process to guide planning teams (and organizations) when developing and implementing individualized support plans; and (e) comparing and contrasting support planning with other planning approaches in the field of intellectual disability and related developmental disabilities.Supports are resources and strategies that enhance human functioning (Luckasson et al., 2002). Although this definition was developed with people with intellectual disability in mind, it is clear that everyone uses supports. The 17th-century theologian John Donne wrote, “No man is an island” (as cited in Jokinen, 2006) to convey the fundamental truth that human beings do not thrive in isolation from others. We live in an interdependent world and everyone needs a variety of supports to function on a daily basis. However, the types and intensity of supports needed by people with intellectual disability are different from those needed by most other people.Support needs, as we use it and position it within our understanding of intellectual disability, is a psychological construct referring to the pattern and intensity of support a person requires to participate in activities associated with normative human functioning. Multiple psychological constructs have been identified regarding both “states” and “traits” of humans. For example, anxiety, intelligence, happiness, and morality are all psychological constructs on which there are extreme points (e.g., euphoric vs. depressed) as well as many points in between, just like the construct of support needs. The support needs construct is based on the premise that human functioning is influenced by the extent of congruence between individual capacity and the environments in which that individual is expected to function. Addressing this congruence (i.e., ensuring person–environment fit) involves understanding the multiple factors that shape human performance, determining the profile and intensity of needed supports for a particular person, and providing the supports necessary to enhance human functioning.The concept of need generally refers to a condition characterized by the absence of some requisite necessity. Within professional literature pertaining to health, the concept of need has traditionally referred to a condition characterized as “a disturbance in health and well-being” (Donabedian, 1973, p. 62). Within psychology, need is defined as “what is necessary for an organism's health and well being” (Harré & Lamb, 1988, p. 409) or a motivated state resulting from “a feeling of unfulfillment or deprivation in the biological system…evidenced by a drive to complete such a lack” (Colman, 2001, p. 631). As discussed by Thompson and colleagues (Thompson et al., 2002, 2004b), support needs are identified on the basis of input from the individual and other respondents. Global (i.e., overall) support needs can be understood in at least four distinct ways:We do not see a person's support needs as necessarily or exclusively reflecting a disturbance of human capacity (although disability certainly may result in a disturbance of human capacity); rather, the person's support needs reflect a limitation in human functioning as a result of either personal capacity or the context in which the person is functioning. Like other psychological constructs, the level of a person's support needs (like the level of a person's motivation or shyness) is inferred and not directly observable. Moreover, an individual's support needs can be measured with varying degrees of accuracy by self-report and other report indicators of the intensity of support needs, such as is accomplished using the Supports Intensity Scale (Thompson et al., 2004a). To be clear, we see the support needs construct as reflecting more of an enduring characteristic of the person than simply a point-in-time description of the need for a particular type of support. People with intellectual disability are people who require the provision of ongoing, extraordinary (when compared with their nondisabled peers) patterns of support. Providing supports to people with intellectual disability enables their functioning in typical life activities in mainstream settings but does not eliminate the possibility that they will continue to need ongoing supports. Put another way, if supports were removed, people with intellectual disability would not be able to function as successfully in typical activities and settings.A major implication of conceptualizing intellectual disability as a state of functioning instead of an inherent trait is that the person–environment mismatch is addressed. The focus is not solely on “fixing” the individual. This implication is shown in the supports model depicted in Figure 1. First, in this model, a mismatch between personal competency and environmental demands results in support needs that necessitate particular types and intensities of individualized supports. Second, to the extent that these individualized supports are based on thoughtful planning and application, it is more likely that they will lead to improved human functioning and personal outcomes. As a bridge between “what is” and “what can be,” the focus of educational and habilitation service systems shift to understanding people by their types and intensity of support needs instead of by their deficits. Although there is a reciprocal relationship between impairments and support needs in that greater personal limitations will almost always be associated with more intense support needs, a focus on reducing the mismatch between peoples' competencies and the environmental requirements where they function, rather than a focus on deficits, is more likely to reveal supports that enhance personal outcomes.Figure 1 also illustrates two related global functions of individualized supports. The first function addresses the discrepancy between what a person is not able to do in different settings and activities and what changes–additions make that person's participation possible (e.g., promote human functioning). The second function of individualized supports focuses on enhancing personal outcomes by improving human functioning. Both functions need to be thoughtfully aligned.Sometimes, planning teams focus solely on what individuals can and cannot do in a variety of settings and, thus, arrange supports to empower individuals to do more things. Although this type of planning may lead to an individual's improved functioning, that individual's personal outcomes may not be significantly enhanced. Such planning may expand the activities available to the person and may even increase participation by the individual, but if these activities are not based on the person's preferences and priorities, any improvement in personal outcomes may be negligible. Equally misguided would be a focus only on personal priorities and preferences without thoughtfully considering the gaps between a person's competence and his or her environmental demands. This approach to planning increases the risk that supports will be arbitrarily applied. For example, an individual may want to live in his or her own home in the community, but may need some support that peers without disabilities will not need due to specific safety related concerns. A “throw in everything plus the kitchen sink” approach to supporting the individual might involve supplying staff inside the home 24 hr a day, 7 days a week who do all the cooking, cleaning, transporting, and so forth. Such excessive support provisions will not enhance the life experiences of the individual and will certainly result in wasting finite resources. Therefore, it is important to thoughtfully analyze and align both personal priorities and areas of need when planning and delivering supports.Supports are resources and strategies that enhance human functioning (Luckasson et al., 2002). Human functioning is enhanced when the person–environmental mismatch is reduced and personal outcomes are improved. Because human functioning is multidimensional, considering supports as a means to improve human functioning provides a structure for thinking about more specific functions of support provision.Human performance technology (HPT) theorists posit that human functioning results from interactions between a person's behavior and his or her environment (Gilbert, 1978). For example, Wile (1996), who created an HPT model by synthesizing five other leading HPT models, suggested that human performance is influenced by the following seven elements: organizational systems, incentives, cognitive supports, tools, physical environment, skills–knowledge, and inherent ability. Examples of support that correspond to each of Wile's human performance elements are listed in Table 1. Wile noted that some of these elements are external to the person (Elements 1–5), whereas others (Elements 6–7) are internal.Wile's (1996) seven elements are interdependent in terms of human performance and, more accurately, should be thought of as being cumulative. Therefore, from a supports perspective, solving a problem for any single element may be of limited value if problems with the other elements are ignored. As Edyburn (2000) pointed out when relating Wile's model to decision making in the area of assistive technology, getting a tool (Element 4) to improve performance would have a negligible impact if the person lacked motivation (Element 2) to be productive on the task for which the tool was to be used. Based on Wile's HTP model, supports should not be delivered to address discrete life activities or separate events, or be based on specific support individuals (e.g., job coaches, teachers). Rather, systems of support should be conceptualized where multiple aspects of human performance are considered in regard to multiple settings.It is not difficult to envision what a system of support would entail when considering the human performance elements in Table 1. Take the case of a man with intellectual disability working on a community job. The man in our hypothetical example was hired through an on-the-job-training (OJT) program offered by a state vocational rehabilitation (VR) agency (Element 1: Organizational Systems). This person was motivated to do well on the job because of opportunities for recognition and advancement (Element 2: Incentives), but he required assistance from coworkers on specific job tasks that he found to be difficult (Element 3: Cognitive Supports). In addition, this employee used assistive technologies to work more efficiently (Element 4: Tools) and needed to have the physical environment modified slightly to complete certain job assignments (Element 5: Physical Environment). Last, task analyses of aspects of the job were developed and then taught to him (Element 6: Skills–Knowledge), and he was matched to a job that was reasonably consistent with his unique talents (relative strengths) and personal interests (intrinsic motivation; Element 7: Inherent Ability). This example illustrates how each element of human performance was addressed through a system of supports, giving the worker a good opportunity to be successful on his job.An interesting implication of Wile's (1996) model is the role supports play at the organizational level. Although legislation is not considered an individualized support, it is evident that laws and regulations can have tremendous influence on people's lives. Consider the passing and subsequent reauthorization of the Individual With Disabilities Education Improvement Act of 2004 and its effect on opportunities provided to children with disabilities in the nation's schools. Prior to 1975, it was legal in many states to deny a child with special needs access to a public education. Although federal and state legislation, as well as local policies, would never be listed as distinct supports on individualized plans, it is important to acknowledge the influence that policymakers and advocacy organizations have had on the quality and quantity of supports that are available.Supports are a universe of resources and strategies that enhance human functioning. No individual will need all of the types of supports that are available. People's support needs differ both quantitatively (in number) and qualitatively (in nature). Planning teams are in the best position to identify the types of supports that people need. As shown in Figure 2, we propose a five-component sequential process for (a) identifying what the person most wants and needs to do, (b) assessing the nature of support a person will require to accomplish what he or she most wants and needs to do, (c) developing an action plan to garner and deliver supports, (d) initiating and monitoring the plan, and (e) evaluating personal outcomes. This support planning and implementation process has evolved from a planning process originally provided by Thompson et al. (2002, 2004b).The first component of this support process requires the use of person-centered planning (PCP) processes. A hallmark of PCP is the focus is on the individual's dreams, personal preferences, and interests. The primary purpose of a PCP process is to find out what is important to a person, and it is essential that discussions are not constrained by available services or by perceived barriers such as fiscal restrictions or limitations in a person's skills (O'Brien & O'Brien, 2002). As a team-planning method, PCP has been shown to yield better outcomes for adults with intellectual disability than do traditional methods of service planning (Holburn, Jacobson, Schwartz, Flory, & Vietze, 2004; Robertson et al., 2006). PCP processes involve the person with the disability and people important to that person. The desired outcome of PCP is a unified vision of a person's life going forward. This vision takes into account those aspects of the individual's current life that are favorable (i.e., aspects to maintain) and adds elements that will enhance his or her life in the future (i.e., aspects to change).The second component of the support process involves assessing the person's support needs. As one example, the Supports Intensity Scale (Thompson et al., 2004a) is a standardized measure used to evaluate an individual's support needs across seven life activity domains as well as to identify exceptional medical and behavioral support needs. However, any method that a planning team finds useful to assess support needs could be used, including direct observation of the person in variety of life activities and structured interviews with the person and his or her family members. The critical information to gather is the nature of the extraordinary support that a person would require to engage successfully in an array of those associated with the life priorities identified through support needs assessment and adaptive behavior assessment are both with typical performance in the two can be is important to that assessing a person's support needs is not the same as assessing his or her personal adaptive behavior assess the adaptive skills that a person has (and, thus, measure or performance associated with personal support needs assessment measure an individual's extraordinary supports needed to participate in the activities of daily life (Thompson et al., As discussed by and of the Association of of Developmental Disabilities support needs assessment to be most should have the following (a) be into and used by and with a of (b) consistent results and outcomes when used across service areas and (c) be person (d) and information to a of (e) identify the support needs of people with and results that are to decision making across a of and be to in the support planning process the of individuals support, their and and third component of the process on the first two to an individualized support the from the future to and it is important that an and plan of action be and Because a plan cannot address all priorities at one some personal priorities identified in 1 may need to be and some difficult may need to be However, the result of should be individualized plan that (a) the settings for and activities in which a person is likely to engage a typical and (b) the types and intensity of support that will be provided (and by (Thompson et al., p. component of the monitoring requires that planning teams the outcomes of the teams should a closely the extent to which the person's individual plan was should be ongoing and in terms of to the congruence between what was and what has to is on the extent to which desired life and personal outcomes are being This involves the individual's life experiences through the of personal outcomes. is important to acknowledge that personal preferences and priorities can over and this component of the process will assure that the when they continue to the person's needs. In addition, on personal outcomes can organizations and state systems with information regarding the extent to which systems are the needs of the field of intellectual disability, there are a of that can be used across individuals, and these are based on the assessment of domains and using both self-report and direct observation methods & 2007). Table 2 domains and indicators that can an at the level of the individual through the use of at the or systems level about the and current use of domains and indicators are found in the listed in the and in et al. should be noted there are a variety of terms across systems for the domains listed in Table the domains among the systems are when considering that these were developed by different at different and for different For example, and in the to the on and in the as well as to the and in the as by the Human and the Association of of Developmental Disabilities this five-component process requires a significant of and a planning process is essential to supports that are with individual needs and desired outcomes of people with intellectual disabilities. Planning teams can always to in the process when needed (e.g., if the plan was not due to the planning team would want to to and the In addition, the of should be as individuals and and require support The process always with assessing personal interests and needs for support, to team planning and is by monitoring of and with an of planning terms and differ as in an individualized support plan individualized service plan individualized program plan individualized plan individualized plan individualized rehabilitation plan individualized habilitation plan plan and individualized family service plan The or in between and plan may significant (e.g., age approach to for all practical planning others are structured by whereas others are of past and that have evolved over Although what a planning should is well the of this it is to between different approaches to planning and the need to support planning as a of any individualized considering different approaches to we that planning teams use only one to the of an individual's Multiple planning the risk of being as well as it would be for different organizations that are an individual in different to use a planning However, within an it would be best to use a single that for multiple planning We that a variety of planning approaches can be on individual and supports are resources and strategies that enhance individual functioning (Luckasson et al., we services as organized means for delivering supports, or other of assistance (e.g., For example, advocacy services a means for people to access a variety of advocacy supports, and such supports could from legal assistance to planning team an individual's services that intellectual and provides opportunities to skills. services medical to health problems as well as such as or physical all services will the same or quality of supports. between service might be due to different and or could be result of different of on our definition of service planning should focus on the types of services that need to be as well as the of that a person should have with a service (e.g., how many of service a person might need in a Because services are to supports and other of it is important for to have systems of A service planning component in an individualized plan is necessary to identify service who can deliver the supports or other types of assistance that is service planning is not a for support identifying of service or in which an individual is going to participate is to result in individualized supports or personal outcomes. in our distinguishing between support planning and service planning is not just an of Planning teams need to identify services an individual needs to but this is not the same as planning the patterns and intensities of supports a person needs to function in activities and settings consistent with his or her also differ from are in and planning where the focus is on and skills. Because the purpose of public and vocational rehabilitation (VR) services is to people in a positive way, and of However, support might involve educational settings for of the focus of support planning in such a case would be on participation plans, support are not characterized by and behavioral that for an individual. Rather, the function of support is to identify the resources and strategies that will bridge the between the that a person with intellectual disability experiences in life activities (i.e., person–environment and the life experiences and opportunities (i.e., that the individual the case of children who are teams are to in (e.g., as well as for However, planning and processes should also support For example, planning for the types of that will be to support a child to access the and an in the least environment would be to the of with intellectual disabilities. is important to that we are not that support planning should the focus of all individualized However, we are that the need for support planning should not be in where planning processes are the AAIDD the American Association on Terminology and Classification Committee the concept of supports in the manual (Luckasson et al., the that supports were an but essential In that the focus was on support resources other technology, and support functions (e.g., employee and and community access and support intensity of a supports intensity assessment and desired outcomes. A was between and supports. This to which at that to be to from individualized supports, which are based on the needs of the individual. a of support were offered on the basis of two (a) supports in and (b) support activities are by individuals or in that AAIDD manual (Luckasson et al., a better understanding of the for support provision and the need to supports in the context of an individualized process that and This understanding due to in the field between the and 2002 among these were (a) a greater of the value of PCP as well as implementation of PCP which personal and and (b) an approach to disability that the of person–environmental interactions and the of human functioning through the use of individualized (c) a on personal well quality of and personal and (d) an of support including in assistive we approach the and of the 11th edition of the there is that we can from past as well as In this we distinguished supports from support needs and discussed how on individual support needs can be through understanding of human In addition, we a supports model that illustrates how supports are a bridge between what is and what can be through the of the mismatch among a person's the demands of environment, and the of personal outcomes. We also a five-component process for and evaluating individualized supports 2) and suggested that support planning can other approaches to planning and in an individualized planning

Occupational therapy practitioners should use evidence-based practices, such as video modeling, to address work occupations supporting people with autism spectrum disorder, including those with co-occurring intellectual and developmental disabilities. To examine the evidence and relevance of video modeling supporting engagement in work occupations for people with autism and to translate these findings to occupational therapy practice. Cochrane Collection Plus, CINAHL, PubMed, ERIC, ProQuest, and peer-reviewed occupational therapy literature from 2008 to 2018. Study Selection and Data Collection: This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study selection and data collection focused on occupational therapy scope of practice, autism spectrum disorder, co-occurring intellectual and developmental disabilities, video modeling, and work occupations for people age 16 yr and older. A total of 464 articles were screened. Six articles met inclusion criteria. Results indicated moderate evidence for video modeling to support work occupations for people with autism, specifically employment seeking and acquisition and specific job-performance skills. Samples were limited to people younger than age 28 yr and represented varied intellectual abilities, indicating potential for benefits across the spectrum of cognitive functioning. This systematic review highlights the promising potential of video modeling to address work occupations for people with autism. However, more rigorous effectiveness research is needed, including studies by occupational therapy practitioners. What This Article Adds: Occupational therapy expertise paired with video modeling, as a strengths-based, client-centered, customizable, socially acceptable intervention, can provide meaningful support for work occupations.

This article describes the use of in-house funding, private contracts, and a mixture of the two for applications in public transit operations. Three transit agencies are presented as examples: SunLine Transit (Thousand Palms, California), Foothill Transit (Los Angeles County), and Phoenix Public Transport (Phoenix, Arizona). Private contracts are often less expensive due to cost-savings measures on the part of the private entity. One such example involves paying employees less money on an hourly wage than is possible within a public organization. In addition, organizations avoid paying for outsourced Social Security, Medical, unemployment, and workers' compensation for these contracts. Lastly, private contracts cut down on slow bureaucratic processes that hinder public organization. However, using in-house employees has advantages such as greater control over quality of service. In the case of a combined public and private operation, the author notes that, due to the potential for maximized efficiency, cost per ride rates are among the lowest for peers. Likewise, the agency is afforded some of the control of public employees while gaining the efficiencies of private.