ACT and Intellectual Disability/Learning Disability

I realize this isn't a "resource" for DD, but if you allow me to ramble a little bit here, I'll share what we do.

The problems we experience for people with limited repertoires is that they often economize their responding to a survival (safety) mode referred to as experiential avoidance in ACT. Unfortunately, we only see these individuals after they have developed a quite strong history of response. A significant effect of spending all one's behavior in "survival mode" is that you don't voluntarily emit behavior that could contact positive reinforcers, and the negative reinforcement paradigm prevails. The higher functioning the person is, the more efficiently these restricting contingencies dominate the individual's repertoire. It is possible that the lower functioning the individual, the less negative reinforcement will dominate responding, but these negative reinforcement contingencies are certainly at work in every individual. The higher functioning people show more internal (language-based) control and the lower functioning people show more external control (historic environmental cues). Interestingly, people who are not reinforced easily by responding to the external environment (e.g., individuals with autism) respond very well to fixed schedules and visual cues regardless of how high they seem to function.

Our basic programmatic plan is to occasion routine behavior the individual is capable of performing and providing reinforcement for it. Sometimes DD programs make the mistake of insisting on targeting behavior the individual cannot do because they are in the business of habilitation. Here the target is for the person to contact positive reinforcement, not contact more punishment from attempting to emit behavior that is difficult. A person who arrives with a very strong negative reinforcement (experiential avoidance) repertoire typically resists emitting any behavior that does not "save his life" even if he or she has the skills to perform it. Our experience has been that if the opportunity is consistently presented they slowly move to these new more positive schedules of reinforcement. Initially, this involves a lot of discrimination training where the person learns what behaviors are reinforced and which aren't, but we move quickly from external prompting to independent performance of the skill. Using a gardening example some discriminations that have to be acquired are, pull the weeds, leave the plant; pick the ripe, leave the green, etc.. This is an important time if the interest is in getting the person the most reinforcement in the shortest amount of time. If most of the person's problematic schedule of reinforcement was internal, it is important to fade to that self or automatic, appetitive reinforcement as quickly as possible. However, given the regnant strength of the negative reinforcement schedule there must be supervision to keep the individual focused on the present so they do not slip back into familiar, "safe" behavior (thoughts or response to the environment). It is apparent to us that the largest physical displays (SIB, destruction, aggression) occur to escape from the "suffering" generated by the history of this very type of escape (i.e., a self-perpetuating cycle). The higher functioning the individual, the more efficient this control can occur. One individual we work with would periodically dash to the bathroom to squeeze out (escape from?) the smallest amount of urine. When his helmet that protected him from head hitting was removed he stopped visiting the restroom because he was more worried about (escaping from the thought of) hitting his head. This "I'll-give-you-something-to-worry-about" treatment (something that has been observed in many poor parenting examples) is not recommended as therapy, but has some value in showing the negative reinforcement control of his behavior. Better treatment seems to be what ACT recommends. That is, keeping the person involved in the present, responding according to their values (positive reinforcement history) that you may have to instill, with enough trials and exemplars that the behavior begins to occur independently giving this individual reasons to live that they likely have never had before.

Interestingly, we have found that giving choice to a person with a very strong history of escape (experiential avoidance) and characteristics of autism simply increased his concern that normal life-responding was dangerous and something that required large physical reactions to escape from it. This points to the dangers of taking common advice (i.e., choice is good) and using this without individualizing the treatment based on the participant's response. Sometimes political correctness can be a political winner but a patient loser.

Martin Ivancic