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SOBRIETY LEISURE WITH INDIVIDUALS WITH SUBSTANCE USE DISORDER AND INTELLECTUAL DISABILITIES

Sobriety Leisure with Individuals with Substance Use Disorder and Intellectual Disabilities

Abigail Fulton and Amy Sale

Longwood University


Table of Contents

Introduction…………………………………………………………………………………..Pg 3

Body………………………………………………………………………………………….Pg 4

Conclusion……………………………………………………………………………………Pg 6

References……………………………………………………………………………………Pg 9

Appendix A…………………………………………………………………………………..Pg 11

Appendix B…………………………………………………………………………………..Pg 23

Pledge………………………………………………………………………………………...Pg 26


Introduction

In the United States, substance use disorders occur 33.8% amongst individuals with

intellectual disabilities (Bhaumik, Tyrer, McGrother, & Ganghadaran, 2008). For the purposes

of this paper substance use disorder (SUD) refers to what was in the DSM 4 substance abuse and

substance dependency which is currently in the DSM 5. The characteristic of substance use

disorders are problems in personal and interpersonal life, employment, control, health and safety,

and physiological sequences. There are three basic categories of substance related conditions

they include substance use disorder, substance intoxication, and substance withdrawal. There are

over 300 substance related disorders in the DSM 5 (Morrison, 2014). The characteristic of

disability is Intellectual Disabilities (ID) are a disorder with onset during the developmental

period that included intellectual and adaptive functioning. There are three criteria that the

individual must meet to be diagnosed with ID. The first one is deficits in intellectual functioning

just as problem solving, learning from experience, and judgement confirmed by both a clinical

assessment and a standardized intelligence test. The second one is deficit is in adaptive function

such as failure to meet developmental and sociocultural standards and have adaptive deficits that

limit functions of daily living. The last one is onset of intellectual and adaptive deficits during

the development (American Psychiatric Association, 2013). “Sobriety is a healthy, happy,

rewarding, productive life which is alcohol and drug free” (Faulkner, 1991). Leisure is activities

free of obligations that people do in their free time. Leisure has to be intrinsically motivated,

have preserve freedom, and have a positive effect (Anderson and Hurd, 2011). Sober Leisure is

doing activities that are free of obligation and are intrinsically motivated without drugs and

alcohol. Therefore, the purpose of this paper is to explore the prevalence among individuals with

intellectual disorders and substance use disorders.


Body

In our research, we found that individuals with ID smoke and use alcohol, but at lower

rates compared to the nondisabled population. We also found that individuals with ID misuse

and overuse alcohol, illicit drugs, and prescribed medications (Taggart, McLaughlin, Quinn, &

McFarlane, 2007). The evidence shows that this argument is true because one article we found

was done in 2007 that interviewed ten individuals with ID who misused drugs and alcohol.

Seven of them were female and three of them were male. Seven of the individuals misused

alcohol only. Three women misused alcohol, illicit drugs (cannabis and ecstasy), and prescribed

medication (paracetamol, codeine and diazepam). All of the individuals reported that they had

long alcohol use, over 5 years (Taggart, McLaughlin, Quinn, & McFarlane, 2007). Another

reason this article is true is in another study that was done in 2014. This study explored people

in prison about their alcohol and drug use. There were 180 prisoners with ID and 269 prisoners

without ID. The substance use of 1 year prior imprisonment were as follows alcohol was 65%,

drugs was 59% and alcohol and drugs were 45%. The drugs that were being used are

amphetamines, benzodiazepines, cannabis, methadone, and opiates. The amount of alcohol and

drug use were similar for both people with ID and without ID (Mc Gillivray, Gaskin, Newton,

Richardson 2014). All three of our articles found that the substances the individuals with ID

used were polysubstances, cocaine, opiates, cannabis, alcohol, ecstasy, paracetamol, codeine,

diazepam, amphetamines, benzodiazepines, and methadone (Dutra et al., 2008; Taggart,

McLaughlin, Quinn, & McFarlane, 2007; Mc Gillivray, Gaskin, Newton, Richardson, 2014).

Multiple studies have indicated that leisure enhances the quality of life of individuals

with ID, helping to make their lives better, relieving tensions, building and maintaining

relationships with family and friends, increasing self-esteem, and enhancing physical health and


fitness. Leisure also can help individuals with ID understand themselves, help them gain a

stronger sense of who they are, and strengthen their sense of belonging (Patterson & Pegg,

2009). For example, there was a study done with adolescents ages 15 to 16 that studied leisure

activity patterns. The researchers’ studies activities such as sports, social clubs, and party

subculture. The researchers discovered that sports and social clubs had a negative effect on

participant wanting to drink. The researchers also discovered that the party subculture had a

positive effect on participants wanting to drink. This means that people involved in leisure

activities were less willing to drink (Thorlidsson & Bornburg, 2006). Another example that

supports our argument is from a study done in 2009. The study interviewed 10 individuals with

mild to moderate ID in relation to their participation in a serious leisure activity. Serious leisure

is the activities of a small segment of people who become increasingly involved in different

types of leisure. Six of the ten were male and four were female. Most of the respondents

reported that they had participated in their activity for at least two years, some even engaged in

their activity for up to 15 years. Some of the leisure activities in this study were lawn bowls, ten‐

pin bowling, track and field athletics, tennis, guitar playing, singing and volunteering. On person

even spent her time training for an athletic competition at the elite level three times a week,

while also going to the gym three times a week and going to pool sessions two times a week.

The results of this study show that participating in serious leisure showed that the individuals

with ID were committed and had the ability to persevere. All individuals that participated in this

study had all of the improvements to their quality of life listed above, including increasing self-

esteem, making new friends, relieving tension, and more (Patterson & Pegg, 2009).

Drugs and alcohol can be used as leisure. Uses of drugs and alcohol can receive a desired effect

quickly. People think that the only way to do leisure is to pay for the feeling that they want.


People who use drugs and alcohol for leisure often have poor leisure skills. They see chemical

free leisure as valueless. The addicts don’t see any problem with their usage if it done it leisure

time. Many of these addicts are in denial about their problems (Faulkner, 1999).

Therapeutic Recreation (TR) can be used as treatment for SUD. This is because it teaches clients

about new leisure skills. There was a study done with 39 participants in an outpatient program

who were low income or no income often homeless individuals. These participants worked on

several types of TR skills including self-determination, leisure education, and coping skills

training programs. The researchers picked these skills because they can enhance problem

solving skills and help with non-drug and alcohol alternatives. The results of this study was not

statistically significant but there were several problems that were addressed. The first one is that

the participants answering in a manner that was a behavior that the therapist was desiring. The

second problem was that all the participants were internally motivated so that they did not have

an effect on motivation. The main problem with this study was there was not enough participants

to make it significant (Cogswell & Negley, 2011).

Conclusion

In conclusion, individuals with intellectual disabilities do have substance use issues and

need sobriety leisure. As seen above, leisure can be very helpful for individuals with ID and

leisure is a valid use of treatment. One of the barriers that we found in the studies was that they

did not aim to generalize to wider population of learning disabilities (Taggart, McLaughlin,

Quinn, & McFarlane, 2007). Another barrier that we found was that there is no current system to

capture those with mild intellectual disorders who access mainstream services (Bhaumik, Tyrer,

McGrother, & Ganghadaran, 2008). The last barrier that we found was that there are problems


of service for people with lower IQ and knowing if a number should affect the services they are

eligible for (?).

There were also a few limitations that we found when doing our research. One of the limitations

that was found was small sample size (Cogswell & Negley 2011; Patterson & Pegg, 2008).

Another limitation that was found was small number of studies (Dutra et al., 2008). Two more

limitations that we found were that there needs to be more training for staff who work with

individuals with ID and that there needs to be more resources to get help and to be diagnosed

(McLaughlin, Taggart, Quinn, & Milligan, 2007). Some more limitations that we found are

methods not consistent with typical practices, facilitator differences between the treatment and

control groups, and the difficulty to recruit participants for the study (Cogswell & Negley, 2011).

One of the recommendations for future research that we found was finding a larger

sample size (Cogswell & Negley 2011; Patterson & Pegg, 2008). Another recommendation that

we found was to utilize more recent advancements in order to fully engage and work with this

resilient population (Taggart, McLaughlin, Quinn, & McFarlane, 2007). Some more

recommendations for future research that we found were to find a larger sample and use a

randomized clinical trial to help increase the likelihood of finding statistically significant results

(Cogswell & Negley 2011).

All of the recommendations for client practice that we found were from our Expert

Opinion (2016). One of the recommendations was to make sure that the client has a leisure

outlet instead of using drugs or alcohol. Another recommendation was to change the habits of

the client through a positive leisure source. Another recommendation was to talk on their level

and to use appropriate language use. The fourth thing our expert opinion told us to do was to

avoid substance use in programs. The last thing that our expert opinion told us was to know


individuals past history. Not everyone has a current substance use issue, but some have used

substances in the past (Expert Opinion, 2016).


References:

Expert Opinion, personal communication, October 6, 2016.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bhaumik, S., Tyrer, F. C., McGrother, C., & Ganghadaran, S. K. (2008). Psychiatric service use

and psychiatric disorders in adults with intellectual disability. Journal of Intellectual

Disability Research, 52(11), 986–995. doi:10.1111/j.1365-2788.2008.01124.x

Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W. (2008).

A Meta-Analytic review of psychosocial interventions for substance use

disorders. American Journal of Psychiatry, 165(2), 179–187.

doi:10.1176/appi.ajp.2007.06111851

McGillivray, J. A., Gaskin, C. J., Newton, D. C., & Richardson, B. A. (2015). Substance use,

offending, and participation in alcohol and drug treatment programmes: A comparison of

prisoners with and without intellectual disabilities. Journal of Applied Research in

Intellectual Disabilities, 29(3), 289–294. doi:10.1111/jar.12175

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY,

United States: Guilford Publications.

Patterson, I., & Pegg, S. (2009). Serious leisure and people with intellectual disabilities: Benefits

and opportunities. Leisure Studies, 28(4), 387–402. doi:10.1080/02614360903071688


Taggart, L., McLaughlin, D., Quinn, B., & McFarlane, C. (2007). Listening to people with

intellectual disabilities who misuse alcohol and drugs. Health & Social Care in the

Community, 15(4), 360–368. doi:10.1111/j.1365-2524.2007.00691.x

Thorlindsson, T., & Bernburg, J. G. (2006). PEER GROUPS AND SUBSTANCE USE:

EXAMINING THE DIRECT AND INTERACTIVE EFFECT OF LEISURE

ACTIVITY. ADOLESCENCE, 41(162).

McLaughlin, D. F., Taggart, L., Quinn, B., & Milligan, V. (2007). The experiences of

professionals who care for people with intellectual disability who have substance‐related

problems. Journal of Substance Use, 12(2), 133–143. doi:10.1080/14659890701237041

Cogswell, J., & Negley, S. (2011). The Effect of Autonomy-Supportive Therapeutic Recreation

Programming on Integrated Motivation for Treatment among Persons Who Abuse

Substances. Therapeutic Recreation Journal, 45(1), 47–61.

Hurd, A. R., & Anderson, D. M. (2010, November 23). Definitions of leisure, play, and

recreation. Retrieved November 7, 2016, from Human Kinetics,

http://www.humankinetics.com/excerpts/excerpts/definitions-of-leisure-play-and-

recreation


Appendix A

Literature Review Table

Research statement (identified on PICO form): For individuals with comorbid intellectual disability and substance use disorder with an increase in sobriety through the use of sober leisure.

Source Purpose Design Outcomes/Focus

Results Conclusions/Issues Identified

Author & Date

Describe the research question being investigated and/or purpose of the study

Describe the research design, measurement tools and number of subjects/participants

List all outcomes measured

Summarize the results including statistical significance

Summarize in bullet points conclusions from findings and/or any concerns regarding study methodology that may have impacted results

Article #1 (Abby)Bhaumik, S., F. C. Tyrer, F. C., McGrother, C. & Ganghadaran, S.

To describe the prevalence of specialist psychiatric service use among adults with ID;

To describe the nature

Cross-sectional study

Leicestershire Learning Disability Register

Structured home interviews using the Disability Assessment Schedule and

Diagnosis Age Sex Ethnicity Residential

status of patient Comorbidity Prescribed

Medication Demographic

1244 (45.9%) adults were seen by specialist psychiatric services in Leicestershire, 707 (56.8%) were men and 537 (43.2%)

The sample includes only people who access specialist ID services and therefore individuals with mild ID and psychiatric disorders are


K.November 2008

and prevalence of psychiatric disorders in adults with ID; and

To identify any differences in the nature and prevalence of psychiatric disorders between men and women and between different severity levels of ID.

questions on demographic details, skill level, behaviour and carer stress

7 questions were also asked to determine level of ID

2711 adults over 6 years

Details Skill level Behavior Communication Dependency

were women Most adults

were living in residential homes (38.4%) and had severe or profound ID (72.1%)

Among those seen by services, 479 (38.5%) adults had epilepsy and 814 (65.4%) adults were prescribed psychotropic medication

The prevalence of psychiatric disorders in the study population was 33.8%

Behavior disorders: 19.8%

Autism spectrum disorder: 8.8%

Depression: 4.3%

Bipolar Affect

likely to be are under-represented in this population

There is no current system to capture those with mild ID who access mainstream services.

In this study psychiatric diagnoses were based on clinical assessment and were not subject to the use of a structured diagnostic tool

Future research would benefit from identifying the complex process of accessing mainstream services by people with mild ID and service users’ and carers’ experiences of this process. The development of


Disorder: 3.0% Psychiatric

service attendance was more common as individuals’ severity of ID increased

short validated screening tool to help professionals to identify people with mild ID in mainstream services may also be important.

Article #2 (Abby)Taggart, L., McLaughlin, D., Quinn, B., and McFarlane, C.2007

To examine the insights of 10 people withintellectual disabilities into the reasons why they may misuse alcohol or drugs, and what impact thisbehavior may have on them; and to explore

Focus groups and semistructured one-to-one interviews

Qualitative approach

Systematic approach

10 participants, ages 28-52

Substance the individual abused

Reasons for misusing substances: psychological trauma and social distance from their community

Life impacts of alcohol misuse

Supports/services: intellectual disability services, mainstream addiction services, and primary care services

Utilization of specialist

8 interviews took place in a private room in a health center or day center

2 interviews took place in the person’s home

8 requested their social worker or community nurse

1 requested his mother sit in with them

1 did not request anyone to sit in with them

7 individuals were alcohol only

3 women

Both individuals with and without ID use and misuse a range of substances to self-medicate against life’s negative experiences.

This study did not aim to generalize to the wider population with learning disabilities.

It may indicate the need for an emphasis to be placed on this population having greater access to a wider range of specialist services that can address these negative life


the services that they receive.

support networks/groups

Service developments

reported using alcohol, illicit drugs, and prescribed medication

All individuals were reported that they had long alcohol use

Within the past 12 months, 2 people stopped because of specific life circumstances, 6 reduced their patterns, and 2 continued to engage in harmful patterns

2 reasons: psychological trauma and social distance from their community

4 life impacts: physiological effects, the effects on the person’s mind,

experiences. Both ID and

addiction staff need to consider utilizing more recent advancements in order to fully engage and work with this resilient population.


financial impacts, and their relationship with family and friends

Article #3 (Abby)Patterson, I. & Pegg, S.2008

To investigate whether serious leisure activities provide opportunities for people with intellectual disabilities to practice, or gain training in work skills in a non‐threatening and enjoyable environment.

Qualitative methodology

Semi‐structured face-to-face interviews

10 individuals with an intellectual disorder in the mild or moderate range (6 male, 4 female)

Serious leisure concept

The importance of serious leisure

The positive benefits of serious leisure

Making new friends

Joining a serious leisure association

Volunteering as a serious leisure activity

The majority of respondents reported that they had participated in their activity for at least two years, with several indicating engagements for up to 15 years.

two respondents participating in each of the following leisure activities – lawn bowls, ten‐pin bowling, track and field athletics

one respondent participated in

Needs a larger sample in the future

serious leisure has been shown to increase their social competencies and provided many with similar individual benefits that can be achieved through open employment


each of the following – tennis, guitar playing, singing and volunteering

7 participants lived at home with their parents and siblings

Three older people lived independently in community housing

7 were employed in part-time jobs

2 were volunteering

1 spent most of her time training at the elite level of athletic competition

Article #4 (Abby)Katz, G., Lazcano-Ponce, E.2008

To define, find the etiological factors, classify, diagnose,

Definition Etiological

Factors Classification Diagnosis Treatment

the treatment objectives must focus on the normalization of behavior in accordance

Intellectual disability should be treated in a comprehensive manner. Nevertheless,


and find the treatment and prognosis of intellectual disorders.

Prognosis with the norms and rules determined by society

intervention as early as possible is fundamental

During the infancy period (zero to two years): motor therapy & sensory integration therapy

When children are diagnosed after two years of age and before puberty, the ideal is to use instruments that determine the maturity level for each one of the developmental areas and apply the same therapies

in addition promoting the

currently, the fundamental task and perhaps the only one that applies is the detection of the limitation and abilities as a function of subjects age and expectations for the future, with the only goal being to provide the support necessary for each one of the dimensions or areas in which the person’s life is expressed and exposed.


development of perceptual abilities, with deficits in, and learning abilities (reading, writing, mathematics, etc.), using techniques similar to those used in children with learning disorders (dyslexia, etc.)

Some programs should cover the areas necessary for achieving a partially or totally self-sufficient life, among which are: the academic-basic skills, community integration programs, developing skills for


managing domestic tasks, personal healthcare and sexuality

prevocational program should be included for the development of abilities for the workplace

Article #5 (Abby)Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., Otto, M. W.2008

Despite significant advancesin psychosocial treatments for substanceuse disorders, the relative success of theseapproaches has not been well documented.

Meta-analysis Literature searches 34 well-controlled

treatment conditions

2,340 patients

Type of Substance used

Treatment Type Control

Condition Weeks of

Treatment Sessions per

week Unique

population Drug content Intent to treat

sample Dropout Abstinence Effect size

14 contingency management

2 cognitive behavioral therapy/contingency management combination

13 general cognitive behavioral therapy

5 relapse prevention

13 of the treatments were polysubstance use

9 for cocaine use

7 for opiate use

Our meta-analysis was limited by the small number of studies for the combination of contingency management and cognitive behavioral therapy as well as for studies of relapse prevention.

fewer studies were completed for cannabis and opiate use disorders

none of the relapse prevention studies


In this meta-analysis, the authorsprovide effect sizes for various typesof psychosocial treatments, as well as abstinenceand treatment-retention ratesfor cannabis, cocaine, opiate, andpolysubstance abuse and dependencetreatment

5 for cannabis use

Treatment types were not significantly associated with (confounded with) the targeted drug use disorders according to chi-square analyses (contingency management versus all other treatments).

43.6% of the studies included samples where the participants received medication maintenance in conjunction with both the experimental treatment and control conditions

Mean length of treatment: 21

analyzed included polysubstance users, the group with the lowest effect size estimates

Directions for future research include studies aimed at improving retention rates for all substance use groups, as well as at improving treatment efficacy for polysubstance users.


trials. weeks Average

number of sessions per week: 1.8 sessions

The mean intent-to-treat sample size per treatment condition: 38.23, ranging from 5 to 135 participants

Article 6 (Amy) McLaughlin D.F.; Taggart L.; Quin B.; Milligan V.; 2007

The purpose of this study was to collect experiences and perceptions working with people with ID and to get the staff views to see if the people with ID’s

Case Study The research design is staff interviews for about 30 to 40 minutes with 13 front line professionals. These professionals have at least 1 person they were working with that had a dual diagnosis.

There is not any not resources for people with ID

There is a lack of training of staff who work with individuals with comorbid ID and SUD/O

High functioning people with ID and not always

There was no statistical data reported

There needs to be more training for staff who work with people with ID. There also needs to be more resources to get help and also to be diagnosed.


needs better met

identified

Article 7 (Amy)Mc Gillivray J.; Gaskin J. ; Newton C.; Richardson B. 2014

To compare drug and alcohol use of people with ID to people without ID

Cross sectional studyAnalysis was used for people with and without ID for year and month how much they wanted to use after participation in treatment program

Lower the amount of drug and alcohol use for people with ID Study was looking at a prison

Use in year prior to prison term was Alcohol for people with ID was .65 and alcohol for people without ID was .74 See page 292 table 2

People without ID use drugs and alcohol more than people with ID but people with ID still use drugs and alcohol

Article 8ThorlidssonT.; Bornburg J 2006

To see how leisure effects drug and alcohol use

This was a study that surveyed students to see if their leisure effected their substance use

It was seen that people who did sports or belonged to clubs used less substances

Look at Table 1 and Table 2 Table 1 for leisure activates Table 2 for demographics

People who do leisure are less likely to do drugs and are less likely to do drugs when people around them are doing drugs.

Article 9Badia M.; Orgaz M.; Verdugo M. ; Ullan A.;

To see if leisure participation helps with QOL for people

Assistants administers a scale for QOL and a GENCAT Psychologist compared the

People with good leisure life styles had high QOL while people with not so good

Look at table 2 and 3 on page 537 and table 4 and 5 on 538

Leisure has effect on QOL. This is true of people with disabilities as well


Martinez M. 2013

with developmental disabilities

scores leisure life styles had lower QOL

Article 10 Roozen H.G.; de Waart R.; van der Kroft P 2010

The purpose was to see what intervention for families were better CRAFT or Al- Anon

Meta-analysis Used data based with 4 control studies and synthesized the data

Craft was better than Al Anon with helping families during treatment

Table 1 on page 1732 talks about demographics and substances used

CRAFT is better for certain groups. Substance use problems are not only the person using but the whole family’s problem


Appendix B

Outline

I. Introduction (Amy)a. Explain the purpose of the paper: PICO statement

i. For individuals with an intellectual disorder, who also have substance use disorder, have increased sobriety by participating in sober leisure instead of using drugs and alcohol.

b. Definitionsi. Substance Use Disorder

1. Substance abuse and dependence2. Drugs and alcohol

ii. Intellectual Disabilitiesiii. Sobrietyiv. Sober Leisurev. Leisure

II. Body (Both worked equally on body)a. Individuals with ID who are using substances

i. Amount of drug and alcohol use (article 7 and 2)ii. Different substances used (article 5)

b. Leisure as a modality to serve people with ID (article 3 and 8)c. Leisure can be used as treatment (article 11 and book)

i. How it can improve motivation ii. Leisure education and skill development

iii. Adds to bag of tricks III. Conclusion (Abby)

a. Barriersi. Did not aim to generalize to the wider population of learning disabilities

ii. There is no current system to capture those with mild ID who access mainstream services.

iii. Problems of service for people with lower IQ and knowing if a number should affect the services they are eligible for.

b. Limitationsi. Small sample size

ii. Small number of studiesc. Recommendations for future research

i. Larger sample sizeii. Utilizing more recent advancements in order to fully engage and work

with this resilient population.d. Recommendations for clinical practice

i. Make sure that they have a leisure outlet instead of using (interview)


ii. Change habits through a positive leisure source (interview)iii. Talk on their level- appropriate language use (interview)iv. Avoid substance use in programs (interview)v. Know individuals past history- not everyone has a current substance use

issue, but some have used substances in the past (interview)


Pledge: I have neither given nor received help on this work, nor am I aware of any infraction of

the Honor Code.

Abigail Fulton

Amy Sale

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