NADD U.S. Policy Update (from the NADD Bulletin Volume VIII Number 4)

Complete listing

Consideration of cultural diversity in service provision and planning for individuals with co-occurring developmental disabilities and mental illness

Jeffrey Keilson. MA

Thomas Wagner, LICSW


There is much written on the challenges in supporting people with co-occurring developmental disabilities and mental illness or challenging behaviors. There has also been growing attention to supporting staff, particularly direct support professionals who are from different countries and different cultures. However, not enough attention, particularly in public policy, has been paid in understanding the complexities of people from diverse cultures who present with co-occurring conditions. Issues of co-occurring conditions, already challenging on their own, become even more complex when issues of race, class, language, culture or religion are not considered. Adding to the complexity is the multiplicity of cultures, languages, and religions that are native to many of the direct care providers who provide front-line support to these individuals. The task is even more challenging when the clinical and administrative staff are from different cultures as well. Cultural diversity enhances everyone's experiences. However it becomes problematic when there is lack of attention in the role diverse backgrounds may play in the determining ways people may interact and define goals.


It is critical to have focused strategies at the state and federal level in supporting individuals with co-existing developmental disabilities and mental illness or challenging behaviors. It is becoming increasingly clear, too, that agencies providing support must have focused strategies on workforce diversity and development. This must include a strategy to provide support and services in ways that are respectful and responsive to an individual's culture of origin, class, family system, and religion.


While the system is challenged in providing supports to persons with complex needs such as the need for collaboration, communication, and skilled professionals, this challenge is exacerbated by lack of attention and understanding of cultural diversity. We've begun to recognize that there is an art in recruiting, retaining and supporting a cross-cultural workforce. We must also begin to recognize there is an art to providing supports that respect and are responsive to people and their families in the context of their culture of origin.


Person centered planning approaches are ideally suited to address these needs. By focusing on the individual and his/her wishes, dreams and desires, the provider is less likely to make untested assumptions based on cultural or linguistic biases. However, for this approach to be successful, a commitment of energy and resources is required. State, federal, and human service agencies must be committed to development of cultural competency for facilitators of the person-centered planning, administrators, clinicians and direct care professionals. Cross-cultural and cross-linguistic training must be provided to assist families, support caregivers and agency personnel to appreciate and understand differences in ways that give credibility and value to experiences people bring with them.


In order to insure quality supports in providing services in this manner, individuals and families must be offered the opportunity to give voice to their beliefs. This requires the commitment to support people from different cultures in gaining skills required to be effective advocates and being mentors for others. Government and provider agencies must gain the cultural skills to be effective listeners.


Acknowledging this complexity is the first step toward redefining and redesigning support systems for people with co-occurring conditions. Support systems must be re-defined to include the natural supports that a person brings to the table . Support systems that include families and significant others and support systems that draw on and individual's native culture and linguistic community. Reimbursement systems must be designed to include accommodations for interpreters who are linguistically and culturally competent. Funding streams must support grassroots community agencies or family support systems that may not meet traditional licensing requirements. Documentation requirements must be respectful of communication methods of different cultures. For example, in Deaf culture communication is visual and not written. Solutions that satisfy government requirements while respecting the different cultures can be developed. The individual's needs and expressed desires, reflected in the person centered plan and budget, should drive funding for culturally competent services and supports. Support brokers working for person should be a reimbursable service and could be funded from an individual's allocation.


In 2003, a survey of State Directors conducted by NASDDDS and NASMHPD identified lack of qualified service providers as the major obstacle to the delivery of services to people with co-existing conditions. Training staff from different cultures to work with consumers of different cultures, in addition to relying more on natural communities, creates an opportunity to develop a uniquely qualified support system. This flexibility is even more critical to insure cost-effective services for people with complex needs.


In conclusion, in meeting the challenge to provide effective services to people with coexisting disorders policy planners must consider issues of cultural diversity in addition to clinical and habilitative needs. This may require targeted resources for recruitment and training. A culturally responsive service network will help to insure successful outcomes for people who live with many challenges, and can be developed with good public policy and effective planning and collaboration. We diminish ourselves by not being responsive. We enrich all of us by being successful.




Moseley, C (2004) NASDDDS Technical Report: Survey on State Strategies for Supporting Individuals with Co-existing Conditions (p5).


Jeffrey Keilson. MA is an independent consultant and Vice-President for Advocates, Inc. in Framingham, Massachusetts and can be reached at