Module 41 Substance Abuse Disorder Treatment for People With Physical and Cognitive Disabilities (ACCSA)
Executive Summary and Recommendations
Nearly one-sixth of Americans have a disability that limits activity; many others have unrecognized cognitive disabilities. The Americans with Disabilities Act (ADA) was signed into law in 1990 to ensure equal access to community services and facilities, including substance use disorder treatment facilities (public and private) for all people regardless of disability.
People with physical and cognitive disabilities are more likely to have a substance use disorder and less likely to receive effective treatment than those without coexisting disabilities.
The ADA requires equal accessibility: physical access (ramps, elevators, lighting, usable door knobs) and communications access; removal of discriminatory policies, practices, and procedures; and attitudinal changes across staff and culture.
Accommodating people with coexisting disabilities in treatment can include adjusting counselling schedules, providing sign language interpreters, suspending rigid no-medication rules when appropriate, and addressing people’s fears and ignorance.
The manual provides guidelines to overcome barriers and deliver effective treatment for adults with coexisting physical or cognitive disabilities; mental illness in this population is covered in Manual 9 (Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse).
Organization-wide recommendations emphasize: eliminating attitudinal, policy-based, communication, and architectural barriers; ongoing staff training; integration with other services when feasible; and, when appropriate, stand-alone specialized services.
Key implementation themes include building linkages with disability services (VR, Centers for Independent Living, etc.), ensuring ADA compliance, and aligning funding streams to support extended case management where needed.
Overview of benefits of accommodating disability in treatment: improved outcomes for all clients, broader access, and potential for expanded funding and compliance with legal mandates.
Section 1: Overview of Treatment Issues
Prevalence and legal backdrop
In 1990, ~36.1 million Americans had a disability limiting functioning (approx. 14.5% of the population). ADA aims to remove barriers so people with disabilities can participate in community services, including substance use treatment.
The ADA covers a broad set of disabilities (physical, sensory, cognitive, affective) and requires equal access to services and facilities.
Substance use disorders as coexisting disabilities
Substance use disorders are considered a disability under the ADA; treatment systems must accommodate coexisting physical or cognitive disabilities to improve outcomes.
Where applicable, refer to Manual 9 for coexisting mental illness and SUDs; this manual focuses on physical, cognitive, and sensory disabilities.
Disability classifications and terminology
Physical disabilities: impairments of mobility or bodily function (e.g., spinal cord injury, diabetes, arthritis).
Sensory disabilities: blindness and deafness; may require specialized communication methods.
Cognitive disabilities: disruptions in thinking, memory, perception, learning, problem-solving.
Affective disabilities: mood disorders (depression, bipolar), etc. (Mental illness is covered in Manual 9).
WHO framework and four categories summarized: Physical, Sensory, Cognitive, Affective.
Key definitions and terminology (putting people first)
Disability, impairment, disease, functional capacities, functional limitations, and terms for seven areas of functioning (Self-care, Mobility, Communication, Learning, Problem-solving, Social skills, Executive functions).
Emphasis on person-first language: e.g., persons with disabilities, not the disabled; avoid referring to disability as the person.
See Appendix C for guidelines on respectful referents.
Data illustrating disability and substance use comorbidity
VR and VR-related data show higher prevalence and complexity of comorbidity; VR studies indicate substantial coexisting disabilities among those seeking or receiving services.
New York OASAS (1997) data: of 248,679 clients, 55,719 (≈ 22.4 extrm{ ext{ percent}}) had a coexisting physical or mental disability; most had non-mental illness disabilities (mobility impairment, visual/hearing impairment).
Many disabilities may be under-reported or hidden (e.g., TBI, learning disabilities) due to under-assessment.
Barriers to treatment and the evolution of practice
Disabilities increase exposure to unemployment, social isolation, victimization, and poverty, which in turn relate to higher substance use risks.
The treatment field has matured by adapting services for other groups (women, adolescents, minorities, LGBTQ) and now extends these adaptable principles to people with disabilities.
Disability typology and functional capacity framework
The manual presents a four-category framework: Physical, Sensory, Cognitive, Affective; with a defined set of seven functional capacity areas used for assessment and treatment planning.
Hidden disabilities and recognition challenges
Hidden cognitive disabilities are common; staff should screen broadly, not just for obvious impairments.
Cognitive impairments may be misinterpreted as lack of motivation, leading to ineffective treatment planning.
Mainstreaming versus specialized services
Mainstreaming is generally feasible, but exceptions exist: Deaf culture preferences; severe psychiatric disorders; developmental/intellectual disabilities; TBI; spinal cord injury; multiple disabilities.
Specialized services can be more effective for specific populations but should be integrated when possible to maximize resources and outcomes.
Working with people with disabilities: practical outlooks
Emphasize inclusive, flexible, and individualized treatment planning; educate staff on disability issues; collaborate with disability services for cross-training.
Notable concepts and examples
Four barriers to treatment (attitudinal, discriminatory policies, communication barriers, architectural barriers) require targeted actions.
ADA compliance includes communication accommodations (interpreters, TDD, CART), accessible materials (Braille, large print, audio), and accessible facilities; when barriers are not readily removable, alternatives must be provided.
Long-term effects include the need for ongoing evaluation, case management, and community partnerships to sustain gains beyond primary treatment.
Key numerical references and formulas (LaTeX format)
ADA implementation year: 1990.
Proportions: nearly rac{1}{6} ext{ of Americans}
ightarrow ext{about 16.7%}.Disability prevalence in the general population: ext{about } 0.167 ext{ (16.7%)}.
Functional areas: 7 core areas: ext{Self-care}, ext{Mobility}, ext{Communication}, ext{Learning}, ext{Problem solving}, ext{Social skills}, ext{Executive functions}.
New York OASAS data: 55{,}719 out of 248{,}679 clients had a disability (≈ 22.4 ext{ ext{%}}).
Section 2: Screening Issues
Disability etiquette and screening philosophy
Disability etiquette requires asking before helping; ask permission to assist; tailor approach to individual preferences; avoid intrusive questions without consent.
Staff should be trained to handle sensitive questions and to balance openness with respect for privacy.
Screening for disabilities: universal screening approach
Screen every new client for disabilities, not just those with obvious impairments.
Assess level of functioning in seven areas to guide treatment planning.
If a disability is diagnosed or suspected, refer to a disabilities professional for formal assessment.
Intake interviews and accommodations
Begin with open, friendly questions; avoid focusing immediately on disability.
For blind clients: offer media options (Braille, large print, audiocassette); orientation to the facility.
For deaf or hard-of-hearing clients: ensure access via sign language interpreters; use TTY/TDD or CART when appropriate; ensure direct eye contact and spoken communication with the client rather than the interpreter.
For cognitive disabilities: be explicit and concrete; use props or concrete examples; allow more time; tailor questions to avoid abstraction.
For physical disabilities: ensure accessible table heights and seating; be mindful of fatigue and pacing; do not touch assistive devices without permission.
Intake instruments and screening forms
Figure 2-1: Educational and Health Survey (sample items) includes questions about disability status, medical care, medications, hearing/vision difficulties, prior head injury, unemployment, tutoring, preferred learning style, and cognitive-behavioral symptoms.
Figure 2-2: Impairment and Functional Limitation Screen (expanded interview prompts and follow-ups) covers areas like attention, memory, reading/writing, learning, problem-solving, social skills, executive functioning, mood/anxiety symptoms, and mental health history.
Case study: John (DUI context) as a partial screen example
John, 26-year-old, with variable work history, potential reading and attention challenges, possible cognitive impairments revealed by interview cues (reading difficulty, attention, problem-solving, social skills).
Treatment planning questions focus on participation barriers, need for neuropsychological assessment, and potential cross-disciplinary consultation.
Recommendations for program adaptation include memory aids, simplified reading material, extended time, and potential referral for neuropsychological testing.
From screening to treatment and next steps
Screening is not a diagnosis; it identifies barriers and accommodations to tailor treatment.
Create a client profile summarizing strengths, needs, and follow-up recommendations.
Notable concepts and examples (LaTeX-formatted numbers where relevant)
Seven areas of functional limitation used in screening: ext{Self-care}, ext{Mobility}, ext{Communication}, ext{Learning}, ext{Problem solving}, ext{Social skills}, ext{Executive functions}.
For cognitive disabilities, use concrete situations and time markers for recall (e.g., “4th of July” as a time reference).
If a client uses an assistive device, document duration and history of use; plan follow-ups with disability professionals.
If a client is deaf or blind, use interpreters or alternative media; ensure privacy and confidentiality in interpreting contexts.
Section 2: Figures and Case Study references
Figure 2-1 (Educational and Health Survey): items 1–18, including disability status, medical care, medications, hearing/vision problems, prior injuries, employment history, reading and learning preferences, attention/problem-solving indicators, and mood symptoms.
Figure 2-2 (Impairment and Functional Limitation Screen): extended questions and follow-ups aligned with screening items; detailed follow-up prompts for care planning, memory aids, accommodations, and follow-up treatment actions.
John profile (Figure 2-3): example of applying screening outputs to an actual case, including Strengths, Needs, and Recommended Followups across Self-Care, Mobility, Communication, Learning, Problem-Solving, Social Skills, and Executive Functions.
Key formulas and numbers in Section 2 (LaTeX)
Seven functional areas: ext{Self-care}, ext{Mobility}, ext{Communication}, ext{Learning}, ext{Problem solving}, ext{Social skills}, ext{Executive functions}.
John case: no explicit numeric calculations; qualitative scoring and recommendations drive planning.
Section 3: Treatment Planning and Service Delivery
Core philosophy
Treat all clients on a case-by-case basis using a strengths-based approach; identify where a person with a disability lies on understanding and acceptance of their disability; plans should be flexible and revisable as conditions change (e.g., Traumatic Brain Injury recovery curves over 1–2 years).
Document all accommodation changes to verify ADA compliance; those changes should be explicit, trackable, and justifiable.
Treatment planning principles
Early identification of exceptions to routines for disability accommodations; discuss openly in group settings if client opts; ensure collaborative decision-making.
Consider longer treatment durations for clients with cognitive disabilities or hearing impairments; extend treatment when necessary to ensure adequate learning and recovery.
Leisure activities should be inclusive; transport barriers should be addressed (home visits, teletherapy, or alternative sites).
If necessary, involve a medical professional early to assess medications; designate a primary physician to monitor medication regimens; avoid non-medical staff advising on medications.
Counselling considerations
Session times should be flexible; adapt to cognitive abilities with simple, concrete questions; use multiple communication cues (verbal, nonverbal) to aid participation; consider expressive therapies and role-playing for cognitive disabilities.
Provide assignments in alternative media for cognitive disabilities; ensure materials for blind clients are translated into Braille or audio formats; longer time allowances for reading.
For Deaf/Hard-of-Hearing clients: use qualified interpreters (neutral third parties); ensure interpreters are trained for treatment contexts; always address the client directly, not the interpreter; consider CART or oral interpreters if sign language is not used by the client.
For physical disabilities: ensure furniture height and layout suit wheelchair users; pace interviews to avoid fatigue; be mindful of physical boundaries and space around the client.
Special considerations by disability type
Cognitively disabled clients: use concrete goals; memory aids; frequent breaks; structured memory books; avoid abstract terms; use short sentences and repeated key points.
Deaf/hard-of-hearing: extended treatment time may be needed; consider longer-term supports; plan employment and relapse prevention strategies; ensure access to interpreters; use visual cues and spoken language aligned with the client’s preferred communication modality.
Visually impaired: use audio/Braille/audiocassette formats; provide descriptive language; adapt learning activities; ensure accessible leisure planning and transportation arrangements.
Physically disabled: ensure scheduling flexibility; provide transportation; avoid touching wheelchair without consent; be sensitive to dignity in using assistive devices.
Role of leisure and employment in treatment
Leisure activities should be accessible; integrated into treatment planning to reduce isolation and promote reintegration.
Employment barriers and supports are central; collaborate with VR to plan for skills development and potential work placements; address transportation and communication barriers that can impede job seeking and retention.
Linkages and case management
Emphasize cross-training with disability services; ensure cross-agency cooperation so that multiple service needs (housing, finances, transportation, medical, cognitive supports) are addressed in tandem.
Use case managers to coordinate services, advocate for accommodations, and prevent service duplication.
Aftercare considerations
Plan for long-term support, especially for cognitive or sensory disabilities; adapt aftercare to disability-specific needs (e.g., sign-language-accessible relapse prevention groups, accessible housing, transportation arrangements).
Section 3: Notable concepts and examples
Denial in disability contexts can involve both denial of the substance use disorder and the disability; consider involving peer counselors from Centers for Independent Living to aid acceptance.
Strengths-based approach: identify client strengths and leverage them to support recovery; encourage recognition of functional abilities and adaptation strategies.
Behavioral contracts may need to be explicit and tailored to disability level; consider extended timelines for relapse contingencies and reinforce positive behavior through contingency planning.
Documentation of accommodation efforts is essential for ADA compliance and for continuity of care.
Section 4: Treatment Planning and the Community: Linkages and Case Management
Linkage models
Single agency model: one case manager coordinates all services with external partners as needed; benefits include a single point of contact but may limit services.
Informal partnership: multidisciplinary teams from multiple agencies collaborate informally; may risk coordination breakdowns.
Formal consortium: three or more providers sign formal agreements; ongoing collaboration, pooled resources, and formal accountability; reduces duplication and strengthens integration but can be more costly and slower to implement.
Goals of linkages
Improve prognosis by addressing unemployment, social isolation, and other disability-related barriers.
Ensure legal compliance with ADA and related disability rights laws.
Increase teamwork and advocacy to remove barriers.
Improve service coordination to leverage multiple funding streams and avoid duplications.
Access scarce resources through VR, CILs, mental health services, SSDI/SSI, and other supports.
Pima Prevention Partnership example
Inclusive board representation and disability service partners; cross-training; development of case management procedures to coordinate disability and SUD services.
Demonstrates how cross-sector collaboration improves access and outcomes for people with disabilities and SUDs.
Building linkages: practical steps (Figure 4-1 and 4-2 references)
Partner with VR, Centers for Independent Living, disability law centers; establish cross-training; share resources and policies.
Create formal agreements outlining duties, referral processes, and service expectations.
Develop resource directories and maintain communication channels across agencies.
Case finding, pre-treatment, and primary treatment linkages
Formal referrals with shared information exchange; onsite screening referrals; collaboration with hospitals, VR, schools, and other agencies to identify potential clients and facilitate entry into treatment.
Ensure accommodation needs are identified early and addressed in treatment planning.
Aftercare linkages
Ongoing monitoring, accessible relapse prevention resources, and community supports (sober living, supported employment, peer groups) to sustain recovery.
Information resources and support networks
Disability service organizations (CILs), VR agencies, and advocacy groups serve as technical and strategic partners.
Data collection and evaluation help justify funding and improvements; use of data to illustrate unmet needs and to advocate for systemic changes.
Section 4: Notable concepts and examples
Intervention for disability-related barriers should occur early in the treatment process; linkages should be established concurrently with primary treatment rather than after.
Cross-training is essential to ensure that disability-specific needs translate into practical treatment improvements.
Examples of common referral sources include VR agencies, hospitals/physicians, schools, centers for independent living, welfare services, and veterans’ services.
Section 5: Administrative Tasks
Organisational commitment and policy development
Develop a policy statement committing to accommodating any individual with a disability; ADA Title III requires accessibility planning.
Consider board representation and/or advisory groups comprising disability representatives to ensure ongoing input and accountability.
Regular re-evaluation of program effectiveness for disability accommodations; use QA methods, consumer satisfaction, and informal feedback.
Staff knowledge and training
Staff across all levels should learn disability basics, barriers to treatment, and accommodation strategies.
Cross-training with disability services; involve disability experts and advocates; use disability-specific trainings and experiential simulations to build empathy and skills.
Support staff (reception, intake) require disability etiquette training and access to assistive technologies (TDD, interpreters, etc.).
Funding mechanisms and blended funding
Funding from multiple sources: Federal block grants, Medicaid/Medicare, SSDI/SSI, private foundations, VR, local dollars, veterans’ funds, etc.
Blended funding across agencies for case management and linked services is recommended to support the extended needs of clients with multiple disabilities.
Managed care considerations: some policies may create barriers (e.g., capitation, access to HMOs) that require advocacy and waivers; document unmet needs and seek systemic changes where possible.
Marketing and outreach
Proactive outreach to disability organizations; ensure accessibility in all marketing materials; include ADA commitments and multiple formats (large print, audio, Braille, captions).
Include universal accessibility symbols and information about accommodations on outreach material.
Recruit people with disabilities onto boards and in staff roles to reflect the client population and to provide role models.
Administrative considerations for service delivery
Ensure open-door policies, even when complex accommodations are needed; refer to alternative programs if necessary.
Document all accommodations for ADA compliance and to justify treatment decisions.
Develop internal policies to handle difficult situations (e.g., safety concerns, direct threats) without discriminating against disability.
Section 5: Notable concepts and examples
ADA compliance is not merely about physical access; administrative, communication, and attitudinal barriers must be addressed.
The importance of viewing disability accommodations as enabling participation rather than as special treatment.
Example: a facility may provide a home visit or remote services to accommodate transportation limitations without charging extra fees.
Section 6: Appendices, Information Resources, and References
Appendix A: Bibliography (extensive sources on disability and addiction treatment; many entries date from the 1980s and 1990s; includes works on TBI, deafness, learning disabilities, psychiatric comorbidity, and rehabilitation).
Appendix B: Information Resources
Lists national and regional disability and addiction resources, including:
Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals (MnCDDeafHH)
National Association on Alcohol, Drugs and Disability (NAADD)
Pima Prevention Partnership (Dayton, AZ-based resources) and SARDI
PRTA (Pacific Research and Training Alliance) services and resources
VR agencies, independent living centers (CILs), and related disability services organizations
Appendix C: How to Refer to People With Disabilities
Preferred terminology: person-first language; avoid terms like “the disabled,” “handicapped,” or “retarded”; examples of acceptable terms for specific conditions (AIDS, brain injury, etc.)
Detailed glossary entries for major disability terms and guidelines for respectful language usage.
Appendix D: Alcohol and Drug Programs and The Americans With Disabilities Act (ADA)
Comprehensive ADA Title III compliance guidance for privately operated alcohol and drug programs: scope, responsibilities, and examples.
Four fundamental barrier groups to address: Attitudinal, Discriminatory policies, Communication, and Architectural barriers; four steps to ADA compliance; auxiliary aids and services; and case-by-case consideration of barriers and improvements.
Step-by-step guidance on accessibility, including examples and decision frameworks for alterations, exemptions, and alternative delivery methods.
Detailed guidance on interpreters, TDDs, CART, service animals, and confidentiality considerations; guidance on potential undue burdens and how to document and justify accommodations.
Appendix E: Resource Panel
Lists experts from NIH, HHS, and related agencies who contributed to the manual’s development and review.
Appendix F: Field Reviewers
Names and affiliations of field reviewers who provided practical input on disability and addiction treatment integration.
Appendix Highlights (Key Takeaways in LaTeX format)
ADA compliance elements by title:
ext{Title I (Employment)}: Employers with at least 15 employees must provide reasonable accommodations and avoid discrimination.
ext{Title II (State and Local Government)}: Public programs/services must be accessible; requires self-evaluation and removal of architectural/communication barriers.
ext{Title III (Public Accommodations)}: Private entities serving the public must be accessible; modifications must be reasonable; auxiliary aids required; barrier removal where readily achievable; alternatives must be provided when barrier removal is not readily achievable.
ext{Title IV (Telecommunications)}: Relay services for hearing/speech disabilities; captioning of federal announcements.
ext{Title V (Nonretaliation, Misc.)}: Protections against retaliation and coercion for ADA rights.
Four barrier categories (conceptual):
ext{Attitudinal barriers}
ext{Discriminatory policies, practices, and procedures}
ext{Communication barriers}
ext{Architectural barriers}
Readily achievable barrier removal priorities (according to DOJ guidance):
ext{Priority 1: Enable physical entry into the facility}
ext{Priority 2: Provide access to areas where services are offered}
ext{Priority 3: Ensure restroom accessibility}
ext{Priority 4: Remove other accessible barriers (e.g., signage, doors)}$$
Notable programmatic accommodations examples (typical):
Providing interpreters and CART for deaf clients; large-print materials and Braille; transportation accommodations; flexible scheduling; home visits; adaptive seating; alternative assignments; use of memory books and cueing systems.
Modifications to group learning (visual aids, role-play, expressive therapies) for cognitive disabilities; extended treatment durations where required; tailored leisure and employment supports.
Practical implications and ethical considerations
Accessible services benefit all clients, not only those with disabilities; staff training and organizational commitment are central to success.
Effective accommodation requires collaboration with disability experts and consumer input; avoid enabling avoidance by over-accommodation and maintain a balance between support and treatment goals.
Documentation of accommodations and treatment modifications is critical for legal compliance and continuous improvement.
Summary and exam-oriented takeaways
The ADA requires substance use treatment programs to be accessible and non-discriminatory toward people with disabilities; accommodations must be made unless they would cause undue burden or fundamentally alter services.
Treat disability-related considerations as part of comprehensive case management and treatment planning; use a strengths-based, flexible approach tailored to each client’s disability profile.
Screening for disabilities should be universal and ongoing; use structured instruments, interviews, and accommodations to identify both obvious and hidden disabilities.
Effective treatment planning includes early identification of accommodation needs, cross-disciplinary collaboration, and detailed documentation of modifications.
Linkages and case management with VR, CILs, healthcare providers, and other service agencies are essential to addressing employment, housing, transportation, and social supports that influence recovery.
Administrative leadership and staff training are critical to changing organizational culture, ensuring ADA compliance, and delivering accessible services.
Appendices and resources provide concrete referral sources, language guidelines, and detailed ADA compliance procedures to help programs implement best practices.