Frontline Initiative Dual Diagnosis

Partnering on mental health needs:
DSPs on the frontline


Thomas Cheetham, MD is Director of Health Services, and Bruce Davis, PhD, is Director of Behavioral and Psychological Services, both in the Tennessee Department of Intellectual and Developmental Disabilities.

Direct Support Professionals (DSPs) know the individuals they support well. They are likely the first to no­tice changes in behavior patterns. DSPs can advocate for mental health evaluation by being alert to early signs of changes in both physical health and mental health. These types of issues can overlap significantly. Acting early can help prevent a crisis.

People with intellectual and developmental disabili­ties (I/DD) are at much higher risk for mental health problems than people without disabilities. Risk factors vary widely across people. Many behavioral health problems first occur during late adolescence and early adulthood. Behavior change may be the only way that a person with I/DD can show that something is wrong. These changes can signal that treatment or more specialized supports are needed.

DSPs play a vital role in recognizing behavior changes. DSPs can take action in three important steps – 

Step 1

Describe and keep detailed records. Note how often, how intensely and how long behaviors occur. Note the circumstances in which they happen. (Use questions I-V to the right.)

Step 2

Consult the person’s primary care physician.

Step 3

Refer to a behavioral health care provider if medical problems are ruled out as a cause. A behavioral health care provider may be a mental health professional, psychiatrist, psychologist, or therapist.

How to advocate for quality healthcare:

When making a referral to a behavioral healthcare provider, it is important to be able to provide as much information as possible. This information can assist a behavioral health care provider with identifying the cause of the change in a person’s behavior. This can also assist in identifying appropriate treatment plans. DSPs are encouraged to think through the following questions when gathering information to share with a behavioral healthcare provider.

I. Describe the behavioral problem

  • When did the behavioral problem start?
  • When was the person last at his or her best or usual self before the issue?

II. Describe the current difficult behavior

  • What specific behaviors or symptoms are occurring?
  • What in the past helped or did not help with it (including medications)?
  • What is being done to help the person manage the behavior? How is it working?
  • Is there risk to self, to others, at home or in the community?
  • Is there aggression to self or others; and is it mild, moderate, or severe?
  • How frequent is the behavior?
  • Subtle changes in the person’s daily routine also may show a problem starting. Has there been a recent change in mood, bowel/bladder habits, appetite, sleep, social involvement, communica­tion, interest in leisure activities or work, self-care, independence, thinking or memory, or movement?
  • Has there been a recent need for change in support or supervision? When did these changes start?

III. Consider possible physical health problem or pain

  • Are you aware of any physical health or medi­cal problem that may be contributing to behavior problem?
  • Could pain, injury or discomfort be contributing to behavior change?
  • How would you know if the person was in pain?
  • Are there concerns about medications or side effects?

IV. Consider changes in environment

  • Were there changes in or stress with caregivers before the concerning behavior began?
  • In care provision? In living situation or daily routine?

V. Consider support issues

  • Is the person receiving needed supports?
  • If there are sensory triggers, what is in place to help?
  • Are there opportunities for suitable physical activity?
  • Are there supports or programs not in place that you think might help?

VI. Consider relational and emotional issues

  • Has there been a recent change in relationships?
  • Additions, losses, separations, deaths?
  • Teasing or bullying?
  • Anxiety about completing tasks?
  • Disappointments?
  • Growing insight into disability and its impact? Life transitions? Traumatic experiences?

By being alert to important changes in behavior, DSPs can be effective partners with behavioral health providers. By collaborating with the person and his or her support team, DSPs play a central role in prevent­ing crises and addressing behavioral needs.