odel to include:
Genetics: Genes serve as the blueprint for brain development. Our older models were deterministic, hence a nature-nurture debate; current models are probabilistic and interactional. Clinical researchers moved beyond Mendelian (autosomal dominant, recessive inheritance) analysis and now emphasize the sequence and integration of gene activation and de-activation during critical periods of development. As a result the focus instead is on epigenetics and gene-environmental interactions. In this world, the nature-nurture argument is an anachronism (9–11).
Neurosciences: Rapid advances in the neurosciences are deepening our understanding of central coherence, executive functions and adaptive behaviors, theory of mind, social communication, memory, attention, impulse control and affect regulation (11). Our challenge is to understand how errors in brain development (errors in neuronal migration, maturation, neuroplasticity, myelinization and interactive specialization and regional interconnections) relate to cognitive, social and emotional development; and how these errors translate into real life problems for adults with dual diagnoses.
Translational research needs: Clinicians concentrate on challenging behaviors and mental disorders and often eschew molecules as well as policy. But we cannot lose sight of the interactions between macrocosmic forces such as socio-cultural, governmental and economic forces and microcosmic ones related to genetics and neurobiology.
As a result, we need to redefine our understanding of the biopsychosocial model to incorporate this new knowledge (12). The challenge for the 21st century is to adapt the biopsychosocial model in order to make sure that our ideas about the multidirectional and systemic forces underlying this concept are kept up to date with scientific and clinical reality. Translating the innovations in the neurosciences into best practices, positive practice models, and evidence-based and outcome-based treatment for busy clinicians is one of our greatest challenges.
Deficits in measured intellectual/cognitive abilities are not enough
IDD are most often considered in terms of performance on individualized measures of intelligence. Historically, the development and introduction of intelligence testing represented a major breakthrough in our ability to measure and classify IDD. But it wasn’t long before researchers and clinicians realized that normalized measures of intelligence provided only a portion of what was needed. Yet in many programs, service providers still use IQ scores to group patients into broad categories (mild, moderate, severe, and profound levels of ID). As we shall see, this view is incomplete (6, 13)
In educational settings, this IQ score shorthand is used in decision-making about classroom placement, setting performance expectations as well as designing educational programs to match academic and daily life skills training needs. Yet the validity of these predictions is often derailed by positive effects of early intervention and better management of neurodevelopmental disorders such as seizures and the negative effects of severe behavioral problems, neuropsychiatric and medical disorders (e.g., cerebral palsy or epilepsy). In addition, disruptive behaviors and the presence of unrecognized or inadequately treated mental disorders have a deleterious effect on educational performance (14). These persist into adulthood as behavioral problems that adversely affect structured employment, community independence, social activities, and residential living and produce levels of psychosocial stress on caregivers and alter the quality of life (7).
Psychodynamic-oriented clinicians use IQ scores to formulate hypotheses about their role in psychosexual, psychosocial and cognitive development. The relationship between mental age and developmental stages is a permeable one but these data do provide a system of staging strengths and vulnerabilities and clarify developmental levels of functioning. Within a psychodynamic framework, arrests and derailments of many lines