Adults with intellectual disabilities: meaningful activity and virtual reality

In a day activity centre (CACI) or a residential home for adults with disabilities, the day has a structure other services would envy: timetables, routines, staff who have known each person for years. It also has a problem everyone who works there knows well: the same room, the same activities, the same route to the minibus. For many adults with intellectual disabilities, the world outside the service is small — and when it grows, for an appointment or a journey, it is frightening.

This article is about meaningful activity for these adults, and about the place virtual reality may or may not have in it.

Meaningful activity is not keeping busy

Portaria no. 70/2021, the Portuguese ordinance that created the CACI (Centres for Activities and Capacity-building for Inclusion) to replace the former occupational activity centres, says something worth repeating: activities are not an end in themselves, but a means towards autonomy and inclusion. The change of name was not cosmetic. Filling the morning is not enough; what counts is whether the activity means something to that person and gives them some kind of choice.

In practice, a meaningful activity for an adult with an intellectual disability usually has four ingredients:

• Their own interest. Trains, football, animals, a childhood beach, their parents' village. Not what staff think ought to interest them.
• A real choice. Between two or three concrete options, shown rather than only spoken.
• Predictability. Knowing what will happen, how long it lasts and how it ends.
• An active role. Doing, showing, telling — not just watching.

The criteria for choosing a scene from each person's interests are in how a scene is chosen.

Communication and choice

Many people supported in a CACI use few words, or communicate in ways only those who know them read well. That does not make them less able to choose; it makes the way of asking more demanding.

• Show rather than describe. A picture of the place, a symbol, an object. “Beach or train?” with two pictures works better than a spoken list.
• Use the communication system the person already uses — symbols, signs, a board, a tablet. Don't invent a new one for the activity.
• Give the answer time. A few extra seconds of silence are more respectful than repeating the question.
• Read the body. Pulling away, covering the eyes, going rigid or moving the hands a lot can be as clear a “no” as the word. Smiling, leaning forward or pointing, a “yes”.
• Accept the first “no”. A refusal respected today makes a “yes” tomorrow more likely.

Predictability and sensory sensitivity

Many adults with intellectual disabilities, especially when autism is also present, are particularly sensitive to sound, light, touch or change. A headset brings several of these at once: something tight on the head, the room disappearing, sound close to the ears. For some people that is interesting; for others it is intolerable, and there is no point insisting.

What usually helps:

• Announce it beforehand, in the usual format. If the person uses a visual schedule, the session goes in it, with a picture.
• Let them see and touch the headset before putting it on. In the hand first, then near the face, then on the head — sometimes on different days.
• Start with the sound low, or off.
• Short sessions, a few minutes, with an announced end (“when the boat arrives, we take it off”).
• The same professional for the first few times, in the same room, at the same time.
• An agreed stop signal the person can make even without speaking.

Comfort, nausea and cybersickness are covered in comfort and nausea, and the general limits of who can use it in accessibility.

Preparing for new places

An appointment at an unfamiliar hospital, a trip on public transport, a visit somewhere new. For people who rely on predictability, the unknown is the hardest part, and staff have long prepared these outings with photographs, social stories and conversation.

A 360° video of a real place can be added to that preparation: seeing what a street, a station or an outdoor space looks like before being there. It is familiarisation and conversation about what lies ahead, led by the staff who know the person.

It matters to say what this is not. It is not exposure therapy, not desensitisation, and not treatment for phobias or anxiety. The RVer Exposure module is in development and is not covered by the base product's registration. And the library does not have, nor aim to have, every clinic or every station: it shows real places chosen for comfort and conversation, which may or may not resemble the destination.

Consent: the person and whoever represents them

For an adult with an intellectual disability, the question “who decides?” has two answers that do not cancel each other out.

The person always takes part. The UN Convention on the Rights of Persons with Disabilities, ratified by Portugal, starts from the principle that the person decides with support, not that someone decides for them. In Portugal, the supported-adult regime (“maior acompanhado”, Law no. 49/2018) replaced the old guardianship arrangements with exactly that logic: measures tailored to the person, rather than a general incapacity.

The representative or supporter, where there is one, is informed and heard on the terms set by the court decision and the service's own rules. Explaining what the session is, how long it lasts, what is seen and how it stops avoids surprises and mistrust.

In practice:

• explain to the person, in a format they understand, what will happen — and ask again at every session;
• record assent and signs of refusal, not just the signature on the form;
• the person's “no” counts, even if the representative said yes.

More in informed consent.

Where RVer can fit in, and where it cannot

RVer can be one activity among others in a CACI or residential home plan: a short session, accompanied by a professional, in a place chosen from the person's interests — the beach, the garden, the village, the church. It can be an occasion to choose, to tell, to show someone which place you like. It can be part of preparing for an outing. All content is on the device and works without internet, and nothing leaves the device.

What it does not do: it is not therapy, it does not replace the work of the technical team, it is not skills training and it is not exposure. And it does not suit everyone. Some people cannot tolerate anything on their head, become distressed when the room disappears, or simply don't want to. For them, the right answer is another activity. What to do in those cases is in when a resident says no, and what we have in mind for this setting in disability.

In summary

• Meaningful activity is one that means something to that person and gives them a choice, not one that fills time.
• Choice is offered through the communication system the person already uses, showing rather than describing.
• Predictability and sensory care decide whether a headset is tolerated; often it isn't, and that is fine.
• Seeing a place before going can help prepare an outing, but it is not exposure therapy.
• The person always takes part in consent; the representative is informed; the person's “no” counts.

This article is for information only and does not replace clinical assessment or the judgement of the technical team supporting each person. Decisions about activities and consent follow the individual plan and the service's own rules.

RVer is a virtual reality system for clinical use designed for healthcare settings, whose base product is registered as a Class I Medical Device in EUDAMED (Basic UDI-DI 56006195127RVERTZ) and with INFARMED (Portugal, CDM 94571546) and bears the CE mark under MDR 2017/745. The RVer Motion, RVer Neuro and RVer Exposure modules are in development and are not covered by that registration.