What services are useful for patients with an intellectual disability?

It is well-known that people with an intellectual disability often face a host of health inequalities and co-morbidities. These include childhood obesity, mental health problems, and challenging behaviour. People with an intellectual disability also have reduced life expectancy. GPs are uniquely placed to advocate for and signpost these patients, ensuring they have access to appropriate support. However, it is often unclear what resources are, in reality, both available and beneficial. Here we aim to summarise some of the common inequalities and complexities when working with patients with an intellectual disability and provide an overview of some potentially helpful services.NIHR School for Primary Care Research [RG94577] and Wellcome Trust [Grant WT103343MA]

Differentiating "Attachment Difficulties" From Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder: Qualitative Interviews With Experienced Health Care Professionals.

OBJECTIVES: "Attachment difficulties" is an umbrella term often used to describe various forms of non-secure attachment. Differentiating "attachment difficulties" from autism spectrum disorder (hereafter autism) and attention deficit hyperactivity disorder (ADHD) has been characterized as challenging. Few studies have explored how this happens in practice, from the perspective of professionals. DESIGN: Qualitative study. METHODS: We conducted in-depth semi-structured interviews with (n = 17) healthcare professionals from five NHS Foundation Trusts in the United Kingdom. Participants were recruited using a combination of snowballing, convenience and purposive sampling. Data were analyzed using a thematic approach. RESULTS: We identified six interrelated themes that might reflect difficulties with differential conceptualization. These include: a clinical lexicon of attachment; approaching attachment with caution; contextual factors; perceived characteristic behaviors; assessing attachment and adjacent supports; spotlighting intervention and dual conceptualization. CONCLUSION: Our results indicate some of the ways suspicions around attachment are raised in practice. We advocate for more dialogue between research and practice communities on issues of differential conceptualization. We call for collaboration between a panel of experts consisting of attachment and neurodevelopmental orientated practitioners and researchers, to clarify issues around differentiating between attachment difficulties, ASD, and ADHD

Effective refractive index tensor for weak field gravity

Gravitational lensing in a weak but otherwise arbitrary gravitational field can be described in terms of a 3 x 3 tensor, the "effective refractive index". If the sources generating the gravitational field all have small internal fluxes, stresses, and pressures, then this tensor is automatically isotropic and the "effective refractive index" is simply a scalar that can be determined in terms of a classic result involving the Newtonian gravitational potential. In contrast if anisotropic stresses are ever important then the gravitational field acts similarly to an anisotropic crystal. We derive simple formulae for the refractive index tensor, and indicate some situations in which this will be important.Comment: V1: 8 pages, no figures, uses iopart.cls. V2: 13 pages, no figures. Significant additions and clarifications. This version to appear in Classical and Quantum Gravit

A modified video-feedback intervention for carers of foster children aged 6 years and under with reactive attachment disorder : a feasibility study and pilot RCT

BACKGROUND: Looked-after children are at risk of suboptimal attachment patterns and reactive attachment disorder. However, access to interventions varies widely and there are no evidence-based interventions for this disorder. OBJECTIVES: (1) To adapt an existing video-feedback intervention to meet the specific needs of foster children in the UK with reactive attachment symptoms, (2) to conduct a case series to road-test the treatment manual and study procedures, (3) to conduct a scoping study of the key hurdles in a pilot trial and (4) to conduct a pilot randomised controlled trial of the adapted intervention to determine the feasibility of a future full-scale trial. DESIGN: This was a mixed-methods study. The adapted treatment manual was developed with expert input and tested on a small case series. Qualitative interviews with key stakeholders were used in the scoping study in preparation for the trial and later with foster carers who received the new intervention. The final stage was a feasibility and pilot randomised controlled trial of the new intervention, compared with usual care. Researchers assessing the outcomes were blinded to group assignment. SETTING: The study was set in outpatient child and adolescent mental health services and partner social services departments. Sites included urban and rural/semirural areas. PARTICIPANTS: Participants were foster carers with children aged ≤ 6 years presenting with difficulties in the domain of reactive attachment disorder. Key stakeholders included children's services managers and mental health service practitioners in the scoping study. Foster carers who received the modified intervention participated in qualitative interviews. INTERVENTION: The video-feedback intervention to promote positive parenting and sensitive discipline is an extensively evaluated and effective treatment approach. This intervention was modified (based on the adapted version for foster care in the Netherlands) to suit the needs of young children with reactive attachment symptoms in foster care in the UK and was delivered to improve the sensitive responding of foster carers, foster carer-child relationships and child outcomes. The modified intervention was delivered in-home by trained mental health professionals over a period of 4-6 months. MAIN OUTCOME MEASURE: The main outcome was reactive attachment symptom scores on the Disturbances of Attachment Interview. RESULTS: A series of minor changes to the intervention programme were introduced, which focused on improving its suitability for the UK foster care context. Challenges in recruitment meant that, despite numerous modifications to the protocol and the inclusion of additional sites, only 30 families (target, n = 40) were recruited to the randomised controlled trial (15 allocated to each group). However, most other trial parameters were deemed feasible and acceptable, particularly the high levels of data and treatment completeness. All randomised families were available for baseline analyses, but two in the treatment arm were not available for post-treatment analyses. The revised intervention was positively received by practitioners and foster carers. LIMITATIONS: Only three-quarters of the target sample size was recruited. Furthermore, the sites' own exclusion of potential participants and the low return rates of screening questionnaires raise the possibility of non-randomness of non-responses. CONCLUSION: A larger-scale trial may be feasible, but only if recruitment barriers can be overcome. Dedicated resources to support recruitment within local authorities and wider inclusion criteria are recommended. Central resourcing of intervention capacity to supplement NHS staff is also recommended. TRIAL REGISTRATION: This trial is registered as ISRCTN18374094. FUNDING: This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 35. See the NIHR Journals Library website for further project information

Secondary trauma and compassion fatigue in foster carers

Background: With the number of children being placed in the care of local authorities increasing, the need to recruit and retain foster carers is essential. Compassion fatigue is recognised as a negative effect for professionals working with adults and children who have experienced trauma. This study aims to confirm the proof of concept within foster carers and to explore the potential risks associated with intent to continue fostering, overall job satisfaction and psychological factors (avoidant coping) that could be targets for interventions. Methods: In total, 131 foster carers completed an online survey including self-report measures of compassion fatigue and associated risk factors. Results: Results confirm the existence of compassion fatigue among foster carers with rates in line with previous studies on other professionals working with children. High compassion fatigue was associated with lower intent to continue fostering and lower job satisfaction. Avoidant cognitive styles of psychological inflexibility and thought suppression were associated with compassion fatigue. Conclusion: The confirmation of compassion fatigue among foster carers and the potential risks to job retention are important findings for social care. The associations with avoidant cognitive styles have clinical implications for potential interventions. Recommendations for further research and the limitations of this study are also discussed. </jats:sec

The negative consequences of over-diagnosing attachment disorders in adopted children:the importance of comprehensive formulations

In many child services across health, education and social care, ‘attachment disorder’ is a popular description and explanation for complex presentations of children who have been neglected or maltreated and is frequently used to describe fostered and adopted children. Very often the use of this term bears little resemblance to the established diagnostic systems, nor indeed to attachment theory as conceptualised by Bowlby. Its misuse can lead professionals to overlook commoner and more treatable conditions, to the detriment of the children. In fact both reactive and disinhibited attachment disorders are rare, but are becoming better characterised by high quality research. Poor understanding about the attachment disorder construct can pose particular problems for clinicians working with adopted children. The current paper briefly reviews the practical difficulties with the attachment disorder diagnosis as applied to adopted children and uses four case studies taken from a specialist Adoption and Fostering Service to highlight some of the problems for services working with adopted children. Finally, we propose some provisional recommendations for the assessment and treatment of adopted children and their families, which aim to be consistent with attachment theory as well as with the existing evidence base on wider child mental health problems. </jats:p

Do children adopted from British foster care show difficulties in executive functioning and social communication?

Early life experiences leave a mark on a child’s emotional, social and cognitive development. It is well established that children adopted from psychosocially depriving institutions have difficulties in executive functioning and social communication ability, but this type of research has not been replicated in children adopted from foster care. In this study, 30 primary school aged UK adoptees without a history of institutionalisation completed an assessment of their intellectual, executive functioning and social communication abilities. Compared to children of a similar age in the general population, the adopted group showed elevated emotional and behavioural difficulties on a parental report measure (Strengths and Difficulties Questionnaire, SDQ). They performed statistically poorer on two of three computerised executive functioning tests (CANTAB Intra-Extra Dimensional Shift and Spatial Working Memory) and elevated scores were observed on a parental report measure of executive functioning (Behavior Rating Inventory of Executive Functioning, BRIEF). A strong negative correlation was found between age of adoption and BRIEF scores controlling for ADHD symptoms; no other pre- or post-adoption variables strongly correlated with executive functioning. Although all participants scored below cut-off on an autism screening measure (Social Communication Questionnaire, SCQ), a moderate positive correlation was observed with age of adoption. The identified elevation in emotional, behavioural and executive functioning difficulties is in line with previous research examining children adopted from institutions; however, the observed negative correlation between BRIEF scores and age of adoption is contrary to previous evidence. Limitations and implications for future research are discussed. </jats:p