Do people with intellectual disabilities have the skills to undertake cognitive behavioural therapy? An investigation into computerised training to improve accessibility

While people with intellectual disabilities (IDs) are at increased risk of developing mental health problems, they are disadvantaged when accessing mental health services. The aims of this thesis are threefold: 1) to evaluate the efficacy of psychological therapies for people with IDs who experience mental health problems, 2) to improve the suitability of adults with IDs for cognitive behavioural therapy (CBT), and 3) to explore the acceptability of computer programmes in therapy as a reasonable adjustment to improve therapy accessibility. A systematic review and meta-analysis of the current literature were conducted and identified CBT and individual therapies as the most efficacious treatment for anger and depression. Although adults with IDs and concurrent mental health problems appear to benefit from psychological therapies, clinical trials need to make use of improved reporting standards and larger samples. Next, in two subsequent single-blind mixed experimental designs the efficacy of computerised training programmes in improving CBT skills in people with mild to moderate IDs is evaluated. Training programmes focused on linking situations to feelings and discriminating between thoughts, feelings and behaviours. When compared to an attention-control condition, training improved cognitive mediation skills, as assessed by the ability to link situations and mediating beliefs to feelings, and improved the ability to differentiate between thoughts, feelings and behaviours. In a concluding qualitative study, the perspectives of service users with IDs and clinicians on using computers in therapy were explored. Both service users and clinicians were positive about the potential functions and benefits of using computers in therapy, but also drew attention to potential challenges and barriers. Together, these studies show that computers can be used to improve the suitability of people with IDs for CBT and meanwhile encourage further exploration into the possibilities that these technologies can open up for improving the accessibility of psychological therapies

Can a computerised training paradigm assist people with intellectual disabilities to learn cognitive mediation skills? A randomised experiment

Aims: The aim was to examine whether specific skills required for cognitive behavioural therapy (CBT) could be taught using a computerised training paradigm with people who have intellectual disabilities (IDs). Training aimed to improve: a) ability to link pairs of situations and mediating beliefs to emotions, and b) ability to link pairs of situations and emotions to mediating beliefs. Method: Using a single-blind mixed experimental design, sixty-five participants with IDs were randomised to receive either computerised training or an attention-control condition. Cognitive mediation skills were assessed before and after training. Results: Participants who received training were significantly better at selecting appropriate emotions within situation-beliefs pairs, controlling for baseline scores and IQ. Despite significant improvements in the ability of those who received training to correctly select intermediating beliefs for situation-feelings pairings, no between-group differences were observed at post-test. Conclusions: The findings indicated that computerised training led to a significant improvement in some aspects of cognitive mediation for people with IDs, but whether this has a positive effect upon outcome from therapy is yet to be established

Feasibility and Acceptability of an Interactive Mental Well-Being Intervention for People With Intellectual Disabilities: Pilot Mixed Methods Study.

Vereenooghe L, Westermann K. Feasibility and Acceptability of an Interactive Mental Well-Being Intervention for People With Intellectual Disabilities: Pilot Mixed Methods Study. JMIR formative research. 2019;3(4): e15190.Background: The availability of both digital and traditional mental well-being interventions is rising, but these interventions typically do not consider people with intellectual disabilities as potential users. Objective: The study aimed to explore the acceptability and feasibility of a new digital intervention, developed with and for people with intellectual disabilities, to improve their subjective well-being. Methods: Using a single-group pre-post design, participants with intellectual disabilities and their caregivers completed the 4-week intervention. Mixed methods questionnaires assessed the acceptability of the intervention, in addition to self-report and proxy-report measures of subjective well-being and behavioral problems. Results: A total of 12 men with mild to moderate intellectual disabilities enrolled in and completed the study alongside 8 caregivers. Participant acceptability of the intervention was high, and feedback covered multiple aspects of the intervention, including (1) program concept and design, (2) program content, and (3) intervention usage. Self-rated mood barometers indicated mood improvements for 5 participants, deteriorations for 2 participants, and no observed changes for the remaining participants. Statistical analyses yielded no difference from pretest (median=79; range 39-86) to posttest (median=79; range 21-96) for subjective well-being in people with intellectual disabilities (W=10.5; P=.17) and for behavioral problems (W=14; P=.05). Conclusions: People with intellectual disabilities and their caregivers are receptive to using digital well-being interventions, and this research shows such interventions to be feasible in routine practice. Given the acceptability of the intervention, its potential efficacy can now be evaluated in people with intellectual disabilities and symptoms of reduced mental well-being

Feasibility and Acceptability of an Interactive Mental Well-Being Intervention for People With Intellectual Disabilities: Pilot Mixed Methods Study.

Vereenooghe L, Westermann K. Feasibility and Acceptability of an Interactive Mental Well-Being Intervention for People With Intellectual Disabilities: Pilot Mixed Methods Study. JMIR formative research. 2019;3(4): e15190.Background: The availability of both digital and traditional mental well-being interventions is rising, but these interventions typically do not consider people with intellectual disabilities as potential users. Objective: The study aimed to explore the acceptability and feasibility of a new digital intervention, developed with and for people with intellectual disabilities, to improve their subjective well-being. Methods: Using a single-group pre-post design, participants with intellectual disabilities and their caregivers completed the 4-week intervention. Mixed methods questionnaires assessed the acceptability of the intervention, in addition to self-report and proxy-report measures of subjective well-being and behavioral problems. Results: A total of 12 men with mild to moderate intellectual disabilities enrolled in and completed the study alongside 8 caregivers. Participant acceptability of the intervention was high, and feedback covered multiple aspects of the intervention, including (1) program concept and design, (2) program content, and (3) intervention usage. Self-rated mood barometers indicated mood improvements for 5 participants, deteriorations for 2 participants, and no observed changes for the remaining participants. Statistical analyses yielded no difference from pretest (median=79; range 39-86) to posttest (median=79; range 21-96) for subjective well-being in people with intellectual disabilities (W=10.5; P=.17) and for behavioral problems (W=14; P=.05). Conclusions: People with intellectual disabilities and their caregivers are receptive to using digital well-being interventions, and this research shows such interventions to be feasible in routine practice. Given the acceptability of the intervention, its potential efficacy can now be evaluated in people with intellectual disabilities and symptoms of reduced mental well-being

Intellectual disability and computers in therapy: views of service users and clinical psychologists

Background: Digital media have increased the accessibility of psychological therapies for the general population, but not for people with intellectual disability (ID), despite their greater mental health needs. This study explores and compares the views of service users and clinicians on how computers can be integrated in psychological therapies for people with ID who are traditionally under-represented in mainstream services. Methods: We conducted in-depth unstructured interviews with three clinicians who had experience of working with people with ID and with three adults with ID who have experienced computerised training in cognitive behaviour therapy skills. The interviews explored the a) potential functions and benefits, b) anticipated challenges and barriers, and c) required design features of computers in therapy for people with ID. We used inductive coding to identify independent themes in the responses of clinicians and service users, and then compared the emerging themes between the two sets of participants to arrive at common themes. Results: Six common themes emerged from service user and clinician responses: confidentiality of personal information and online applications, barriers in the communication with the therapist, value of therapist and personal contact, access to computer technologies, engagement potential of computer programmes and home practice. Three further themes were specific to clinician responses: patient suitability for computerised approaches, clinician distrust of computerised interventions, and involving a third party. Conclusion: Computer technologies open up possibilities for psychological therapy with people with ID by helping them overcome in-session communication difficulties and practise skills at home. On-screen pictures, interactive games, symbols, sign language and touch-screen are key design features to help engagement. The main challenges are clinician-reported difficulties in their own capacity and capability to access and use computers and in fitting computers into their own defined roles

Psychological therapies for people with intellectual disabilities : an updated systematic review and meta-analysis

Objective The aim of this systematic review and meta-analysis (PROSPERO 2020 CRD42020169323) was to evaluate the efficacy of psychological therapy for people with intellectual disabilities. Method A comprehensive literature search yielded 22,444 studies which were screened for eligibility. Studies were eligible for inclusion if a psychological therapy was delivered to people with intellectual disabilities compared to a group who did not receive the therapy. Thirty-three controlled trials were eligible for inclusion in the review, with 19 included within a DerSimonian-Laird random effects meta-analysis. Subgroup analysis was completed by clinical presentation, and by comparing randomised trials to non-randomised trials, and group-based to individually delivered psychotherapy. Results Following the removal of outliers, psychological therapy for a range of mental health problems was associated with a small and significant effect size, g = 0.43, 95% CI [0.20, 0.67], N = 698. There was evidence of heterogeneity and bias due to studies with small sample sizes and a lack of randomisation. Non-randomised studies were associated with a large effect size, g = 0.90, 95% CI [0.47, 1.32], N = 174, while randomised studies were associated with a small effect size, g = 0.36, 95% CI [0.17, 0.55], N = 438, excluding outliers. Individually delivered psychological therapy was associated with a small and non-significant effect size, g = 0.32, 95% CI [−0.01, 0.65], N = 146, while group-based interventions were associated with a small and significant effect size, g = 0.37, 95% CI [0.05, 0.68], N = 361, again, excluding outliers. Psychological therapy for anger was associated with a moderate effect size, g = 0.60, 95% CI [0.26, 0.93], N = 324, while treatment for depression and anxiety was associated with a small and non-significant effect size, g = 0.38, 95% CI [−0.10, 0.85], N = 216, after outliers were removed. Conclusions Studies are fraught with methodological weaknesses limiting the ability to make firm conclusions about the effectiveness of psychological therapy for people with intellectual disabilities. Improved reporting standards, appropriately powered and well-designed trials, and greater consideration of the nature and degree of adaptations to therapy are needed to minimise bias and increase the certainty of conclusions

Interventions for mental health problems in children and adults with severe intellectual disabilities: a systematic review

Objective Mental health problems are more prevalent in people with than without intellectual disabilities, yet treatment options have received little attention. The aim of this study was to identify and evaluate the effectiveness of pharmacological and psychological interventions in the treatment of mental health problems in children and adults with severe and profound intellectual disabilities, given their difficulties in accessing standard mental health interventions, particularly talking therapies, and difficulties reporting drug side effects. Design A systematic review using electronic searches of PsycINFO, PsycTESTS, EMBASE, MEDLINE, CINAHL, ERIC, ASSIA, Science Citation Index, Social Science Citation Index and CENTRAL was conducted to identify eligible intervention studies. Study selection, data extraction and quality appraisal were performed by two independent reviewers. Participants Study samples included at least 70% children and/or adults with severe or profound intellectual disabilities or reported the outcomes of this subpopulation separate from participants with other levels of intellectual disabilities. Interventions Eligible intervention studies evaluated a psychological or pharmacological intervention using a control condition or pre-post design. Outcomes Symptom severity, frequency or other quantitative dimension (e.g., impact), as assessed with standardised measures of mental health problems. Results We retrieved 41 232 records, reviewed 573 full-text articles and identified five studies eligible for inclusion: three studies evaluating pharmacological interventions, and two studies evaluating psychological interventions. Study designs ranged from double-blind placebo controlled crossover trials to single-case experimental reversal designs. Quality appraisals of this very limited literature base revealed good experimental control, poor reporting standards and a lack of follow-up data. Conclusions Mental ill health requires vigorous treatment, yet the current evidence base is too limited to identify with precision effective treatments specifically for children or adults with severe and profound intellectual disabilities. Clinicians therefore must work on the basis of general population evidence, while researchers work to generate more precise evidence for people with severe and profound intellectual disabilities

Adapting and evaluating a tree of life group for women with learning disabilities

Background: This study describes how a specific narrative therapy approach called‘the tree of life’ was adapted to run a group for women with learning disabilities. Thegroup consisted of four participants and ran for five consecutive weeks.Materials and Methods: Participants each constructed a tree to represent their livesand presented their tree to the group who responded with positive feedback andaffirming statements. This led to discussion about overcoming the storms of life anda celebration of the journey the group had been through together.Key Results: Although no change was found on quantitative measures of well-beingand self-esteem, participants reported benefitting from the peer support and socialconnectedness that the group offered, particularly in relation to themes of loss andchange in their lives.Conclusions: ‘The tree of life’ approach has potential value as an intervention forpeople with learning disabilities. The benefits and challenges of this approach within the context of working with people with learning disabilities are discussed

How service‐users with intellectual disabilities understand challenging behaviour and approaches to managing it

Background This study explored understandings that service‐users with intellectual disabilities and challenging behaviour held around their behaviour, what shaped these understandings, and the relationship between how behaviours are managed and well‐being. Methods Eight participants (three female, five male) partook in individual semi‐structured qualitative interviews. Interviews were transcribed and analysed using interpretative phenomenological analysis. Results Three master themes emerged from this analysis: (a) challenging behaviour can be explained via an internal or external frame of reference, with each framework having different implications for how participants attempted to manage behaviour. (b) Positive relationships provide a long‐term buffer to challenging behaviour, with positive relationships with family, staff and peers operating through different mechanisms to achieve this. (c) A greater ability to exert power and control in day‐to‐day life was perceived to reduce challenging behaviour in the long term. Conclusions Implications for practice are discussed

Non-pharmacological interventions for adults with intellectual disabilities and depression

Background: Although high rates of depression symptoms are reported in adults with intellectual disabilities (IDs), there is a lack of knowledge about non-pharmacological treatment options for depression in this population. The first research question of this paper is: Which non-pharmacological interventions have been studied in adults with ID and depression? The second research question is: What were the results of these non-pharmacological interventions?. Method: Systematic review of the literature with an electronic search in six databases has been completed with hand searches. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines have been followed. Selected studies met predefined inclusion criteria. Results: Literature search resulted in 4267 papers of which 15 met the inclusion criteria. Five different types of non-pharmacological interventions have been studied: cognitive behavioural therapy, behavioural therapy, exercise intervention, social problem-solving skills programme and bright light therapy. Conclusion: There are only a few studies of good quality evaluating non-pharmacological interventions for adults with ID and depression. Some of these studies, especially studies on cognitive behavioural therapy, show good results in decreasing depressive symptoms. High-quality randomised controlled trials evaluating non-pharmacological