The Psychological Therapy Outcome Scale – Intellectual Disabilities (PTOS-ID): the development of a psychological therapy outcome measure for adults with intellectual disabilities

People with intellectual disabilities are more likely to experience living circumstances and life events associated with an increased risk of mental health problems, compared to the general population (Hulbert-Williams & Hastings, 2008). These include: lack of meaningful relationships, stigmatization, unemployment, and discrimination (Martorell et al., 2009; Thornicroft, 2006). Prevalence of mental health problems are difficult to determine within this population, with estimates ranging from 10% to 39% (Emerson & Hatton, 2007). Pharmacological and behavioural approaches have often been used in the treatment of mental health problems for people with intellectual disabilities (Vereenooghe & Langdon, 2013). Bender (1993) argued that the lack of psychotherapeutic interventions available was due to a perceived “therapeutic disdain” towards this population. Difficulties identifying mental health problems in people with intellectual disabilities, perceived lack of training amongst practitioners, and lack of research evidence have also been cited as reasons for lack of provision of psychotherapy services (Emerson, Moss & Kiernan, 1999; Royal College of Psychiatrists, 2004; Taylor & Knapp, 2013). These views have been challenged by clinicians, and there is a growing evidence base of the effectiveness of psychological therapies with people with intellectual disabilities (Willner, 2005). The research has come from both single case studies (Kellett, Beail, Bush, Dyson & Wilbram, 2009; Salvadori & Jackson, 2009) and controlled clinical trials (Taylor, Novaco, Gillmer, Robertson & Thorne, 2005). Recent systematic reviews and meta-analyses have also highlighted the effectiveness of Cognitive Behavioural Therapy (CBT) and psychodynamic therapy with this population (James & Stacey, 2014; Nicoll, Beail & Saxon, 2013; Vereenooghe & Langdon, 2013). In one of the most comprehensive reviews to date, Prout and Nowak-Drabik (2003) reviewed the outcome and effectiveness of 92 studies and found that there was a moderate benefit of psychotherapy for people with intellectual disabilities. Recent legislation in the United Kingdom has responded by recommending improved access to psychological therapy for people with intellectual disabilities (Department of Health (DoH), 2007; 2009). The emergence of practice-based evidence has also meant that there is a growing expectation that services that provide psychological therapies show some evidence for the effectiveness of what they do (DoH, 2010). Coupled with this is the Payment by Results (PbR) initiative, where commissioners will pay healthcare providers dependent on the number of patients seen and outcomes achieved (DoH, 2013). One of the difficulties for providers of psychological therapies for people with intellectual disabilities is the availability of valid and reliable therapy outcome measures that can be easily used in service settings and accurately assess the effectiveness of interventions (Skelly, 2011; Weston, Elsworth & Stacey, 2011). Thesis This thesis aims to address the difficulties in measuring outcomes of psychological therapy with people with intellectual disabilities. The first paper will systematically review the quality of outcome measures that have been used in psychological therapies with adults with intellectual disabilities. The second paper will assess the psychometric properties of the Psychological Therapy Outcome Scale – Intellectual Disabilities (PTOS-ID), a newly developed therapy outcome measure designed specifically for use with people with intellectual disabilities. Timeline of Work Elements of research reported in this thesis were completed before the commencement of the Doctorate in Clinical Psychology programme. These were the development of the PTOS-ID, which included selection of the dependent variables through the use of focus groups; the selection of the item pool; and the development of the response format (please see the Introduction of the research paper for further details). The assessment of the psychometric properties of the PTOS-ID (i.e. construct validity, concurrent validity and internal consistency) was completed for the research study reported in this thesis in partial fulfilment of the award of Doctor of Clinical Psychology. Data were collected through service audits both prior to, and during, the period of study for this doctorate

Recaf: Java dialects as libraries

Mainstream programming languages like Java have limited support for language extensibility. Without mechanisms for syntactic abstraction, new programming styles can only be embedded in the form of libraries, limiting expressiveness. In this paper, we present Recaf, a lightweight tool for creating Java dialects; effectively extending Java with new language constructs and user defined semantics. The Recaf compiler generically transforms designated method bodies to code that is parameterized by a semantic factory (Object Algebra), defined in plain Java. The implementation of such a factory defines the desired runtime semantics. We applied our design to produce several examples from a diverse set of programming styles and two case studies: We define i) extensions for generators, asynchronous computations and asynchronous streams and ii) a Domain-Specific Language (DSL) for Parsing Expression Grammars (PEGs), in a few lines of code

Recaf: Java dialects as libraries

Mainstream programming languages like Java have limited support for language extensibility. Without mechanisms for syntactic abstraction, new programming styles can only be embedded in the form of libraries, limiting expressiveness. In this paper, we present Recaf, a lightweight tool for creating Java dialects; effectively extending Java with new language constructs and user defined semantics. The Recaf compiler generically transforms designated method bodies to code that is parameterized by a semantic factory (Object Algebra), defined in plain Java. The implementation of such a factory defines the desired runtime semantics. We applied our design to produce several examples from a diverse set of programming styles and two case studies: We define i) extensions for generators, asynchronous computations and asynchronous streams and ii) a Domain-Specific Language (DSL) for Parsing Expression Grammars (PEGs), in a few lines of code

Darwinian Data Structure Selection

Data structure selection and tuning is laborious but can vastly improve an application's performance and memory footprint. Some data structures share a common interface and enjoy multiple implementations. We call them Darwinian Data Structures (DDS), since we can subject their implementations to survival of the fittest. We introduce ARTEMIS a multi-objective, cloud-based search-based optimisation framework that automatically finds optimal, tuned DDS modulo a test suite, then changes an application to use that DDS. ARTEMIS achieves substantial performance improvements for \emph{every} project in $5$ Java projects from DaCapo benchmark, $8$ popular projects and $30$ uniformly sampled projects from GitHub. For execution time, CPU usage, and memory consumption, ARTEMIS finds at least one solution that improves \emph{all} measures for $86\%$ ($37/43$) of the projects. The median improvement across the best solutions is $4.8\%$, $10.1\%$, $5.1\%$ for runtime, memory and CPU usage. These aggregate results understate ARTEMIS's potential impact. Some of the benchmarks it improves are libraries or utility functions. Two examples are gson, a ubiquitous Java serialization framework, and xalan, Apache's XML transformation tool. ARTEMIS improves gson by $16.5$\%, $1\%$ and $2.2\%$ for memory, runtime, and CPU; ARTEMIS improves xalan's memory consumption by $23.5$\%. \emph{Every} client of these projects will benefit from these performance improvements.Comment: 11 page

Enveloping Sophisticated Tools into Process-Centered Environments

We present a tool integration strategy based on enveloping pre-existing tools without source code modifications or recompilation, and without assuming an extension language, application programming interface, or any other special capabilities on the part of the tool. This Black Box enveloping (or wrapping) idea has existed for a long time, but was previously restricted to relatively simple tools. We describe the design and implementation of, and experimentation with, a new Black Box enveloping facility intended for sophisticated tools --- with particular concern for the emerging class of groupware applications

Psychometric properties of the Clinical Outcome Routine Evaluation‐Learning Disabilities 30‐Item (CORE‐LD30)

Background There is paucity in availability of valid and reliable measures of psychopathology that can be routinely applied with an ID population in clinical practice. The psychometric properties of the Clinical Outcome Routine Evaluation-Learning Disabilities 30-Item version (CORE-LD30) are examined. Method The CORE-LD30 was administered to 271 sequential referrals to three NHS ID services providing psychological support. A Principal Components Analysis with oblique rotation was conducted with examination of convergent validity for extracted domains. Results Three rotated factors were extracted with good levels of internal consistency reported for the overall measure (α=.92) and each of the domains, conceptually labelled Problems/Symptoms (PS; α=.90), Risk to Self (RS; α=.76) and Risk to Others (RO; α=.71). Convergent validity is reported for two domains (PS with the GDS-LD, and RO with the HoNOS-LD), and support for the CORE-LD30 as a ‘core’ measure indicated. Conclusion The CORE-LD30 is recommended as a useful broad ranging measure of psychopathology for use with an ID population. Domains may prove to be useful for research and clinical purposes. Further research is recommended to examine the ability to monitor clinical change associated with specific levels of presentation and different clinical presentations/cohorts

Advances in the treatment of prolactinomas

Prolactinomas account for approximately 40% of all pituitary adenomas and are an important cause of hypogonadism and infertility. The ultimate goal of therapy for prolactinomas is restoration or achievement of eugonadism through the normalization of hyperprolactinemia and control of tumor mass. Medical therapy with dopamine agonists is highly effective in the majority of cases and represents the mainstay of therapy. Recent data indicating successful withdrawal of these agents in a subset of patients challenge the previously held concept that medical therapy is a lifelong requirement. Complicated situations, such as those encountered in resistance to dopamine agonists, pregnancy, and giant or malignant prolactinomas, may require multimodal therapy involving surgery, radiotherapy, or both. Progress in elucidating the mechanisms underlying the pathogenesis of prolactinomas may enable future development of novel molecular therapies for treatment-resistant cases. This review provides a critical analysis of the efficacy and safety of the various modes of therapy available for the treatment of patients with prolactinomas with an emphasis on challenging situations, a discussion of the data regarding withdrawal of medical therapy, and a foreshadowing of novel approaches to therapy that may become available in the future