Putting the C into CBT: Cognitive challenging with adults with mild to moderate intellectual disabilities and anxiety disorders

The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and anxiety: a systematic review

INTRODUCTION

Individuals with intellectual disability (ID) are at higher risk of experiencing difficulties with anxiety than the general population. However, there are major barriers for individuals to receive appropriate services. There is a growing understanding of the importance of developing appropriate psychological interventions for this group. The objective of the current review was to systematically evaluate the findings of studies investigating the effectiveness of cognitive behavioural therapy (CBT) for individuals with ID and anxiety. Another aim was to explore which adaptions to CBT and treatment components were currently being utilised within the field.

METHOD

The electronic databases of CINAHL, EMBASE, Medline, PsycINFO, Psychology and Behavioural Sciences Collection and Scopus were searched to identify relevant studies. The methodological quality of these studies was assessed using established quality assessment tools by the National Institutes of Health for pre and post studies and case series.

RESULTS

Nine studies were included in this systematic review, all of which reported improvements in anxiety severity for some participants (25%-100%; N = 60) following CBT. Only three studies reported moderate effect sizes for CBT interventions on anxiety for individuals with ID.

DISCUSSION AND CONCLUSIONS

There is emerging literature supporting the effectiveness of CBT for individuals with mild ID. Findings highlight that CBT for individuals with anxiety and mild ID, including cognitive components, may be feasible and tolerable. While the field is gradually receiving more attention, there are significant methodological flaws present, which limit the conclusions that can be drawn regarding the effectiveness of CBT for individuals with ID. However, there is emerging evidence for techniques such as cognitive restructuring and thought replacement and modifications such as visual aids, modelling and smaller groups based on this review. Future research is warranted to investigate whether individuals with more severe ID can benefit from CBT, as well as further exploring what are the necessary components and modifications.

Empirically supported psychological treatments: The challenges of comorbid psychiatric and behavioral disorders in people with intellectual disability

This paper reviews the current state of knowledge on psychological interventions with empirical evidence of efficacy in treating common psychiatric and behavioral disorders in people with intellectual disability (ID) at all stages of their life. We begin with a brief presentation of what is meant by psychiatric and behavioral disorders in this population, along with an explanation of some of the factors that contribute to the increased psychosocial vulnerability of this group to present with these problems. We then conduct a review of empirically supported psychological therapies used to treat psychiatric and behavioral disorders in people with ID. The review is structured around the three generations of therapies: Applied behavior analysis (e.g., positive behavior support), cognitive behavioral therapies (e.g., mindfulness-based cognitive therapy), and contextual therapies (e.g., dialectical behavior therapy). We conclude with some recommendations for professional practice in the fields of ID and psychiatry.

Treatment Approach and Sequence Effects in Cognitive Behavioral Therapy Targeting Emotion Regulation Among Adolescents with Externalizing Problems and Intellectual Disabilities

Background

Over the past years, it has become clear that adapted cognitive behavior therapy can be effective for adolescents with externalizing problems and mild intellectual disabilities or borderline intellectual functioning (MID–BIF). Most adapted treatment protocols consist, however, of a combined cognitive and behavioral approach, even though it is actually unclear which approach is most suitable for these adolescents. This experimental study aimed to examine which treatment approach (cognitive versus behavioral) and which treatment sequence (cognitive–behavioral versus behavioral–cognitive) is most effective.

Methods

Participating adolescents (N = 42, 50% boys, Mage = 15.52, SD = 1.43) consecutively received a cognitive and behavioral emotion regulation training module, but were randomly assigned to a different module sequence condition. Emotion regulation and externalizing problems were measured before and after the modules, and with continuing weekly assessments.

Results

Results indicated that the cognitive module, by itself, was more effective than the behavioral module. In addition, the results indicated that it is most effective to include behavioral exercises after (rather than before) cognitive training.

Conclusions

These findings highlight the importance of cognitive treatment approaches for adolescents with MID–BIF, and show that treatment approaches may have different effects, depending on the order in which they are presented.

Concussion in para sport: the first position statement of the Concussion in Para Sport (CIPS) Group

Concussion is a frequent injury in many sports and is also common in para athletes. However, there is a paucity of concussion research related to para sport, and prior International Concussion in Sport (CIS) consensus papers have not substantively addressed this population. To remedy this and to improve concussion care provided to para athletes, the concussion in para sport (CIPS) multidisciplinary expert group was created. This group analysed and discussed in-depth para athlete-specific issues within the established key clinical domains of the current (2017) consensus statement on CIS. Due to the onset of the COVID-19 pandemic, the group held all meetings by video conferencing. The existing Sport Concussion Assessment Tool 5 (SCAT5) for the immediate on-field and office-based off-field assessment of concussion was evaluated as part of this process, to identify any para athlete-specific concerns. Regular preparticipation and periodic health examinations are essential to determine a baseline reference point for concussion symptoms but pose additional challenges for the interpreting clinician. Further considerations for concussion management for the para athlete are required within the remove, rest, reconsider and refer consensus statement framework. Considering return to sport (RTS), the 2017 CIS consensus statement has limitations when considering the RTS of the para athlete. Case-by-case decision making related to RTS following concussion is imperative for para athletes. Additional challenges exist for the evaluation and management of concussion in para athletes. There is a need for greater understanding of existing knowledge gaps and attitudes towards concussion among athlete medical staff, coaches and para athletes. Future research should investigate the use and performance of common assessment tools in the para athlete population to better guide their clinical application and inform potential modifications. Concussion prevention strategies and sport-specific rule changes, such as in Para Alpine Skiing and Cerebral Palsy Football, also should be carefully considered to reduce the occurrence of concussion in para athletes.

Potential for children with intellectual disability to engage in cognitive behaviour therapy: the parent perspective

BACKGROUND

This study aimed to obtain the opinions of parents and carers of children with intellectual disability (ID) as to whether cognitive behaviour therapy (CBT) could be useful for their children.

METHODS

A mixed qualitative and quantitative method was employed. Twenty-one carers of children aged 10 to 17 having borderline to moderate intellectual functioning responded to an online questionnaire. Participants were provided with information about CBT and asked to respond to open-ended questions. Quantitative data pertained to questions about their child's ability to identify and describe thoughts, feelings and behaviours. Thematic analysis of responses was conducted using an inductive method of identifying themes from the qualitative data collected.

RESULTS

Five themes emerged from the qualitative analysis: Emotional Attunement (i.e. parent's understanding and recognition of their child's emotions), Role of the Therapist (i.e. ways therapists could facilitate the intervention), Role of the Parent (i.e. ways parents could engage in the therapy process), Anticipated Obstacles (i.e. what may get in the way of the therapy) and Suggested Adaptations for Therapy (i.e. how CBT can be adapted to suit the needs of children with ID). Seventy-six per cent agreed that their child would be able to engage in CBT with assistance.

CONCLUSIONS

The majority of parents believed that CBT is an intervention that children with ID could engage in, provided the therapy is adapted, and the therapist accommodates their needs.