On Some Recent Claims for the Efficacy of Cognitive Therapy for People with Intellectual Disabilities

A Systematic Review of Treatment Interventions for Individuals With Intellectual Disability and Trauma Symptoms: A Review of the Recent Literature

Individuals with intellectual disabilities (IDs) are at increased susceptibility to adverse life experiences and trauma sequelae. There is a disparate range of therapeutic interventions for post-traumatic stress disorder (PTSD) and associated symptoms. This systematic review aimed to appraise the effectiveness of both cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) for PTSD and associated symptoms for both adults and children with mild, moderate, or severe intellectual delay. A systematic search, in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, of the PsychInfo, PubMed, Cochrane Database of Systematic Reviews, and MEDLINE databases were performed, and all relevant articles published between 2010 and March 2020 were included. A total of 11 articles were included, eight that focused on EMDR and three on CBT. The methodological quality of many of these articles was generally weak. Tentative findings suggest that EMDR and CBT are both acceptable and feasible treatment options among adults and children with varying levels of intellectual delay, but no firm conclusions can be drawn regarding effectiveness due to small sample sizes, lack of standardized assessment, and a paucity of methodological rigorous treatment designs. This review highlights the continued use of therapeutic approaches with clients presenting with IDs and PTSD. It adds to the extant literature by providing an expansive and broad overview of the current effectiveness of both EMDR and CBT. Further high-quality research is needed to provide more conclusive findings regarding treatment effectiveness and modifications to treatment needed with this population.

Group Cognitive Behavioural Treatment for Anxiety in Autistic Adolescents with Intellectual Disability: A Pilot and Feasibility Study

BACKGROUND

Adolescents with Autism Spectrum Disorder (ASD) and intellectual disability evidence significant anxiety. This study aimed to adapt a group cognitive behaviour therapies (CBT) programme designed for youth with ASD and anxiety to meet the cognitive, communication, and behavioural needs of adolescents with intellectual disability, and assess initial feasibility and efficacy of the intervention.

METHODS

Structural, content and procedural adaptations were made to a 14-week family-focused CBT intervention. Twenty-three adolescents with ASD, intellectual disability and anxiety were included. Treatment acceptability along with adolescent anxiety symptoms was assessed via parent report measures.

RESULTS

Of the 23 participants, 19 completed treatment and attended 94% of sessions. Parent acceptability was high. Significant reductions were noted on anxiety symptoms post-intervention.

CONCLUSIONS

Results indicate that the CBT group was feasible and acceptable. Preliminary outcomes suggest that adolescent anxiety improved, although replication with a larger sample and comparison to a control group is needed.

Who Am I? A Life Story Intervention for Persons With Intellectual Disability and Psychiatric Problems

This article describes an innovative intervention based on narrative and life review therapy that is tailored to people with intellectual disability (ID) and psychiatric problems. The current study provides a first evaluation of the intervention. A symptom checklist (SCL-90) was used in a pre- and post-follow-up design, and a qualitative evaluation of the intervention was carried out with 25 participants. Results showed large changes in psychiatric symptoms, in particular on depression, anxiety, obsessive-compulsive disorder, and interpersonal sensitivity. Participants were mainly positive in their general explicit evaluations of the therapy as well as on personal learning points, intervention-specific, group-related, and therapist-related aspects. It is concluded that the intervention is promising for the treatment of people with ID and psychiatric complaints.

Assessment of Anger-Related Cognitions of People with Intellectual Disabilities

BACKGROUND

Interventions for anger represent the largest body of research on the adaptation of cognitive behavioural therapy (CBT) for people with intellectual disabilities. The extent to which the effectiveness of these interventions reflects the behavioural or cognitive components of CBT is uncertain. This arises in part because there are few measures of anger-related cognitions.

METHOD

The Profile of Anger-related Cognitions (PAC) is built around interpersonal scenarios that the participant identifies as personally anger-provoking, and was designed as an extension of the Profile of Anger Coping Skills (PACS). A conversational presentational style is used to approach ratings of anger experienced in those situations and of four relevant cognitive dimensions: attribution of hostile intent, unfairness, victimhood, and helplessness. The PAC, and other measures, including the PACS, was administered to (i) people with ID identified as having problems with anger control (n = 12) and (ii) university students (n = 23); its psychometric properties were investigated and content analyses were conducted of participants' verbal responses. In a third study, clinicians (n = 6) were surveyed for their impression of using the PAC in the assessment of clients referred for help with anger problems.

RESULTS

The PAC had good consistency and test-retest reliability, and the total score on the four cognitive dimensions correlated significantly with anger ratings but not with impersonal measures of anger disposition. The predominant cognitions reported were perceptions of unfairness and helplessness. People with ID and university students were in most respects very similar in both the psychometric analyses and the content analyses of their verbal responses. The PAC had high acceptability both to people with ID and to clinicians.

CONCLUSIONS

The PAC may be a useful instrument for both clinical and research purposes. Personal relevance and the conversational mode of administration are particular strengths.

Acceptance and Commitment Therapy for Individuals with Disabilities: A Behavior Analytic Strategy for Addressing Private Events in Challenging Behavior

Applied behavior analysts work with many populations including individuals with developmental and intellectual disabilities. Although behavior analysts have a variety of empirically supported treatments to implement when working with individuals with disabilities, sometimes, other variables may adversely impact treatment effectiveness. The degree to which problematic thoughts and feelings (private events) influence behavior may be a variable that contributes to treatment efficacy. Traditional behavior analytic services are not always equipped to successfully address the private events influencing client behavior. In such cases, it may be beneficial for behavior analysts to consider additional philosophically aligned treatments for private events. One such treatment, acceptance and commitment therapy, may be a useful tool for behavior analysts to incorporate into their toolbox in order to help clients. The purpose of this paper is to introduce behavior analysts to a potential solution to the problem of effectively addressing private events in behavior analytic services. We then propose a model for thinking about private events in relation to clients with disabilities and present a guide for taking steps to address private events in the clinical setting. We conclude this paper with a call for research and present a possible research agenda for behavior analysts.

A feasibility study of behavioural activation for depressive symptoms in adults with intellectual disabilities

BACKGROUND

Important work has been carried out adapting cognitive behavioural therapy for people with intellectual disabilities. However, there is a lack of alternative psychological therapies available for people with intellectual disabilities and emotional difficulties. Behavioural activation for depression is less reliant on verbal communication and focuses on increasing purposeful activity and reducing avoidance.

METHOD

This feasibility study involved the development and piloting of an adapted manual of behavioural activation for people with intellectual disabilities. The intervention consisted of 10-12 sessions and a key adaptation was that the therapist worked with the clients alongside a significant other in their life, either a paid carer or family member. Baseline, post-intervention (3 months after entering the study) and 6-month quantitative follow-up data were obtained. Primary outcome data were gathered, concerning depressive symptoms, participants' levels of activity and general well-being.

RESULTS

Twenty-three adults with intellectual disabilities with symptoms of depression were recruited from specialist health services. In terms of acceptability, the behavioural activation intervention was well received and only two individuals dropped out, with a further two lost to follow-up. The main measures of depression appeared to be sensitive to change. Pre- to post-intervention data showed a significant reduction in self-report of depressive symptoms with a strong effect size (r = 0.78), that was maintained at follow-up (r = 0.86). Positive change was also obtained for informant reports of depressive symptoms from pre- to post-intervention, with a strong effect size (r = 0.7). Once again, this positive change was maintained at follow-up (r = 0.72).

CONCLUSIONS

The study suggested that behavioural activation may be a feasible and worthwhile approach to tackling depression in people with intellectual disabilities. However, a randomised controlled trial would be required to establish its effectiveness, with more sensitive measurement of change in activity.

Do we need both cognitive and behavioural components in interventions for depressed mood in people with mild intellectual disability?

BACKGROUND

A growing literature suggests that people with mild intellectual disability (ID) who have depressed mood may benefit from cognitive-behavioural interventions. There has been some speculation regarding the relative merit of the components of this approach. The aim of this study was to compare (i) cognitive strategies; (ii) behavioural strategies; and (iii) combined cognitive-behavioural (CB) strategies on depressed mood among a sample of 70 individuals with mild ID.

METHODS

Staff from three participating agencies received training in how to screen individuals with mild ID for depressive symptoms and risk factors for depression. Depressive symptoms and negative automatic thoughts were assessed prior to and at the conclusion of the intervention, and at 6-month follow-up. The interventions were run in groups by the same therapist.

RESULTS

A post-intervention reduction in depression scores was evident in participants of all three interventions, with no significant difference between groups. A significant reduction in negative automatic thoughts post-intervention was evident in the CB combination group and was maintained at follow-up. Examination of clinical effectiveness suggests some advantage of the CB combination in terms of improvement and highlights the possible short term impact of behavioural strategies in comparison with the longer-term potential of cognitive strategies.

CONCLUSIONS

The findings support the use of group cognitive-behavioural interventions for addressing symptoms of depression among people with ID. Further research is necessary to determine the effectiveness of components.

Psychological treatments in intellectual disability: the challenges of building a good evidence base

Psychological treatments are widely used for the management of mental health and behavioural problems in people with intellectual disabilities. The evidence base, including the cost-effectiveness of such interventions, is limited. This editorial explores the current evidence base and analyses its strengths and limitations. The editorial also highlights current problems in conducting randomised controlled trials in this area and suggests a way forward.

A review of the literature relating to psychological interventions and people with intellectual disabilities: issues for research, policy, education and clinical practice

The aim of this review is to identify and analyse the published evidence base and wider literature in relation to psychological interventions for adults with intellectual disabilities. The review suggests that the evidence base regarding psychological interventions is sparse yet growing, and if the therapeutic approaches are modified and adapted to meet the distinct needs of people with intellectual disabilities these may be life enhancing. The lack of access to psychotherapies for people with intellectual disabilities has led to their exclusion from mainstream research, thereby limiting the evidence base on effective interventions and treatment approaches. This has significant implications for research, policy, education and clinical practice and is an area requiring strategic and local attention and development in the future.

PTSD and its treatment in people with intellectual disabilities: a review of the literature

Although there is evidence to suggest that people with intellectual disabilities (ID) are likely to suffer from Post-Traumatic Stress Disorder (PTSD), reviews of the evidence base, and the potential consequences of this contention are absent. The purpose of this article is to present a comprehensive account of the literature on prevalence, assessment, and treatment of PTSD in people with ID. Some support was found for the notion that people with ID have a predisposition to the development of PTSD. Differences in comparison with the general population may consist of the expression of symptoms, and the interpretation of distressing experiences, as the manifestation of possible PTSD seems to vary with the level of ID. Since reliable and valid instruments for assessing PTSD in this population are completely lacking, there are no prevalence data on PTSD among people with ID. Nine articles involve treatment of PTSD in people with ID. Interventions reported involve those aimed to establish environmental change, the use of medication and psychological treatments (i.e., cognitive behavioral therapy, EMDR and psychodynamic based treatments). Case reports suggest positive treatment effects for various treatment methods. Development of diagnostic instruments for assessment of PTSD symptomatology in this population is required, as it could facilitate further research on its prevalence and treatment.

The provision of psychological therapy to people with intellectual disabilities: an investigation into some of the relevant factors

BACKGROUND

Five factors are proposed as important in influencing the provision of psychological therapy to people with intellectual disabilities (IDs): the perceived effectiveness of psychological therapy, individual clinician competence, service resources (number of trained clinicians), the level of the client's disability and the diagnostic overshadowing bias.

METHOD

A prospective questionnaire design was used. A survey style questionnaire was sent out to clinical psychologists (n = 412) and psychiatrists (n = 274) working in ID services in the UK. Responses were received from 133 psychologists and 90 psychiatrists.

RESULTS

Perceived competence, the level of the client's disability and the diagnostic overshadowing bias all appeared to be important factors. The perceived effectiveness of psychological therapy with this client group and service resources appeared less important than hypothesized.

CONCLUSION

Whereas the debates in research publications tend to focus on broad issues of effectiveness, clinicians themselves appear more concerned with their personal skill levels. The issue of the appropriateness of psychological therapies for people with more severe levels of disability remains largely unresearched.