An investigation into the factor structure of the Health of the Nation Outcome Scales for People with Learning Disabilities

BACKGROUND

The Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD) is one of the most used outcome measures in learning disability services in the United Kingdom. There is relatively little known of the psychometric properties of the scales.

METHOD

A data set of HoNOS-LD scales from 571 people with learning disabilities was randomly split into two halves. Exploratory Mokken analysis was applied to the first dataset, and confirmatory scale factor analysis was applied to the second dataset to test the fit of scale structures.

RESULTS

Two-factor and three-factor solutions were explored in the Mokken analysis, with the three-factor option having somewhat better characteristics. One-factor, three-factor and seven-factor solutions were explored using confirmatory factor analysis; a three-factor solution with items 8, 16, 17 and 18 used separately offers the best characteristics.

CONCLUSIONS

The HoNOS-LD is best conceptualised as consisting of three scales, accounting for 14 items that can be labelled as 'Cognitive and Physical Functioning', 'Behaviour and Mood Disturbances' and 'Functional Difficulties'.

Predictors and moderators of the response of adults with intellectual disabilities and depression to behavioural activation and guided self-help therapies

BACKGROUND

No previous studies have reported predictors and moderators of outcome of psychological therapies for depression experienced by adults with intellectual disabilities (IDs). We investigated baseline variables as outcome predictors and moderators based on a randomised controlled trial where behavioural activation was compared with guided self-help.

METHODS

This study was an exploratory secondary data analysis of data collected during a randomised clinical trial. Participants (n = 161) were randomised to behavioural activation or guided self-help and followed up for 12 months. Pre-treatment variables were included if they have previously been shown to be associated with an increased risk of having depression in adults with IDs or have been reported as a potential predictor or moderator of outcome of treatment for depression with psychological therapies. The primary outcome measure, the Glasgow Depression Scale for Adults with Learning Disabilities (GDS-LD), was used as the dependant variable in mixed effects regression analyses testing for predictors and moderators of outcome, with baseline GDS-LD, treatment group, study centre and antidepressant use as fixed effects, and therapist as a random effect.

RESULTS

Higher baseline anxiety (mean difference in outcome associated with a 1 point increase in anxiety 0.164, 95% confidence interval [CI] 0.031, 0.297; P = 0.016), lower performance intelligence quotient (IQ) (mean difference in outcome associated with a 1 point increase in IQ 0.145, 95% CI 0.009, 0.280; P = 0.037) and hearing impairment (mean difference 3.449, 95% CI 0.466, 6.432; P = 0.024) were predictors of poorer outcomes, whilst greater severity of depressive symptoms at baseline (mean difference in outcome associated with 1 point increase in depression -0.160, 95% CI -0.806, -0.414; P < 0.001), higher expectation of change (mean difference in outcome associated with a 1 point increase in expectation of change -1.013, 95% CI -1.711, -0.314; p 0.005) and greater percentage of therapy sessions attended (mean difference in outcome with 1 point increase in percentage of sessions attended -0.058, 95% CI -0.099, -0.016; P = 0.007) were predictors of more positive outcomes for treatment after adjusting for randomised group allocation. The final model included severity of depressive and anxiety symptoms, lower WASI performance IQ subscale, hearing impairment, higher expectation of change and percentage of therapy sessions attended and explained 35.3% of the variance in the total GDS-LD score at 12 months (R2  = 0.353, F4, 128  = 17.24, P < 0.001). There is no evidence that baseline variables had a moderating effect on outcome for treatment with behavioural activation or guided self-help.

CONCLUSIONS

Our results suggest that baseline variables may be useful predictors of outcomes of psychological therapies for adults with IDs. Further research is required to examine the value of these potential predictors. However, our findings suggest that therapists consider how baseline variables may enable them to tailor their therapeutic approach when using psychological therapies to treat depression experienced by adults with IDs.

A systematic review of cognitive behavioural therapy for anxiety in adults with intellectual disabilities

BACKGROUND

Anxiety disorders have high prevalence in people with intellectual disabilities. In populations without intellectual disabilities, cognitive behavioural therapy is a first line psychological therapy for these presentations. There is no existing review of the range of methods and outcomes from intervention studies in this area.

METHOD

A systematic review was carried out following guidance in the Cochrane handbook for systematic reviews of interventions.

RESULTS

Nineteen studies were identified. The majority of reports were descriptive case studies; the most frequently described presentations were non-specific anxiety disorders and post-traumatic stress disorder; the most frequently described cognitive techniques were psycho-education and interventions directly aimed at thoughts and beliefs and most studies reported positive outcomes, although the better controlled studies tended to report less comprehensive impacts.

CONCLUSIONS

A range of presentations have been described although the area is still at a primarily descriptive stage. We discuss intervention structures and approaches that require further research.

Leaving school: a comparison of the worries held by adolescents with and without intellectual disabilities

BACKGROUND

Leaving school is an important time for adolescents, with increasing autonomy and developing adult identities. The present study sought to shed light on the content and emotional impact of worries amongst adolescents with and without intellectual disabilities (IDs) at this time of change.

METHODS

Twenty-five adolescents with mild to moderate IDs and 27 adolescents without IDs, aged 15 to 18 years, took part in the study. Participants' worries were elicited using a structured interview. The levels of rumination and distress related to their most salient worries were also examined, along with their self-reported levels of anxiety.

RESULTS

Content analysis of the interviews identified differences between the worries of the two groups of participants, with the adolescents with IDs expressing more general worries about failure and personal threat. Level of distress about worries was positively correlated with anxiety in both groups. The adolescents with IDs were significantly more anxious than their non-disabled peers.

CONCLUSIONS

The differences between the groups' worries may be linked to differences in life experience and expectations. Consideration should be given to the specific worries of adolescents at the stage of leaving school. Doing so may allow solutions for their concerns to be identified, thus easing distress and leading to a less stressful transition.

Feasibility and acceptability of web-based enhanced relapse prevention for bipolar disorder (ERPonline): trial protocol

BACKGROUND

Relapse prevention interventions for Bipolar Disorder are effective but implementation in routine clinical services is poor. Web-based approaches offer a way to offer easily accessible access to evidence based interventions at low cost, and have been shown to be effective for other mood disorders.

METHODS/DESIGN

This protocol describes the development and feasibility testing of the ERPonline web-based intervention using a single blind randomised controlled trial. Data will include the extent to which the site was used, detailed feedback from users about their experiences of the site, reported benefits and costs to mental health and wellbeing of users, and costs and savings to health services. We will gain an estimate of the likely effect size of ERPonline on a range of important outcomes including mood, functioning, quality of life and recovery. We will explore potential mechanisms of change, giving us a greater understanding of the underlying processes of change, and consequently how the site could be made more effective. We will be able to determine rates of recruitment and retention, and identify what factors could improve these rates.

DISCUSSION

The findings will be used to improve the site in accordance with user needs, and inform the design of a large scale evaluation of the clinical and cost effectiveness of ERPonline. They will further contribute to the growing evidence base for web-based interventions designed to support people with mental health problems.

The controllability beliefs scale used with carers of people with intellectual disabilities: psychometric properties

BACKGROUND

Beliefs about the controllability of behaviour have been consistently shown to be important in understanding the responses of carers to the challenging behaviour of people with intellectual disabilities (IDs). This paper reports the reliability and validity of the controllability beliefs scale (CBS), a 15-item measure of beliefs regarding the controllability of challenging behaviour when used with carers of people with IDs.

METHODS

Two hundred and sixty-four carers of people with IDs completed the CBS, 74 people also completed the modified attributional style questionnaire and the self-injury behavioural understanding questionnaire scale to determine concurrent and convergent validity and 34 people completed the scale twice within a 2- to 4-week period to determine test-retest reliability.

RESULTS

The scale has a two-factor structure and has adequate internal reliable. The scale is significantly correlated with the controllability, internality and stability items from the Modified Attributional Style Questionnaire, showed expected associations with behavioural and internal emotional understanding items from the self-injury behavioural understanding questionnaire. The scale has good test-retest reliability.

CONCLUSIONS

The data support use of the CBS in clinical practice and research to assess carers' beliefs regarding challenging behaviour of people with IDs.

Cognitive behavioural therapy from the perspective of clients with mild intellectual disabilities: a qualitative investigation of process issues

BACKGROUND

Clinicians working with clients who have mild intellectual disabilities (IDs) have shown growing enthusiasm for using a cognitive behavioural approach, amid increasing evidence of good treatment outcomes for this client group. However, very little is known about the views and experiences of clients with IDs who have undergone cognitive behavioural therapy. This study aims to explore the perspective of these clients.

METHODS

Fifteen participants with borderline to mild IDs and problems of anxiety, depression and anger were interviewed regarding their experience of cognitive behavioural therapy (CBT). Two semi-structured interviews were carried out in the first phase of therapy between session four and session nine. An interpretive phenomenological approach was taken to seek out themes from participants' own personal accounts.

RESULTS

Participants valued the opportunity to talk about problems with their therapist and benefitted from therapeutic relationships characterised by warmth, empathy and validation. Participants identified areas of positive change; however, many thought that this may be short lived or not maintained beyond discharge.

CONCLUSIONS

The supportive aspects of therapeutic relationships were particularly important to participants undergoing CBT. The clinical implications are considered.

Adaptation and validation of the Tower of London test of planning and problem solving in people with intellectual disabilities

BACKGROUND

There is a need for validated, standardised tools for the assessment of executive functions in adults with intellectual disabilities (ID). This study examines the validity of a test of planning and problem solving (Tower of London) with adults with ID.

METHOD

Participants completed an adapted version of the Tower of London (ToL) while day-centre staff completed adaptive function (Adaptive Behaviour Scale - Residential and Community: Second Edition, modified version) and dysexecutive function (DEX-Independent Rater) questionnaires for each participant. Correlation analyses of test and questionnaire variables were undertaken.

RESULTS

The adapted ToL has a robust structure and shows significant associations with independent living skills, challenging behaviour and behaviours related to dysexecutive function.

CONCLUSIONS

The adapted ToL is a valid test for use with people with ID. However, there is also a need to develop other ecologically valid tools based on everyday planning tasks undertaken by people with ID.

Cognitive behavioural therapy: from face to face interaction to a broader contextual understanding of change

Cognitive behavioural therapy (CBT) is increasingly used to address the emotional and interpersonal problems of people with ID. There is a limited but promising evidence base supporting this activity. However, these individuals face real and continuing challenges in their lives that have implications for their self and interpersonal perceptions. These adversities have implications for the adaptation of CBT. First, it may mean that characteristically negative perceptions may be more common and may be the result of a complex interaction with a truly aversive environment and should not simply be considered as cognitive distortions. Secondly, clients may have limited control over their everyday lives, with limited opportunity to negotiate change with their informal and formal sources of support. This review suggests that it is important to consider the interpersonal context of therapy both to ensure effective work within sessions and to enable real change in clients' everyday lives. The review draws upon Vygotsky's theory of the zone of proximal development and ecological models of change to consider the challenges of establishing collaborative relationships and the potential to use CBT within a broad psychosocial model. The aim is to offer a helpful framework for practitioners and to identify directions for future research.

The psychometric properties of the Hospital Anxiety and Depressions Scale adapted for use with people with intellectual disabilities

BACKGROUND

There is increasing recognition of depression in people with intellectual disabilities (ID). There is a need to develop well-standardised self-report measures for both clinical and research purposes. This paper presents some psychometric properties of the Hospital Anxiety and Depression Scale (HADS) adapted for use with people with ID. The anhedonic emphasis in the depression scale of the HADS may be particularly useful for people with ID who present with high rates of physical co-morbidity.

METHOD

A total of 197 people with ID completed an adapted HADS; 32 participants also completed the Zung Depression Scale and 42 also completed the Glasgow Depression Scale.

RESULTS

The obtained factor structure is similar to the original form of the scale used with people without ID. However, the underlying question wording of the HADS, where most depression items are phrased positively and most anxiety items are phrased negatively, makes clear interpretation of the factor structure difficult. The HADS has an adequate internal reliability and correlates well with other self-report measures of depression.

CONCLUSIONS

The HADS may need further adaptation; however, the measurement of anhedonia is a useful addition to the self-report measures of depression available for people with ID.

Staff judgements of responsibility for the challenging behaviour of adults with intellectual disabilities

BACKGROUND

This study examines the importance of staff judgements of responsibility for challenging behaviour in predicting their emotional and intended helping responses.

METHODS

Sixty-two carers completed questionnaires rating attributions of internality, stability and controllability, emotions of sympathy and anger, judgements of responsibility for the development of challenging behaviour and for its resolution and intended effort in helping in response to a scenario describing an aggressive behaviour.

RESULTS

Results showed significant correlations between judgements of responsibility and attributions, emotions and intended effort in helping. Regression analysis showed that the best predictor of intended helping is the emotion of sympathy and that sympathy is best predicted by the attribution of internality, the judgement that people are not responsible for the development of challenging behaviour and the judgement that they are responsible for the resolution of the behaviour.

CONCLUSIONS

Judgements of responsibility predict emotional and intended behavioural responses of carers of people with intellectual disabilities and challenging behaviour. The results are discussed in relation to previous work on carer attributions in response to challenging behaviour. Implications for clinical work with carers are considered.

Psychometric properties of the Hospital Anxiety and Depression Scale with a population of members of a depression self-help group

This paper reports the psychometric properties of the Hospital Anxiety and Depression Scale when used with 341 members of a self-help group for people with depression. We report internal reliability and factor structure for the complete data set and factor structure for groups split by gender, previous hospitalization for depression and current use of medication for depression. In each instance the factor structure reflects the intended depression and anxiety subscales. We comment on the usefulness of the HADS in studies of cognitive processes in depression and anxiety.

Assessing the ability of people with a learning disability to give informed consent to treatment

BACKGROUND

People with a learning disability are increasingly being encouraged to take a more active role in decisions about their psychological and medical treatment, raising complex questions concerning their ability to consent. This study investigates the capacity of people with a learning disability to consent in the context of three treatment vignettes, and the influence of verbal and memory ability on this capacity.

METHODS

Measures of verbal ability, memory ability and ability to consent to treatment (ACQ) were administered to 40 people with a learning disability. The ACQ consisted of three vignettes depicting a restraint, psychiatric or surgical intervention. These were followed by questions addressing people's ability to understand the presenting problem; the nature of the proposed intervention; the alternatives, risks and benefits; their involvement in the decision-making process; and their ability to express a clear decision with a rationale for treatment.

RESULTS

Five people (12.5%) could be construed as able to consent to all three vignettes; 26 (65%) could be construed as able to consent to at least one. The questions that were most difficult to answer concerned a participants' rights, options and the impact of their choices. Verbal and memory ability both influenced ability to consent.

CONCLUSIONS

This study introduces a measure that may enable clinicians to make more systematic assessments of people's capacity to consent. A number of issues surrounding the complex area of consent to treatment are also raised.

Social comparison, self-esteem and depression in people with intellectual disability

The present study explores the relationship between social comparison processes, self-esteem and depression in people with intellectual disability. Forty-three people with mild and moderate intellectual disability completed adapted measures of self-esteem and social comparison. The social comparison scale offers subscale scores on achievement, social attractiveness and group belonging dimensions. The self-esteem scale offers subscale scores for positive and negative self-esteem. A significant positive correlation was found between positive self-esteem and social comparison on the achievement dimension. Depression was significantly negatively correlated with social comparison on the social attractiveness and group belonging dimensions, and with positive self-esteem. Regression analysis showed that depression was significantly and independently predicted only by social comparison on the social attractiveness dimension. The present authors conclude that social comparison is associated with self-esteem and depression in people with intellectual disability in the same way as it is for people without intellectual disability. Further exploration of social comparison process in people with intellectual disability may inform cognitive behavioural interventions for this group of people.

A greater role of emotional than physical or sexual abuse in predicting disordered eating attitudes: the role of mediating variables

OBJECTIVE

Previous research on the role of trauma in eating psychopathology has generally focused on reported childhood sexual abuse. There has been relatively little research addressing the full range of abusive experiences, and none considering their long-term impact on eating. This study investigated the relationships between four forms of reported childhood abuse (physical abuse, sexual abuse, emotional abuse, neglect) and unhealthy eating attitudes in adult life. Within this relationship, depression, anxiety, and dissociation were considered potential mediators, and age of onset of abuse was considered a potential moderator.

METHOD

A nonclinical sample of 236 women completed self-report measures of abuse, eating psychopathology, and psychological function. Multiple regression analyses were used to test for associations as well as for mediating and moderating influences.

RESULTS

When the intercorrelations of the different forms of reported abuse were controlled for, emotional abuse was the only form of childhood trauma that predicted unhealthy adult eating attitudes. That relationship was perfectly mediated by the women's levels of anxiety and dissociation. Age at onset of emotional abuse did not moderate these relationships.

DISCUSSION

Although these results require extension to a clinical sample, the findings underscore the need to consider a history of emotional trauma as a potentially central factor in any abusive history. Treatment may depend on addressing the psychological consequences of such trauma.

A longitudinal study of the quality of life of older people with intellectual disability after leaving hospital

A study was made of the quality of life of 29 older people with intellectual disability who left hospital to live in ordinary three- or four-bedroom houses. A short version of the Questionnaire on Quality of Life was used to measure quality of life before moving and at three points in the first 53 months after changing residence. Results showed that there were improvements in quality-of-life subscales in the first 41 months with an eventual levelling out after 53 months. Social and leisure activity have been identified as particular important in the quality of life of older people. Therefore, items from the scale that measure participation in community leisure activities, contact with people without intellectual disability during these activities and engagement in leisure activities within the home were selected for detailed analysis. These data also showed increased activity and contacts in the first 41 months with a levelling out after 53 months.

Care staff responses to people with learning disabilities and challenging behaviour: a cognitive-emotional analysis

This study explores the application of Weiner's cognitive-emotional model of helping behaviour to care staff responses to challenging behaviour of people with learning disabilities. Participants were 20 residential care staff who worked with people with challenging behaviour and 20 who did not. Six examples of challenging behaviour were presented, and for each behaviour participants were asked to give a probable cause, rate attributions of stability, internality, globality and controllability for their cause, their optimism for change of the behaviour, their evaluation of the behaviour and a person showing the behaviour, their emotional response to the behaviour and their willingness to put extra effort in to helping change the behaviour. Data were analysed using correlation and regression methods. Carers working with people with challenging behaviour were more likely to evaluate the person more positively and report they would be more likely to offer extra effort in helping. A path analysis showed that helping behaviour was best predicted by optimism, which was best predicted by negative emotion which was best predicted by the attribution of controllability. We conclude that attributions and emotions reported by carers in response to challenging behaviour are consistent with Weiner's cognitive-emotional model of helping behaviour. Formulating carer behaviour using such models offers the possibility of using cognitive-behavioural methods in working with staff beliefs, emotions and behaviour in response to challenging behaviour.

Changes in the quality of life of people with learning disabilities who moved from hospital to live in community-based homes

This paper describes a longitudinal study of the change in quality of life experienced by 36 residents of community-based homes after leaving a hospital for people with learning disabilities. The measure used to evaluate quality of life was Living in a Supervised Home: A Questionnaire on Quality of Life (Cragg and Harrison, 1986). The questionnaire was completed before and after the study group left the hospital. The analyses of the scale shows that there has been a considerable improvement in the quality of life of people who have moved from hospital to community-based homes. Specific data are presented from quality of life sub-scales relating to the use of community facilities and contact with other members of the community.

A move from hospital to community-based homes for people with learning disabilities: activities outside the home

Eighteen people with learning disabilities who moved from hospital to community-based homes were compared with a matched group of 18 who did not. A week-long time budget diary was used to record each occasion that the person left their home, the people accompanying them on each trip, their mode of transport and their destination. The diary was completed before they left the hospital and was repeated at least 1 year later. There was a strong correlation between the number of trips made from hospital wards at baseline and the number made at follow-up in both groups. Moving from the hospital had no significant effect on the number of trips made, but it did change their nature. Movers made more trips to unsegregated facilities; they made fewer trips alone and more in groups which included both staff and residents.