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Objectives: To characterise the changes at work experienced by psychologists working with people with intellectual disabilities during the pandemic and whether these changes, stressors and aspects of working life were associated with mental wellbeing and occupational stress.\ud Methods: Ninety-seven psychologists completed an online survey. Free text comments were analysed using thematic analysis and triangulated with our quantitative findings.\ud Results: Occupational stress, learning new roles, demands at home, and changes due to COVID-19 were associated with poorer mental wellbeing, while uncertainty about the role, a shortage of personal protective equipment, and poorer mental wellbeing were associated with occupational\ud stress. Two main themes emerged during the thematic analysis: being human and being an employee, and triangulation revealed agreement.\ud Conclusions: The wellbeing and occupational stress of psychologists working with people with intellectual disabilities have been affected during the pandemic. It is of note that almost a quarter of our sample reported having been redeployed.

Background:\ud The recent COVID-19 pandemic led to widespread international restrictions, severely impacting on health and social care services. For many individuals with an intellectual disability (ID) this meant reduced access to services and support for them and their carers.\ud \ud Aim:\ud The aim of this study was to gain insight into the ways parents of adults with ID coped during the first 2020 lockdown period.\ud \ud Methods:\ud Eight parents of adults with ID were interviewed. The recordings of these interviews were subjected to a thematic analysis.\ud \ud Results:\ud Four main themes were identified: powerless and unappreciated; coping under lockdown; support; and the impact of lockdown on well-being.\ud \ud Conclusions:\ud The parents of adults with ID who made up our sample reported that they received little support from services and experienced a sense of powerlessness. Nevertheless, they were open to accepting support from family and friends and showed remarkable resilience. These findings are discussed in the light of the Willner et al. (2020) survey results on parental mental health and coping, and suggestions for future service provision during pandemic conditions are proposed.

Background:\ud Recent COVID‐19 lockdown restrictions resulted in reduced access to educational, professional and social support systems for children with intellectual disabilities and their carers.\ud \ud Aim:\ud The aim of this study was to gain insight into the ways mothers of children with intellectual disabilities coped during the first 2020 lockdown period.\ud \ud Methods:\ud Eight mothers of children with intellectual disabilities were interviewed. The recordings of these interviews were subjected to a thematic analysis.\ud \ud Results:\ud Three main themes were identified: carrying the burden; a time of stress; and embracing change and looking to the future.\ud \ud Conclusions:\ud All mothers experienced increased burden and stress. However, some also described some positive impact of lockdown conditions on them as well as on their child's well‐being and behaviour. These findings are discussed in the light of the (Journal of Applied Research in Intellectual Disabilities, 33, 2020, 1523) survey results on parental coping and suggestions for future service provision during pandemic conditions are proposed.\ud \ud

Purpose The purpose of this paper is to evaluate the prevalence of mental health disorder symptoms in a sample of prisoners in Trinidadian prisons who volunteered to attend anger management groups. Design/methodology/approach A survey was conducted using the 90-item Symptom Check-List revised (SCL-90-R) which was administered to prisoners in groups within the prison system. In total 132 prisoners (about 9 per cent of the prison population) completed the measure. The effect sizes of prisoners’ similarities to a psychiatric inpatient group and their differences from a non-patient group were used to identify symptoms most indicative of pathology in these prisoners. Findings The results on the SCL-90-R indicate that this group of prisoners (77.3 per cent male) had scores of psychiatric symptomatology that were much closer to a psychiatric inpatient population rather than to a general community population. Practical implications These results suggest there may be unmet psychiatric need among the population served by the prison services in Trinidad. It is not known how this sample differs from the general prison population. However, the unmet psychiatric need in this specific population suggests that a greater mental health focus in health services within prisons is to be considered to meet these needs. Originality/value These data suggest that there are significant mental health issues for some prisoners in Trinidad and possibly more generally in similar prison systems within the Caribbean and this may have significant implications for the treatment of prisoners and the delivery of mental health services in these prisons.

Sleep contributes to the consolidation of memories. This process may involve extracting the gist of learned material at the expense of details. It has thus been proposed that sleep might lead to false memory formation. Previous research examined the effect of sleep on false memory using the Deese-Roediger-McDermott (DRM) paradigm. Mixed results were found, including increases and decreases in false memory after sleep relative to wake. It has been questioned whether DRM false memories occur by the same processes as real-world false memories. Here, the effect of sleep on false memory was investigated using the Gudjonsson Suggestibility Scale. Veridical memory deteriorated after a 12-h period of wake, but not after a 12-h period including a night’s sleep. No difference in false memory was found between conditions. Although the literature supports sleep-dependent memory consolidation, the results here call into question extending this to a gist-based false memory effect.

Cognitive deficits in depression can be modelled using the novel object recognition (NOR) test, performance in which is impaired by chronic mild stress (CMS). We aimed to examine the involvement of mesocorticolimbic DA terminal regions, and to establish the substrate for CMS-induced impairment of NOR and its reversal by chronic antidepressant treatment. In experiments 1 and 2, we examined the effect of infusions into medial PFC, dorsal hippocampus (HPC), and nucleus accumbens (NAc) shell of D1 and D2 antagonists and D3 agonist, which were predicted to impair NOR with a short (1 h) delay, and of D1 and D2 agonists and D3 antagonist, which were predicted to facilitate NOR with a long (24 h) delay. Using optimal doses identified in experiment 2, in experiments 3 and 4, we examined effects on drug-stimulated NOR of CMS and chronic treatment with venlafaxine (VFX) or risperidone (RSP). We found a wide involvement of DA systems in memory for NOR: D1 receptors in PFC, HPC, and NAc; D3 receptors in PFC and HPC; and D2 receptors in PFC. CMS impaired D2- and D3-mediated effects in PFC and HPC; antidepressants rescued those effects in PFC but not HPC. The involvement of DA in NOR is multifaceted, but the effects of CMS and antidepressants are more discrete, involving D2 and D3 receptors in PFC specifically. While raising many difficult questions, these results suggest that the D2 and D3 receptors in the medial PFC may be an important substrate for cognitive deficits in depression and their remediation. Electronic supplementary material The online version of this article (doi:10.1007/s00213-017-4651-4) contains supplementary material, which is available to authorized users.

This paper describes the characteristics of groups of prisoners selected to take part in an anger management programme in prisons in Trinidad. Participants completed demographic measures, an IQ assessment, mental health measures and anger rating scales. Fifty-six inmates were screened with the WASI-2 and characteristics of this group are explored in this paper. The mean IQ for the group was 72.34 and 22 had a recorded IQ below 70 (37.5%). All of the respondents reported high levels of mental health problems with their mean ratings on the SCL-90 being closer to those of inpatient psychiatric group norms than non-clinical groups. A score of less than 70 on the WASI-2 is not sufficient for a diagnosis of an Intellectual Disability. Nevertheless, the results suggest that a significant number of individuals in these prisons may have an Intellectual Disability. More research is needed to help identify these individuals and provide support.

Now 30 years old, the chronic mild stress (CMS) model of depression has been used in >1300 published studies, with a year-on-year increase rising to >200 papers in 2015. Data from a survey of users show that while a variety of names are in use (chronic mild/unpredictable/varied stress), these describe essentially the same procedure. This paper provides an update on the validity and reliability of the CMS model, and reviews recent data on the neurobiological basis of CMS effects and the mechanisms of antidepressant action: the volume of this research may be unique in providing a comprehensive account of antidepressant action within a single model. Also discussed is the use of CMS in drug discovery, with particular reference to hippocampal and extra-hippocampal targets. The high translational potential of the CMS model means that the neurobiological mechanisms described may be of particular relevance to human depression and mechanisms of clinical antidepressant action.

Introduction: \ud The measures implemented to manage the COVID‐19 pandemic have been shown to impair mental health. This problem is likely to be exacerbated for carers. Method: Informal carers (mainly parents) of children and adults with intellectual disabilities, and a comparison group of parents of children without disabilities, completed an online questionnaire. Almost all the data were collected while strict lockdown conditions were in place. Results: Relative to carers of children without intellectual disability, carers of both children and adults with intellectual disability had significantly greater levels of a wish fulfilment coping style, defeat/entrapment, anxiety, and depression. Differences were 2–3 times greater than reported in earlier pre‐pandemic studies. Positive correlations were found between objective stress scores and all mental health outcomes. Despite their greater mental health needs, carers of those with intellectual disability received less social support from a variety of sources. Conclusions: The greater mental health needs of carers in the context of lesser social support raises serious concerns. We consider the policy implications of these findings.

Background: Anger causes significant problems in offenders and to date few interventions have been described in the Caribbean region. Aim: To evaluate a package of CBT-based Anger Management Training provided to offenders in prison in Trinidad. Method: A controlled clinical trial with 85 participants who participated in a 12-week prison-based group anger management programme, of whom 57 (67%: 16 control, 41 intervention) provided pretrial and posttrial outcome data at Times 1 and 2. Results: Intervention and control groups were not directly comparable so outcome was analysed using t-tests. Reductions were noted for state and trait anger and anger expression, with an increase in coping skills for the intervention group. No changes were noted in the control group. The improvements seen on intervention were maintained at 4 month follow-up for a sub-group of participants for whom data were available. Several predictors of outcomes were identified.

Purpose Trauma-focussed cognitive-behaviour therapy (TF-CBT) is the most effective treatment for post-traumatic stress disorder (PTSD). Individuals who present with complex PTSD are among the most complex and challenging patients seen by intellectual disability psychology and psychiatry services. The purpose of this paper is to study TF-CBT intervention for people with intellectual disabilities and complex PTSD. Design/methodology/approach Three groups of adults with intellectual disabilities (ID) presenting with complex PTSD (n=3, n=5 and n=4) were treated using a 12-week manualised intervention adapted from a procedure routinely used in adult mental health services. Participants completed the Impact of Event Scale as adapted for people with intellectual disabilities (IES-ID) before and after the intervention, and interviews conducted to ascertain their experiences of the group were analysed using interpretative phenomenological analysis (IPA). Findings The ten participants who completed the intervention showed a 27 per cent decrease in median Impact of Event Scale Intellectual Disabilities scores, equivalent to a medium effect size (d=0.50). Five themes were identified from the interviews: being listened to; it is nice to know you are not the only one; being in a group can be stressful; the importance of feeling safe; achieving and maintaining change. Participants also provided constructive feedback to promote improvements to the manual. Research limitations/implications A feasibility study followed by methodologically robust clinical trials is now needed to establish the effectiveness of the intervention and its utility in clinical practice. Practical implications This small study has confirmed the potential of TF-CBT as an intervention for extremely vulnerable individuals with ID who present with complex PTSD. Social implications The findings indicate that a group intervention is both feasible for and acceptable to adults with ID. Originality/value To date, no study has investigated the effectiveness and feasibility of a TF-CBT group intervention for adults with mild ID.

This paper considers the meaning of the term ‘intrusive research’, as used in the UK Mental Capacity Act 2005 (MCA), in relation to studies in which an informant is asked to provide information about or on behalf of a person who lacks capacity to consent, and who is not otherwise involved in the study. The MCA defines ‘intrusive research’ as research that would legally require consent if it involved people with capacity. The relevant ethical principles are that consent should be sought from people who would be affected by a piece of research and that this requirement should be implemented proportionately. The critical question, for investigators and research ethics committees, is: would provision of the personal information specified in the research protocol significantly affect a person whose capacity is not impaired? If the answer to this question is ‘no’, then the study falls outside the definition of ‘intrusive research’, and the MCA does not apply.

Objectives The purpose of this study was to evaluate the effects of homework-task difficulty and electronic-diary reminders on written homework completion during cognitive-behavioural therapy (CBT) for addiction. Completion of homework is an important element in CBT that may affect outcome. Design All participants received all combinations of our two interventions in a factorial 2 × 2 counterbalanced Latin-square design. Methods Methadone-maintained cocaine and heroin users were given homework between each of 12 weekly CBT sessions and carried electronic diaries that collected ecological momentary assessment (EMA) data on craving and exposure to drug-use triggers in four 3-week blocks assessing two levels of homework difficulty and prompted and unprompted homework. Results Neither simplified (picture-based) homework nor electronic reminders increased homework completion. In EMA reports, standard but not simplified homework seemed to buffer the craving that followed environmental exposure to drug cues. EMA recordings before and after the CBT intervention confirmed a decrease over time in craving for cocaine and heroin. Conclusions These findings demonstrate the utility of EMA to assess treatment effects. However, the hypothesis that simplified homework would increase compliance was not supported. Practitioner points Our simplifications of homework assignments for cognitive-behavioural therapy were mostly ineffective, or even counterproductive, perhaps because they did not engage sufficient depth of processing or because they were perceived as too simplistic. Our reminder beeps for homework were mostly ineffective, or even counterproductive, suggesting that mobile electronic interventions for substance-use disorders may need to be more interactive.

Background People with intellectual disabilities (ID) are rarely asked about their experiences as users of psychological services and little is known about the views of clients with ID who have undergone cognitive behavioural therapy (CBT). This study aimed to gather the views of adults with ID who had recently taken part in a cluster randomised control trial (RCT) of a staff-delivered manualised CBT anger management group intervention. Method A qualitative method, Interpretative Phenomenological Analysis (IPA), was employed and eleven participants were interviewed. The interviews took place after the intervention, within two weeks of the end of the group, to gain an understanding of service users' experiences of participating in a CBT group. Results IPA of the interview transcripts indicated that the intervention was experienced as effective and enjoyable and a number of themes were identified including: ‘the importance of relationships’, ‘a new me’, ‘new and improved relationships’, ‘presenting myself in a positive light’ and ‘what the group didn't change’. Conclusions The results will be discussed in the context of applying group CBT for adults with ID and implications for service development.

Aim The aim of this review is to summarise current understanding of the neurobiology of aggression and within this context to consider the evidence base for the pharmacotherapy of aggressive challenging behaviour by people with intellectual disabilities (ID). Evidence Aggressive encounters involve a variety of psychological processes and progress has been made in understanding the brain mechanisms involved. However, the role in aggression of the neurotransmitters serotonin, dopamine and γ-aminobutyric acid is no longer as clear as it once appeared, with the result that predictions cannot be made with confidence about drug effects on aggression. There have been relatively few controlled trials of pharmacotherapy for aggression in people with ID, or, indeed, in the general population, and their outcomes have largely been negative. Conclusion With the possible exception of risperidone, there is no reliable evidence that antidepressant, neuroleptic or anticonvulsant drugs are effective treatments for aggression by people with ID.

Background Anger and aggression among adults with intellectual disability (ID) are associated with a range of adverse consequences for their well-being and that of their family or staff carers. The aims were to evaluate the effectiveness of an anger management intervention for adults with mild to moderate ID and to evaluate the costs of the intervention and its impact on health and social care resource use. This paper is concerned with the latter aim. Methods A cluster-randomised controlled trial was conducted involving day services for adults with ID in Scotland, England and Wales. Incremental costs of delivering the intervention and its impact on subsequent total health and social care package costs were calculated. Full data comparing costs between baseline and follow-up 10 months later were collected for 67 participants in the intervention arm and 62 participants in the control arm. Cost differences between the groups at follow-up, adjusted for baseline levels, were calculated using non-parametric bootstrapping controlling for clustering. Results The mean hourly excess cost of intervention over treatment as usual was £12.34. A mean adjusted cost difference of £22.46 per person per week in favour of the intervention group was found but this was not statistically significant. Conclusions The baseline-adjusted cost difference at follow-up would result in a fairly immediate compensation for the excess costs of intervention, provided the difference is not a statistical artefact. Further research is needed to clarify the extent to which it might represent a real saving in service support costs.

The context for the present study was a cluster-randomized controlled trial of a group-based anger-management intervention, delivered by day-service staff. We aimed to develop a scale to measure the fidelity of manualized cognitive-behavioural therapy (CBT) delivered to adults with intellectual disabilities in group-based settings. A 30-item monitoring instrument (the MAnualized Group Intervention Check: MAGIC) was adapted from an existing fidelity-monitor instrument for individual CBT. Two sessions for 27 groups were observed by pairs of monitors who had no other contact with the intervention. 16 observers participated, in 15 unique pairings. Observers recorded high levels of inter-rater reliability and the scale had good internal consistency. Fidelity ratings predicted two key outcomes of the intervention, and were themselves predicted by the therapists' clinical supervisors.

BackgroundMany people with intellectual disabilities find it hard to control their anger and this often leads to aggression which can have serious consequences, such as exclusion from mainstream services and the need for potentially more expensive emergency placements.AimsTo evaluate the effectiveness of a cognitive–behavioural therapy (CBT) intervention for anger management in people with intellectual disabilities.MethodA cluster-randomised trial of group-based 12-week CBT, which took place in day services for people with intellectual disabilities and was delivered by care staff using a treatment manual. Participants were 179 service users identified as having problems with anger control randomly assigned to either anger management or treatment as usual. Assessments were conducted before the intervention, and at 16 weeks and 10 months after randomisation (trial registration: ISRCTN37509773).ResultsThe intervention had only a small, and non-significant, effect on participants' reports of anger on the Provocation Index, the primary outcome measure (mean difference 2.8, 95% Cl −1.7 to 7.4 at 10 months). However, keyworker Provocation Index ratings were significantly lower in both follow-up assessments, as were service-user ratings on another self-report anger measure based on personally salient triggers. Both service users and their keyworkers reported greater usage of anger coping skills at both follow-up assessments and keyworkers and home carers reported lower levels of challenging behaviour.ConclusionsThe intervention was effective in improving anger control by people with intellectual disabilities. It provides evidence of the effectiveness of a CBT intervention for this client group and demonstrates that the staff who work with them can be trained and supervised to deliver such an intervention with reasonable fidelity.

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.

The chronic mild stress (CMS) model of depression is considered by many to be the animal model of depression that has the greatest validity and translational potential, but it has often been criticized for a perceived lack of reliability. The aims of this study were to establish the extent to which the procedure is reproducible, and to identify experimental variables relevant to its reliability. Because failures to replicate frequently remain unpublished, a survey methodology was used. A questionnaire was circulated to 170 labs identified from a PubMed search as having published a CMS study in the years 2010 or 2015 (with no selection in respect of the results reported). Responses were returned by 71 (42%) of the recipients, followed by further correspondence with some of them. Most of the respondents (n = 53: 75%) reported that the CMS procedure worked reliably in their hands. Of the others, 15 (21%) reported that the procedure was usually reliable, but not always (n = 9: 13%) or not for all measures (n = 6: 8%). Only three respondents (4%) reported being unable to reproduce the characteristic effects, two of whom may be using an insufficient duration of CMS exposure. A series of analyses compared the 75% of ‘reliable’ labs with the 25% of ‘less reliable’ labs on a range of experimenter, subject, stress and outcome variables. Few if any significant differences between these two samples were identified, possibly because of the small size and diversity of the ‘less reliable’ sample. Two other limitations of the study include the (unavoidable) omission of labs that may have worked with the model but not published their data, and the use of ad hoc measures to compare the severity of different stress regimes. The results are discussed in relation to relevant published observations. It is concluded that CMS is in fact a rather robust model, but the factors that result in a less effective implementation in a minority of laboratories remain to be firmly established.

Purpose. Many studies have reported that professionals have a limited understanding of mental capacity issues. Implementation (in England and Wales) of the Mental Capacity Act (MCA) (2005) presents a challenge to services. The aim of this study was to evaluate the extent to which National Health Service (NHS) staff benefited from attending MCA training courses. Methods. Participants were assessed before and after MCA training using a structured interview, which included three scenarios describing mental capacity dilemmas, four vignettes addressing the role of the Independent Mental Capacity Advocate (IMCA), and 16 true–false items. Results. Interview performance improved post-training, but this could be largely ascribed to an increased awareness of mental capacity issues, with minimal improvements in the knowledge that would be needed to undertake the assessments. Nine areas were identified where there remained significant gaps in participants’ knowledge post-training. Participants with experience of dealing with mental capacity issues performed better than those without. Conclusions. The results suggest that methods other than formal training events may be needed to prepare health staff to implement new legislation.

Purpose – The terms capacity and competence are often used interchangeably, but are actually distinct. This aim of this paper is to clarify the application of these terms, and to illustrate some of the practical benefits of distinguishing them.Design/methodology/approach – The concepts of capacity and competence are discussed in relation to restrictions that are placed on choice and action, respectively, when these qualities are judged to be absent. The paper explores the distinction between these two concepts in relation to their legal status, assessment, and scope.Findings – Mental capacity refers to the ability to make decisions, while competence refers to the ability to perform the actions needed to put decisions into effect. Questions of capacity are governed by legislation (in the UK: the Mental Capacity Act (MCA); the Adults with Incapacity (Scotland) Act and the Sexual Offences Act); they apply only to people who can be demonstrated to have a “mental disorder”, and trigger best‐interests decision ...

Background Previous research has demonstrated that people with mild intellectual disabilities (ID) have difficulty in ‘weighing up’ information, defined as integrating disparate items of information in order to reach a decision. However, this problem could be overcome by the use of a visual aid to decision making. In an earlier study, participants were taught to translate information about the pros and cons of different choices into a single evaluative dimension, by manipulating green (good) and red (bad) bars of varying lengths (corresponding to the value ascribed). Use of the visual calculator increased the consistency of performance (and decreased impulsive responding) in a temporal discounting task, and increased the amount of information that participants provided to justify their decisions in scenario-based financial decision-making tasks. Methods The present study examined some practical aspects of visual calculator training, using a pen-and-paper version of two temporal discounting tasks. Participants with mild ID were tested, individually and in a group setting, before and after training in the group setting, and 2 months later. Results (i) The visual aid improved temporal discounting performance using pen-and-paper presentation in a group setting as effectively as previously demonstrated using computer-based individual presentation. (ii) Following withdrawal of the aid, improvements in temporal discounting performance were maintained at 1 day post training, but lost following a 2-month hiatus; however, participants showed perfect retention, over 2 months, of how to use the aid. (iii) In addition to decreasing impulsivity in a hypothetical task, as previously demonstrated, use of the visual calculator also increased the ability of impulsive participants to wait in real time. Conclusion The results suggest that the visual calculator has practical applicability to support decision making by people with mild ID in community settings.

Background The aim of this study was to evaluate the state of knowledge of mental capacity issues among health and social services professionals working in community teams supporting people with learning disabilities. Methods A structured interview was constructed around three scenarios, based on actual cases, concerning a financial/legal issue, a health issue and a relationships issue, as well as a set of ten ‘true/false’ statements. The interview aimed to elicit respondents’ understanding in relation, primarily, to assessment of capacity and best-interests decision making. Forty interviews were conducted (two social workers and two health professionals from each of ten community teams). Most participants had attended training on the Mental Capacity Act (2005). Results Performance of social services and health staff was similar throughout. Fourteen areas of concern were identified where there appeared to be significant gaps in knowledge. Conclusions Participants, particularly those who had experience of dealing with mental capacity issues, had good insight into the extent of their knowledge, and most participants said that the interview had made them aware of further training needs.

Crimes against people with intellectual disabilities frequently do not result in prosecutions because it is assumed that the victim would be unreliable as a witness. Similarly, crimes in which a pe...

Background The aim of this study was to evaluate the extent to which care managers in learning disability services understand the role of the Independent Mental Capacity Advocate (IMCA) service, and the difference between the newly created statutory IMCA and existing general advocacy (GA) services. Method There were 22 participants from three community teams within learning disabilities services, all but one of whom had attended training on the Mental Capacity Act (2005). Participants completed a questionnaire based on a set of nine scenarios where they were asked to identify the appropriate professional to contact in relation to the situation described, and to explain what their role would be. Results Respondents’ understanding of these issues was generally poor. There was a substantially less than 50% correct response rate for identification of scenarios that called for an IMCA referral, and respondents’ ability to discriminate between the roles of GA and IMCA was limited. Only around half of the respondents correctly identified that the function of advocacy is to represent the client’s views, and a significant minority incorrectly attributed decision-making functions to the IMCA. Only a single participant identified the statutory requirement to involve an IMCA in relation to a change of long-term accommodation (where the person lacks capacity and has no other non-professional support), and none of the participants identified this as a statutory requirement in relation to serious medical treatment. Conclusion A better understanding of the statutory functions of the IMCA service may require a different approach to Mental Capacity Act training.

Introduction We describe a simple and rapid screening test for basic financial knowledge that is suitable for administration to people with mild intellectual disabilities. Method The Coins and Costs test asks respondents to name coins, and to estimate prices of objects ranging between £1 (an ice cream) and £100K (a small house). The test was administered, alongside a battery of neuropsychological tests, to 40 people attending day services (mean Full-Scale IQ = 59.1). Results Total scores were normally distributed, and correlated significantly with receptive language ability and performance on memory tests, but not with IQ or executive functioning. Conclusion The test provides a rapid (

Background Executive functioning (EF) is an important concept in cognitive psychology that has rarely been studied in people with intellectual disabilities (IDs). The aim of this study was to examine the validity of two test batteries and the structure of EF in this client group. Methods We administered the children's version of the Behavioural Assessment of the Dysexecutive Syndrome (BADS-C) and the Cambridge Executive Functioning Assessment (CEFA) for people with ID, to 40 participants who attended day centres for people with mild to moderate learning disabilities [mean full-scale intelligence quotient (IQ) = 59]. The BADS-C consists of six EF subtests while the CEFA contains eight EF (including two executive memory) subtests and four memory subtests. IQ and receptive language ability were also assessed. The results were subjected to principal components analysis, and regression analysis was used to examine the relationship of the ensuing factors to other cognitive variables. Results Scores on both sets of EF tests were only weakly related to receptive language ability, and even more weakly related to IQ. Scores on the BADS-C were substantially lower than predicted from the published norms for people in higher IQ ranges, and many participants scored zero on three of the six subtests. This potential floor effect was less evident with scores on the CEFA. Principal components analyses produced one usable factor for the BADS-C, and two factors for the CEFA that differed in both the extent of involvement of working memory and the predominant sensory modality. A combined analysis of the subtests retained from both analyses produced three factors that related uniquely to aspects of IQ and memory. Conclusions The CEFA is suitable for use with people with mild to moderate learning disabilities, whereas the BADS-C is at the lower limit of usability with this client group. The lower-than-expected scores observed on the BADS-C may indicate that people known to learning disability services may be more impaired than people of comparable IQ not known to services. The structure of EF seen in people with IDs closely resembles a model of EF in the general population that has received a broad level of support.

Individuals with intellectual and developmental disabilities often have difficulties foregoing short-term loss for long-term gain. The Iowa Gambling Task (IGT) has been extensively adopted as a laboratory measure of this ability. In the present study, we undertook the first investigation with people with intellectual disabilities using a two-choice child version of the IGT, with measures of intellectual and executive functioning. Compared to a group of matched controls, people with intellectual disabilities performed advantageously and showed high levels of subjective awareness about the relative goodness and badness of the decks. A symbol labelling intervention, in which participants were taught to label the good and bad decks at regular intervals significantly improved advantageous decision-making to levels approximating that of controls. Factor analysis of executive functioning scores identified working memory and mental flexibility (response initiation and set shifting), with a near-significant inverse correlation between the extent to which the intervention was required and mental flexibility. These findings show, for the first time, that people with intellectual disabilities are capable of performing advantageously on the IGT and add to the growing clinical literature on decision-making.

Background An assessment of mental capacity includes an evaluation of the ability to 'weigh up' information, but how to do this is uncertain. We have previously used a laboratory decision-making task, temporal discounting, which involves a trade-off between the value and the delay of expected rewards. Participants with intellectual disabilities (ID) showed very little evidence of 'weighing up' of information: only a third of participants showed consistent temporal discounting performance, and when present, consistent performance was usually impulsive; and the ability to perform consistently was more strongly related to executive functioning than to IQ. The aim of the present study was to replicate these observations and extend them to a more realistic financial decision-making task. Methods We administered a temporal discounting task and a financial decision-making task, as well as tests of executive functioning and IQ, to 20 participants who attended day services for people with learning disabilities (mean Full-Scale IQ = 59), and to 10 staff members. Results Performance in both decision-making tasks was related more strongly to executive functioning than to IQ. In both tasks, decisions by service users were made largely on the basis of a single item of information: there was very little evidence in either task that information from two sources was being 'weighed'. Conclusions The results suggest that difficulty in 'weighing up' information may be a general problem for people with ID, pointing to a need for psycho-educational remediation strategies to address this issue. The importance of executive functioning in decision-making by people with ID is not recognized in the legal test for mental capacity, which in practice includes a possibly irrelevant IQ criterion.

Cognitive behavioural therapy (CBT) assumes that psychological disorders are characterized by distorted or dysfunctional thinking, and can be treated by working with the patient to modify thinking in the direction of more realistic or adaptive evaluations of events. CBT has been evaluated extensively and is now the first-line treatment of choice for many psychological disorders. It is increasingly being used with people with learning disabilities, although the evidence base with this population is relatively weak, consisting largely of case studies and case series. There are also controlled trials in anger and depression, for which all published studies report significant clinical improvements that are well maintained over 3–6-month follow-up periods. There are many barriers to engagement with CBT for people with learning disabilities, which reflect limitations of ability and motivation. The limitations of ability reflect the fact that people with learning disabilities have to cope with cognitive deficits in addition to the cognitive distortions that are the target of CBT interventions. If barriers to treatment are recognized, significant steps can be taken to increase accessibility by adapting the therapy. Adaptations include involving carers, simplifications of the delivery of therapy (e.g. by using simple language and a slower pace), and simplifications of the model (e.g. by the therapist adopting a more directive, less collaborative, approach). If the current policy of increasing access to psychological therapies is extended to people with learning disabilities, it is likely that evidence will also accrue to support the use of other psychotherapeutic approaches.

Historically people with intellectual disabilities have not been offered or received cognitive behavioural interventions that have been shown to be effective for mental health and emotional problems experienced by those without such disabilities. This is despite many people with intellectual disabilities having life experiences that potentially result in them having an increased risk to such problems. This paper discusses whether such therapeutic disdain is justified based on the evidence that is available and emerging concerning the application of cognitive behavioural interventions for this population. Issues concerning access to services, the ability of people with intellectual disabilities to engage in and benefit from the cognitive components of CBT, and the effect of cognitive abilities and IQ level on treatment effectiveness are explored in relation to this question.

Introduction Attribution theory posits that helping behaviour is determined in part by the potential helper’s attributions and emotions regarding the behaviour that requires help. Specifically, helping is considered to be more likely if stability is perceived as low, generating optimism for change, and if controllability is perceived as low, engendering high levels of sympathy and low levels of anger. Method We conducted a systematic literature search to identify studies that have tested these predictions in relation to carers’ propensity to help people with intellectual disabilities who display challenging behaviour. Results The literature is inconsistent and provides at best partial support for the theory. This situation differs from that seen in the general population, where the predictions of attribution theory are broadly supported. Discussion We consider three potential explanations for this discrepancy: the reliability of the largely vignette-based methodology, the fact that most studies fail to define ‘helping’ explicitly and the possibility that attribution theory might apply only to low-frequency behaviours.

Cognitive behavioral therapy (CBT) is the predominant form of psychological therapy, with a substantial evidence base of randomized controlled trials across a wide range of mental health disorders. Overturning the earlier assumption that psychotherapeutic interventions were unsuitable for people with intellectual and developmental disabilities (IDD), CBT is now in widespread use by clinical psychologists working with people with IDD, particularly in the UK. The first section of this chapter reviews briefly the basic principles of CBT, and considers the need to adapt CBT for people with IDD, which arises from the fact that, in addition to the cognitive distortions that are the major focus of CBT interventions, it is also necessary, when working with people with IDD, to take account of cognitive deficits in the areas of emotional literacy, memory, executive functioning, and self-direction. We consider the kinds of adaptations that may typically be needed in relation to each of the specific components of a CBT intervention. We next review the evidence for the effectiveness of CBT interventions for people with IDD. This includes a large number of controlled trials of interventions for problem anger, a much smaller literature on interventions for depression, and a relatively large body of case-study material in other conditions. Though, for the most part, methodologically weak, the evidence suggests that the effectiveness of CBT for people with IDD is comparable to that seen in the general population. Finally, we present some practice recommendations in relation to screening, formulation, overcoming dependency and stigma, promoting motivation and engagement, and setting an appropriate pace of treatment.

Objective To evaluate the extent to which anger management training provided within a learning disabilities day service generalizes to residential settings. Method Eleven day-service users participated in one of two anger management groups. Treatment was delivered by day-service staff and an assistant psychologist, using a standard cognitive-behavioural therapy (CBT) package shown to be effective in earlier studies. Evaluation was by the Provocation Index and the Profile of Anger-Coping Skills, which measure, respectively, the potential to react in an angry manner, and the utilization of eight different anger-coping skills. Results Participants showed a decrease in anger and an increase in anger-coping skills, which was maintained at 6-month follow-up. Similar changes were reported by day-service key-workers and by residential carers (and by the participants themselves). At the level of the group, key-workers and home carers did not differ significantly, at any time, in their ratings of anger, aggregate coping skills or individual coping skills. Within each setting, profiles of coping skills differed between individuals but were relatively stable across the 6-month follow-up period. However, there was no significant correlation between the profiles of coping skills reported for individual service users in the two settings. Conclusions The results confirm that group-based CBT is an effective treatment for people with learning disabilities and anger management problems. Therapeutic gains are maintained for at least 6 months and generalize across settings. Different anger-coping skills may be used by different people, or by the same person in different environments. A Manual for the group is available on request.

Cognitive behavioural therapy (CBT) is being used increasingly with people with learning disabilities. The evidence base to support these developments comes from uncontrolled trials of CBT in a variety of psychological disorders and eight to nine controlled trials of CBT for anger (plus a single controlled study in depression). This paper reviews the evidence for the effectiveness of group‐based anger management and the acquisition of anger coping skills, and the effectiveness of individual anger treatment, with some discussion of the status of CBT for other indications and the difficulties of conducting outcome research in this area.

Resistance to antidepressant drug treatment remains a major health problem. Animal models of depression are efficient in detecting effective treatments but have done little to increase the reach of antidepressant drugs. This may be because most animal models of depression target the reversal of stress-induced behavioural change, whereas treatment-resistant depression is typically associated with risk factors that predispose to the precipitation of depressive episodes by relatively low levels of stress. Therefore, the search for treatments for resistant depression may require models that incorporate predisposing factors leading to heightened stress responsiveness. Using a diathesis-stress framework, we review developmental, genetic and genomic models against four criteria: (i) increased sensitivity to stress precipitation of a depressive behavioural phenotype, (ii) resistance to chronic treatment with conventional antidepressants, (iii) a good response to novel modes of antidepressant treatment (e.g. ketamine; deep brain stimulation) that are reported to be effective in treatment-resistant depression and (iv) a parallel to a known clinical risk factor. We identify 18 models that may have some potential. All require further validation. Currently, the most promising are the Wistar-Kyoto (WKY) and congenital learned helplessness (cLH) rat strains, the high anxiety behaviour (HAB) mouse strain and the CB1 receptor knockout and OCT2 null mutant mouse strains. Further development is needed to validate models of antidepressant resistance that are fit for purpose. The criteria used in this review may provide a helpful framework to guide research in this area.

Aims Cognitive therapies are increasingly being offered by clinical psychologists to people with intellectual disabilities. This paper reviews some of the factors that influence people's readiness to engage in cognitive therapy. Literature review Limited verbal ability, psychological-mindedness (particularly in relation to the understanding of emotions and the mediating role of cognitions), and self-efficacy, are all likely to present significant barriers. There may also be motivational barriers to treatment, including the functionality of some psychological presentations, maladaptive beliefs promoting resistance to change, the intellectually challenging nature of cognitive therapy, and external factors such as inappropriate settings. Engagement with therapy can be promoted by involving carers to support the therapy, but carers may themselves display a range of limitations of ability and motivation similar to those displayed by clients, which need to be recognized, and where possible addressed, in order for their involvement to be effective. Recommendations If barriers to treatment are recognized, significant steps can be taken to increase accessibility. In addition to simplifying the delivery of therapy, there is also scope to simplify the model; this point is illustrated by case examples, and some principles for formalizing modifications to standard procedures are suggested. As barriers to treatment can often be surmounted, a decision whether or not to offer cognitive therapy should be derived from a comprehensive formulation, and should never be based solely on a client's performance on tests of cognitive ability.

Aims This case study describes the formulation and cognitive–behavioural treatment (CBT) of obsessive–compulsive thoughts and behaviours in a woman with an intellectual disability. The report aimed to distinguish the cognitive deficits that reflect her disability from the cognitive distortions integral to her obsessive–compulsive disorder. Case study Hence, we present one account of the cognitive–behavioural interventions aimed at correcting the cognitive distortions, and a separate account of the modifications necessary to compensate for specific cognitive deficits, which include impairments not only of ‘cognitive therapy skills’, but also of aspects of memory and executive functioning skills. Discussion We suggest that this analysis may provide a rational approach to the problem of simplifying CBT to meet the needs of people with intellectually disabilities, by identifying more clearly the specific adaptations that are needed by a particular individual. We also discuss the assessment of cognitive deficits that might impact on CBT, and some implications of this approach for research and training.

Aim: The Gudjonsson Suggestibility Scale (GSS) assesses suggestibility by asking respondents to recall a short story, using leading questions and pressure to change their responses. Suggestibility, as assessed by the GSS, is elevated in people with intellectual disabilities. Unlike real life incidents, the information presented is of no personal significance to the respondent. The aim of the present study was to investigate whether this factor influences suggestibility in people with intellectual disabilities. Method: We created two alternative suggestibility scales (ASS and ASS2), based on real events in a learning disabilities day service. In Experiment 1, two groups of service users (n = 20) were administered both the GSS and the ASS, presented in a counterbalanced order. The experimental group had witnessed the events described in the ASS, which took place 18 months earlier. The control group attended a different day service; therefore, for this group, the information presented in the GSS and...

Aim: One of the tenets of the incentive sensitization theory of drug addiction is that 'as drugs come to be wanted more and more, they often come to be liked less and less'. The aim of this study was to test whether this assumption holds true. Specifically, the study aimed to test the hypothesis that in non-clinical samples, dependence on amphetamines and excessive alcohol use are associated with increased 'wanting' but decreased 'liking' for the drug. Design, setting and participants: In two studies, the Desires for Alcohol Questionnaire (DAQ) was administered to 380 recreational drinkers, and the Desires for Speed Questionnaire (DSQ) and the Leeds Dependence Questionnaire (LDQ) were administered to 174 amphetamine users. Scales were derived from the DAQ and DSQ representing craving, on one hand, and positive and negative reinforcement on the other hand. Craving and positive reinforcement were taken as measures of alcohol or amphetamine 'wanting' and 'liking', respectively. Findings: Scores on all three DAQ scales increased monotonically as a function of the extent of alcohol consumption. Scores on all three DSQ scales increased monotonically as a function of dependence, as measured by the LDQ. 'Liking' for amphetamine was unrelated to time since the drug was last taken. (These data were not available for alcohol.) Conclusions: The finding that 'wanting' increased as a function of dependence on amphetamine or level of consumption in the case of alcohol is as predicted by the incentive sensitization theory, but the finding that 'liking' also increased as a function of dependence or excess is the opposite of the predicted effects While not refuting the incentive sensitization theory directly, the study questions the validity of one of the tenets of the theory

Historically, people with learning disabilities have had little or no access to psychotherapeutic interventions, although there are signs that, over the past decade, this situation has seen some gradual improvement. This paper provides an overview of the evidence for the effectiveness of psychodynamic, cognitive-behavioural and cognitive therapies in this client group. The available data support the position that all three approaches can be effective in people with mild learning disabilities and in a proportion of people with more severe conditions. However, the literature reporting outcomes of psychotherapeutic interventions in people with learning disabilities is extremely limited, and there is a conspicuous and unjustified poverty of randomized controlled trials. There is also very little evidence regarding either the importance of specific components of therapeutic packages, or the optimal manner of delivering these interventions to people with learning disabilities.

Aim This study examined the responses of care managers and direct care staff to vignettes of inappropriate sexual behaviour (ISB) by a man with an intellectual disability. The aim was to identify psychological factors that influenced their assessment of risk and the perceived need for risk management strategies. Method The vignettes varied in response topography and the age of the victim. Regression analysis was used to examine the effect of three sets of psychological factors (causal explanations, causal attributions and emotional responses) on perceptions of risk, seriousness and appropriate service level responses to the ISB, and the inter-relationships between these outcome variables. Results Behaviours involving intimate sexual contact or a child victim were rated as more serious, and more in need of supervision and management, than vignettes describing non-contact behaviours or in which the victim was another adult with an intellectual disability. Levels of concern were generally lower for care managers than for direct care staff. The study cast little light on how care staff make decisions concerning the risk of recurrence of ISB. For care managers, high levels of concern were associated with the perception that the ISB was sexually motivated or was triggered by a negative emotional state, and with high levels of anger. Care managers appeared to make decisions about the appropriate intensity of service response based on an evaluation of the seriousness of the ISB, which was informed by the topography of the ISB and the identity of the victim. For direct care staff, high levels of concern were associated primarily with the perception that the cause of the behaviour was poor management; other factors associated with high levels of concern were the perception that the ISB was sexually motivated, and attributions that the ISB was controllable and stable. The central constructs in the decision making of direct care staff appeared to be the perceptions that, for it to have occurred, the behaviour must have been badly managed, and that offences against children require a response. Implications These differing approaches to decision making by care managers and care staff may lead to conflict in the implementation of care plans for men with intellectual disabilities who display ISB.

Care professionals were interviewed regarding the extent, nature and victims of inappropriate sexual behaviour of 46 men with learning disabilities, and an adapted form of a version of the Structured Anchored Clinical Judgement risk assessment protocol (SACJ-Min: Hanson and Thornton, 2000) was completed for each. Risk judgements were unrelated to objective risk, as assessed by the SACJ-Min, to seriousness or frequency of sexual offending, to treatment outcome, or to a wide variety of other factors examined. The variables most strongly associated with risk judgements were the presence of a child victim and criminal convictions for inappropriate sexual behaviour, both of which, paradoxically, were perceived to decrease the risk of reoffending. Respondents were confident that existing management arrangements were effective in decreasing the risk of reoffending, and that the more intensely clients were supervised, the greater was the decrease in risk. However, level of supervision was unrelated to objective r...

Background Fourteen clients with learning disabilities referred for anger management were randomly assigned to a treatment group and a waiting-list control group. Methods Treatment consisted of nine 2-h group sessions, using brainstorming, role-play and homework. Topics addressed included: the triggers that evoke anger; physiological and behavioural components of anger; behavioural and cognitive strategies to avoid the build-up of anger and for coping with anger-provoking situations; and acceptable ways of displaying anger (assertiveness). The intervention was evaluated using two inventories of anger-provoking situations, which were completed independently by both clients and carers. Results Clients in the treated group improved, on both self- and carer-ratings, relative to their own pre-treatment scores, and to the control group post-treatment. The within-group improvement corresponds to a ‘moderate’ (0.68 SD) effect size, whereas the between-group improvement corresponds to a ‘large’ (1.76 SD) effect size. The degree of improvement during treatment was strongly correlated with Verbal IQ. Clients in the treated group showed further improvement relative to their own pre-treatment scores at 3-month follow-up. Conclusions The treatment was effective in decreasing anger, in this randomized controlled trial of routine clinical practice.

Recent studies have reported that depression is strongly associated with perceptions of defeat and entrapment, and have proposed that such perceptions are central features of depression. This study used experimental mood induction procedures to investigate the putative causal relationship between perceptions of defeat/entrapment and depressed mood. Two groups of female undergraduate volunteers (n = 16) completed visual analogue mood scales, as well as Defeat and Entrapment scales, before and after either a negative or a positive musical mood induction procedure (MIP). Scores on the Defeat and Entrapment Scales were significantly correlated with scores on the Beck Depression Inventory (BDI). The negative MIP caused a worsening of mood and significantly increased perceptions of defeat and entrapment, particularly internal entrapment. The positive MIP caused a small but significant improvement in mood, and significantly decreased defeat scores. Individuals with elevated BDI or internal entrapment scores prio...