A Randomized Controlled Trial of the Efficacy of a Cognitive‐Behavioural Anger Management Group for Clients with Learning Disabilities

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.     

Community‐based Residential Supports for People with Intellectual Disabilities and Challenging Behaviour: The Views of Neighbours

Background The issue of the views of neighbours of community‐based residential supports for people with intellectual disabilities and challenging behaviour has not been examined till date. This study looks at the views of neighbours of two types of community‐based residential supports: non‐congregate settings where the minority of residents have challenging behaviour; and congregate settings where the majority of residents have challenging behaviour. Materials and methods A self‐completion questionnaire was used to collect information on contact between neighbours, residents and staff, and the views of neighbours. Information was also collected by semi‐structured interview with service staff on the characteristics of settings. Results Sixty‐four questionnaires were returned. Contact between neighbours and service users was limited for both types of setting, with two‐thirds of neighbours not knowing any service users by name, and a third having had no active contact with service users. Neighbours of non‐congregate settings were more likely to think that community care was a ‘good policy’ (76%) than neighbours of congregate settings (53%) and to believe that there were benefits to the neighbourhood from having the group home in the area (46% versus 29%) but these differences were not significant. Contact with people with intellectual disabilities was associated with more positive attitudes to community care and specific characteristics of the settings. Conclusions Contact between neighbours and people with severe intellectual disabilities and challenging behaviour is limited. However, the majority of neighbours are positive about community care and the problems reported by neighbours are predominantly minor. The results point to the key role that contact plays in fostering positive attitudes. Findings regarding differences between congregate and non‐congregate settings are limited by the small number of responses from neighbours of congregate settings.     

Indicators of choking risk in adults with learning disabilities: a questionnaire survey and interview study

Purpose. Feeding and swallowing impairments are key predictors of increased morbidity and mortality in adults with learning disabilities. This postal survey and interview study sought to identify risk factors in adults with learning disabilities who have histories of choking. Method. A total of 2000 questionnaires were sent to carers of all adults with learning disabilities registered as service users by three local health authorities. (A 'service user' may be using any specialist learning disability health or social care facility with day, residential or therapeutic services). Of the 674 service users for whom surveys were returned, 47 were living in hospital, 396 were living in residential or group homes and 208 were living with relatives, or in their own homes. Eighteen subjects who had reported serious or repeated episodes of choking were interviewed in depth in their residences or workplaces. Responses were subjected to frequency analyses. Personal characteristics were analysed. Choking patterns were differentiated by food texture. Results. A total of 34% of questionnaires on 674 service users were returned; 42% of respondents reported one or more choking episodes. There was a significantly greater occurrence of choking among people with more severe learning disability, with Down syndrome, people who had an incomplete dentition or were taking a greater number of psychotropic drugs. Antisocial eating habits learnt in institutional settings presented an additional choking hazard for some individuals. Conclusion. Choking is a serious hazard for many adults with learning disabilities. This study establishes many of the characteristics associated with swallowing problems in this population. Clinicians and carers should benefit from awareness of these predictors, leading to better management of eating behaviours and habits. A choking and swallowing risk assessment should be included in routine health assessments of adults with learning disability, paying especial attention to the condition of a person's teeth; possible side effects from prescribed medication, and abnormal eating behaviour.     

Indicators of choking risk in adults with learning disabilities: A questionnaire survey and interview study

Purpose.?Feeding and swallowing impairments are key predictors of increased morbidity and mortality in adults with learning disabilities. This postal survey and interview study sought to identify risk factors in adults with learning disabilities who have histories of choking.

Method.?A total of 2000 questionnaires were sent to carers of all adults with learning disabilities registered as service users by three local health authorities. (A ‘service user’ may be using any specialist learning disability health or social care facility with day, residential or therapeutic services). Of the 674 service users for whom surveys were returned, 47 were living in hospital, 396 were living in residential or group homes and 208 were living with relatives, or in their own homes. Eighteen subjects who had reported serious or repeated episodes of choking were interviewed in depth in their residences or workplaces. Responses were subjected to frequency analyses. Personal characteristics were analysed. Choking patterns were differentiated by food texture.

Results.?A total of 34% of questionnaires on 674 service users were returned; 42% of respondents reported one or more choking episodes. There was a significantly greater occurrence of choking among people with more severe learning disability, with Down syndrome, people who had an incomplete dentition or were taking a greater number of psychotropic drugs. Antisocial eating habits learnt in institutional settings presented an additional choking hazard for some individuals.

Conclusion.?Choking is a serious hazard for many adults with learning disabilities. This study establishes many of the characteristics associated with swallowing problems in this population. Clinicians and carers should benefit from awareness of these predictors, leading to better management of eating behaviours and habits. A choking and swallowing risk assessment should be included in routine health assessments of adults with learning disability, paying especial attention to the condition of a person's teeth; possible side effects from prescribed medication, and abnormal eating behaviour.     

Attention management as a treatment for chronic pain

Attention management is often included in cognitive‐behavioural treatments (CBT). The aim of this study was to evaluate the effects of attention management strategies in the treatment for chronic pain. The present pilot study consisted of six weekly 90‐min treatment sessions and was based on a CBT attention management manual describing techniques such as attention diversion, imagery and mindfulness exercises. The intended outcomes were reduction in pain‐related anxiety and hypervigilance to pain and decrease in pain impact of everyday life, measured by self‐report. Information was collected at baseline, pre‐treatment, post‐treatment, and at 3 and 6 months follow‐up. The results at the end of treatment, and at 3‐month follow‐up, show significant reductions in pain‐related anxiety, hypervigilance and interference of pain (effect sizes 0.40–0.90). Reduction in pain‐related interference and anxiety remained at the 6‐month follow‐up. The results indicate that attention control skills can be a useful method to reduce anxiety in the short term. Clinical implications of the results are discussed.     

Mainstream In‐Patient Mental Health Care for People with Intellectual Disabilities: Service User,Carer and Provider Experiences

Background Government guidelines promote the use of mainstream mental health services for people with intellectual disabilities whenever possible. However, little is known about the experiences of people with intellectual disabilities who use such services. Materials and Methods Face‐to‐face interviews with service users, carers and community nurses were completed and analysed on a case by case basis using interpretative phenomenological analysis. The results were followed up in focus groups with service providers. Results Positive aspects included the provision of respite, particularly for carers, and good basic care. These were outweighed by a perception of the admission as disempowering and lacking in flexible treatment provision. Accessing help emerged as a major problem, as well as the prospect of staff neglecting the specific needs of people with intellectual disabilities. Conclusions While there were some indications of improvements in line with recent policies and guidance, mainstream services seem a long way off realizing aims of easy accessibility, person‐centred practices and active partnership with intellectual disability services.     

Spouse‐assisted training in pain coping skills and the outcome of multidisciplinary pain management for chronic low back pain treatment: A 1‐year randomized controlled trial

This study examined the comparative efficacy of three interventions: a spouse‐assisted coping skills training protocol for patients undergoing a multidisciplinary pain management programme (SA‐MPMP), conventional patient‐oriented multidisciplinary pain management programme (P‐MPMP) and standard medical care (SMC). Thirty‐six chronic low back pain (CLBP) patients and their spouses were randomly assigned to one of the three conditions. The SA‐MPMP condition consisted of seven, weekly, 2‐h, group sessions of training in dyadic pain coping and couple skills, delivered by a clinical psychologist with support of a multidisciplinary team of specialists, to patients together with their spouses. P‐MPMP consisted of the SA‐MPMP training delivered to the patient only (i.e., no spouse participation and assistance). The SMC condition entailed continuation of routine treatment, entailing medical care only. Data analysis revealed that, at the 12‐month follow‐up time point, patients receiving SA‐MPMP had significant improvements in kinesiophobia and rumination about pain compared to those receiving P‐MPMP and SMC. In patients suffering from CLBP, an intervention that combines spouse‐assisted coping skills training with a multidisciplinary pain management programme can improve fear of movement and rumination about low back pain.     

End‐of‐Life Care for People with Intellectual Disabilities: Paid Carer Perspectives

Background Little is known of paid carers’ perspectives when caring for people with intellectual disabilities at the end‐of‐life. Materials and methods Sixty four individuals from intellectual disability services took part in 12 focus groups. Interviews were analysed using framework analysis. Results Participants wanted to provide palliative care and felt the experience enriched practice. However, they were inadequately prepared to meet need and this often led to staff stress. A number of issues appeared to heighten stress: situations when end‐of‐life care decision making was challenging, when staff felt ‘pushed out’ by relatives and when staff did not have sufficient support or time to provide care or mourn the loss of service users. Conclusions The study describes issues which contribute to the development of staff stress when providing palliative care and draws attention to areas where strategies should be developed in order to improve the quality of care provided to people with intellectual disabilities.     

Service Use and Costs of Support 12 Years after Leaving Hospital

Background There have been major changes in the provision and organization of services for people with intellectual disabilities in England over the last 30 years, particularly deinstitutionalization and the development of the mixed economy of care. The experiences of the people who participated in the Care in the Community Demonstration Programme in the mid‐1980s provide evidence of the immediate and longer‐term effects of the reprovision policy. Methods Cross‐sectional and longitudinal evidence was gathered on service use and costs for over 250 people 12 years after they left long‐stay hospitals for community living arrangements. Comparisons were made with the situation in hospital, and 1 and 5 years after leaving. Relationships between costs after 12 years and individual characteristics assessed before people left hospital were explored. Results Community care at the 12‐year follow‐up remained more expensive than hospital‐based support, although the average cost was lower than at either of the 1‐ or 5‐year community follow‐up points. Service users were living in a wide variety of accommodation settings. Management responsibility fell on National Health Service (NHS) trusts, local authorities, voluntary agencies, or to private organizations or individuals. After standardizing for users’ skills and abilities, costs in minimum support accommodation were significantly lower than those in residential and nursing homes, costs in staffed group homes significantly higher, and costs in hostels slightly lower. When looking at differences between individuals, no relationship was found between costs and outcomes although, overall, people were better off in the community than they had been when in hospital. Conclusions Reprovision planning for hospital and other institutional modes of care requires major and long‐term commitment of resources. Quality of life improvements can be achieved at a cost little different in the long‐run from that for hospital care. The link between needs and costs (reflecting the services intended to meet those needs) would be made stronger through the individualization of care.     

Women be Healthy: Evaluation of a Women's Health Curriculum for Women with Intellectual Disabilities

Background Insufficient attention has been paid towards treating the unique health needs of women with intellectual disabilities. This paper describes an 8‐week curriculum, ‘Women Be Healthy’, developed for women with intellectual disabilities to help them become more equal partners in their health care. The curriculum includes psycho‐education, coping skills training, exposure to the medical setting and assertiveness training. Materials and methods Twenty‐two women completed assessments of health knowledge, health behaviour beliefs and coping strategies, prior to and following participation in the 8‐week curriculum, which took place in a group setting at a clinic for people with intellectual disabilities. Results Women showed significant improvements in health knowledge, health behaviour beliefs and coping strategies following intervention, and maintained some of these treatment gains (health knowledge and health behaviour beliefs) at a 10‐week follow‐up. Conclusions ‘Women Be Healthy’ is an example of a group‐based intervention that helps women with intellectual disabilities become more knowledgeable and perhaps more comfortable with health‐care procedures.     

Telephone survey of service‐user experiences of a telephone‐based mental health triage service

The participation of service users in all aspects of mental health service delivery including policy development, service planning and evaluation is increasingly an expectation of contemporary mental health care. Although there are a growing number of publications reporting service‐user perspectives in the evaluation of mental health services, little attention has been paid to the views of service users about mental health triage services. The purpose of the study reported here was to examine service‐users' (consumers and informal carers) experiences of a telephone‐based mental health triage service. Using a framework developed from the World Health Organisation's elements of responsiveness, we conducted structured telephone interviews with service users who had contacted a telephone‐based mental health triage service in regional Victoria, Australia. The main findings of the study were that consumers experienced more difficulty than carers in accessing the service and that, although most participants were satisfied, only a minority reported being involved in decision‐making. Further work is needed to improve accessibility of mental health triage services and to investigate barriers to consumer self‐referral. Professional development and practice support systems should be established to support mental health triage nurses in the development of collaborative, consumer‐focused care.     

Lay Trainers With Migraine for a Home‐Based Behavioral Training: A 6‐Month Follow‐Up Study

Objective.— To evaluate the changes at 6‐month follow‐up after a home‐based behavioral training (BT) provided by lay trainers with migraine to small groups of fellow patients. Background.— The need for self‐management programs and cost‐effective treatments gave rise to this study. Methods.— In a previous randomized controlled trial, we compared the BT group with a waitlist‐control group, receiving usual care. The control group was trained directly after their waitlist period. The present study examined the follow‐up results in both groups and measurements were held pre BT, post BT, and at 6‐month follow‐up. Results.— Six months after BT, 42% was categorized as responders (≥?50% decrease in attack frequency), 42% did not change (?49 to 49%), and 16% responded adversely (≥50% increase). In the group as a whole (n = 95), attack frequency significantly decreased from 3.0 attacks at baseline to 2.5 post BT and to 2.3 at 6‐month follow‐up (?23%, medium effect size 0.6). The strong improvements of perceived control over and self‐confidence in attack prevention were maintained at follow‐up. Disability and health status were unchanged but quality of life significantly improved over time (P = .007). BT was more beneficial for patients who entered the training with a high attack frequency. Linear regression analysis demonstrated that a stronger belief at baseline that the occurrence of migraine is due to chance (external control) significantly predicted a lower attack frequency at follow‐up. Conclusion.— Lay trainers with migraine can train small groups of fellow patients at home in behavioral attack prevention. At 6‐month follow‐up, attack frequency and quality of life were significantly but modestly improved and feelings of control and self‐confidence remained strongly improved.     

Cognitive‐Behavioral Therapy: How Medical Providers Can Increase Patient and Family Openness and Access to Evidence‐Based Multimodal Therapy for Pediatric Migraine

Although evidence supports the recommendation for cognitive‐behavioral therapy (CBT) for pediatric migraine, few children actually receive this evidence‐based intervention. In this article, we briefly review the most recent empirical evidence supporting CBT. We then identify both provider‐ and system‐related barriers as well as patient‐related barriers. Finally, we provide practical solutions to addressing these barriers in the service of facilitating children receiving optimal comprehensive management of their headaches.     

Service User Outcomes of Staff Training in Positive Behaviour Support Using Person‐Focused Training: A Control Group Study

Background Effectively supporting individuals with intellectual disabilities who display challenging behaviours continues to be a priority for service providers. Person‐focused training (PFT) is a model of service delivery which provides staff with skills in functional assessment and intervention development. Existing longitudinal data from a study of 138 cases suggest that implementation of staff‐developed behaviour support plans through PFT is effective in reducing challenging behaviour in approximately 77% of cases [McClean et al.Journal of Intellectual Disability Research (2005) vol. 49, pp. 340–353]. However, no control group was used in this study. Method The current study involves the use of a control group of individuals with challenging behaviours matched against those selected for PFT over a 6‐month period. Groups were matched on type of challenging behaviour, duration of challenging behaviour, gender and level of disability. Information on the frequency, management difficulty and severity of challenging behaviour was collected pre‐ and post‐training using the Checklist of Challenging Behaviours (CCB) for both groups. Observational data were collected for the target group alone. Rates of psychotropic medication were tracked across the training period. Results Significant reductions in the frequency, management difficulty and severity of challenging behaviour were found for service users in the target group but not in the control group after 6 months. No significant changes were found in the use of psychotropic medication for either group over the 6‐month period. Conclusion Overall results suggest that PFT is an effective model for providing support to individuals with challenging behaviours.     

Cognitive–Behavioural Treatment of Anger Intensity among Offenders with Intellectual Disabilities

Background Aggressive behaviour has been identified as a significant problem amongst people with intellectual disabilities living in institutional settings. Anger is a key activator of aggressive behaviour, as well as being an important element of clinical distress related to adverse life experiences. There is some evidence for the value of cognitive–behavioural treatments for anger problems with people having intellectual disabilities. No controlled studies of anger treatment involving intellectually disabled offenders living in secure settings have been conducted to date. A pilot study of an elaborated anger treatment protocol for this client population was undertaken, comparing the specialised anger treatment with routine care. Methods Detained men with intellectual disabilities and histories of offending were allocated to specially modified cognitive–behavioural anger treatment (n = 9) or to routine care waiting‐list control (n = 10) conditions. Eighteen sessions of individual treatment were delivered over a period of 12 weeks. Treatment outcome was evaluated by participants' self‐report of anger intensity to an inventory of provocations and by staff‐ratings of the anger attributes of participants' ward behaviour. Results Participants' reported anger intensity was significantly lower following the anger treatment, compared to the routine care wait‐list condition. There were largely no treatment condition effects in staff‐rated anger. Limited evidence for the effectiveness of anger treatment was provided by the staff ratings of participant behaviour post‐treatment. Conclusions Detained offenders with intellectual disabilities can benefit from intensive individual cognitive–behavioural anger treatment. Further research is required to examine the mechanisms for change and their sustainability.     

Staff Morale in Day Care Centres for Adults with Intellectual Disabilities

Background Levels of burnout, job satisfaction and intended turnover of staff working in day care centres for adults with intellectual disabilities are investigated in relation to role clarity, staff support and supervision, and coping strategies used by staff. Materials and methods Thirty six direct‐care staff of four day care centres in the UK were administered the Maslach Burnout Inventory, The Staff Support Questionnaire (SSQ), and The Shortened Ways of Coping (Revised) Questionnaire (SWC‐R). Results Although staff reported high levels of job satisfaction, they experienced moderate degrees of emotional exhaustion and personal accomplishment and reported a high propensity to leave the service. Factors identified as relating to staff morale were staff support and supervision, role clarity, wishful thinking, staff cooperation, and other practical issues regarding the day‐to‐day running of the service. Conclusions Staff in day care services for people with intellectual disabilities experience similar stressors to those experienced by staff in residential facilities with the informal culture of the service being of most importance to staff morale. Suggestions for the enhancement of staff morale are provided.     

Enhancing the Emotion Recognition Skills of Individuals With Learning Disabilities: A Review of the Literature

Background It has been repeatedly demonstrated that individuals with intellectual disabilities experience significant difficulties in recognizing facial expressions of emotion. The aim of this review was to address whether such skills can be enhanced amongst individuals with intellectual disabilities. Materials and Methods The PsychInfo database on Dialog DataStar (1972–2006) was searched for all published journal articles investigating whether emotion recognition skills can be enhanced amongst individuals with intellectual disabilities. Results Four relevant articles were identified. Training in emotion recognition skills resulted in improvements in all four studies, with one study maintaining improvements at 8‐month follow‐up. Conclusions The four published studies identified that emotion recognition skills can be enhanced and maintained over time. Despite claims in the literature that training in emotion recognition skills will enhance the social skills of individuals with intellectual disabilities, none of the studies considered the impact of training upon everyday functioning, leaving the ultimate efficacy of such training open to question.     

Evaluating a Survivors Group Pilot for Women with Significant Intellectual Disabilities who have been Sexually Abused

Background Sexual abuse has been associated with trauma, low self‐esteem, anger, depression and challenging behaviours. This pilot study builds on a small published literature by evaluating a survivors group (SG) for women with an intellectual disability and an educational support group (ESG) for their carers. Method The SG was delivered weekly over 5 months for 20 sessions and the ESG ran concurrently for their seven carers in a separate room within the same community‐based building. Participants were helped to build trust and rapport, provided with education about sexual abuse designed for their level of ability, and helped to reprocess the trauma of their sexual abuse. Results Both the SG and the ESG were evaluated using a repeated‐measures design (double baseline, mid‐treatment, post‐treatment and follow up), to see whether there was any improvement in relevant clinical dependent variables associated with the consequences of sexual abuse (i.e. trauma, self‐esteem, anger, depression and challenging behaviour). Improvements occurred in sexual knowledge, trauma and depression. Neither self‐esteem nor anger improved for most of the SG and challenging behaviour worsened at first before improving. Conclusions The SG seemed to be successful in improving sexual knowledge and in reducing trauma and depression, although challenging behaviours worsened at first before improving. There is a need for more sexual abuse/sexual education groups for men and women with intellectual disabilities.