A literature review of Cognitive Behavioural Therapy and anxiety in Learning Disabilities- staff training Sabiha Azmi- Lead Clinical Psychologist: BCHC NHS Trust Ioanna Tsimopoulou- Mres Student- University of Birmingham Gemma Unwin- Research Fellow- University of Birmingham FLD Conference -27 th March Llandudno- Wales

Introduction People with LD suffer from mental health problems more often than the general population and anxiety is between the most common disorders (Cooper et al., 2007; Reid et al. 2011; Richards et al. 2001; Smiley 2005). CBT is being used by therapists for its treatment, but there is little evidence on how effective these interventions are (Willner 2005). Staff training is crucial, as it increases their ability to recognize mental health problems that coexist with LD and improves their emotional intelligence (Costello et al.2007; Quigley et al. 2001; Zijlmans et al. 2011). 1. Examine the effectiveness of CBT interventions that are delivered by therapists or staff for people with LD and anxiety. 2. Determine which are the most effective techniques of training staff that works with people with LD and anxiety.

Methodology We searched the following databases: Embase, MEDLINE and PsycINFO Terms related to: LD, CBT, anxiety, staff and staff training. Question 1Question 2 Population: Learning disabilities, adults, anxiety Intervention: CBT Outcomes: effectiveness Study: any study in English from a peer-reviewed journal Population: care staff working with people with LD Intervention: training Outcomes: most effective methods/techniques of training staff Study: any study in English from a peer-reviewed journal

Results 90 records identified through database searching. 76 records after duplicates removed. 76 titles and abstracts screened61 records excluded 15 full texts assessed for eligibility10 records excluded 5 studies includedPlus 2 more studies from cross- referencing 7 studies included No staff-administered CBT intervention for anxiety. The majority of the studies have important methodological limitations and flaws Small number of participants No control group Short-term or no follow-up assessment No masking process or fidelity assessment A. Effectiveness of CBT for adults with LD and anxiety

Results A1. LD and anxiety -Douglass et al., Lindsay, Marwood & Hewitt, 2012 Quantitative VS Qualitative CBT is not effectiveCBT is effective More and of higher quality research is needed!

Results A2. LD and a mixed clinical picture with anxiety and depression or anger -Ghafoori et al., Hassiotis et al., Pert et al., Stenfert Kroese et al., 2013 Qualitative CBT seems to be effective service users staff QuantitativeVS Mixed results The RCT shows no significant decrease in anxiety Generally, there is a difference between the quantitative and the qualitative studies.

Results B. Most effective methods of training staff that works with people with LD and anxiety 120 records identified through database searching. 87 records after duplicates removed. 87 titles and abstracts screened74 records excluded 13 full texts assessed for eligibility13 records excluded 0 studies included A meta-analysis from van Oorsouw et al. (2009) o 55 studies in a period of 20 years

Results B1. Most effective methods of training staff that works with people with LD Goals Format Techniques In service format Coaching-on-the-job format Package of training techniques, with verbal feedback Verbal feedback–corrective, neutral and praise Avoid instructions

Conclusions and recommendations for future research 1.Not much persuading quantitative evidence for the effectiveness of CBT interventions in reducing anxiety in people with LD. RCTs Sensitivity of the existing evaluation tools 2.No staff-administered CBT intervention for anxiety. Development of CBT programmes delivered by staff 3.No study for effective techniques in training staff that works with people with LD and anxiety Identify the most effective methods and techniques Training staff in CBT techniques o Dodd et al. (2013) o Brown & Marshall (2006)

Contact: Dr. Sabiha Azmi unity.nhs.uk Thank you!

Brown, M. and Marshall, K. (2006). Cognitive behaviour therapy and people with learning disabilities: implications for developing nursing practice. Journal of Psychiatric and Mental Health Nursing, 13(2), 234–241. Cooper, S.A., Smiley, E., Morrison, J., Williamson, A. & Allan, L. (2007). Mental ill-health in adults with intellectual disabilities: prevalence and associated factors. The British Journal of Psychiatry, 190, 27–35. Costello, H., Bouras, N. and Davis H. (2007). The Role of Training in Improving Community Care Staff Awareness of Mental Health Problems in People with Intellectual Disabilities. Journal of Applied Research in Intellectual Disabilities, 20(3), 228–235. Dodd, K., Austin, K., Baxter, L., Jennison, J. et al. (2013). Effectiveness of brief training in cognitive-behaviour therapy techniques for staff working with people with intellectual disabilities. Advances in Mental Health and Intellectual Disabilities, 7(5), Douglass, S., Palmer, K., O’Connor, C. (2007). Experiences of running an anxiety management group for people with an intellectual disability using a cognitive behavioural intervention. British Journal of Learning Disabilities, 35(4), 245–252. Ghafoori, B., Ratanasiripong, P., Holladay, C. (2010). Cognitive Behavioral Group Therapy for Mood Management in Individuals With Intellectual Disabilities: A Pilot Study. Journal of Mental Health Research in Intellectual Disabilities, 3(1), Hassiotis, Α., Serfaty, Μ., Azam, Κ., Strydom, Α., Blizard, R., Romeo, R., Martin, S. & King, M. (2013). Manualised Individual Cognitive Behavioural Therapy for mood disorders in people with mild to moderate intellectual disability: A feasibility randomised controlled trial. Journal of Affective Disorders, 151(1), 186–195. Lindsay, W. (1999). Cognitive therapy. The psychologist, 12, Marwood, H. and Hewitt, O. (2012). Evaluating an anxiety group for people with learning disabilities using a mixed methodology. British Journal of Learning Disabilities, 41(2), 150–158. Pert, C., Jahoda, A., Stenfert Kroese, B., Trower, P., Dagnan, D. & Selkirk, M. (2013). Cognitive behavioural therapy from the perspective of clients with mild intellectual disabilities: a qualitative investigation of process issues. Journal of Intellectual Disability Research, 57(4), 359–369. Quigley, A., Murray, G. C., McKenzie, K. and Elliot, G. (2001). Staff knowledge about symptoms of mental health problems in people with learning disabilities. Journal of Learning Disabilities, 5(3), Reid, K.A., Smiley, E. & Cooper, S.A. (2011). Prevalence and associations of anxiety disorders in adults with intellectual disabilities. Journal of Intellectual Disability Research, 55(2), Richards, M., Maughan, B., Hardy, R., Hall, I., Strydom, A., Wadsworth, M. (2001).Long-term affective disorder in people with mild learning disability. British Journal of Psychiatry, 179, 523–527. References

Smiley, E. (2005). Epidemiology of mental health problems in adults with learning disability: an update. Advances in Psychiatric Treatment, 11, 214–222. Stenfert Kroese, B., Jahoda, A., Pert, C., Trower, P., Dagnan, D. & Selkirk, M. (2013). Staff Expectations and Views of Cognitive Behaviour Therapy (CBT) for Adults with Intellectual Disabilities. Journal of Applied Research in Intellectual Disabilities. van Oorsouw, W.M.W.J., Embregts, P.J.C.M., Bosman, A.M.T. and Jahoda, Α. (2009). Training staff serving clients with intellectual disabilities: A meta- analysis of aspects determining effectiveness. Research in Developmental Disabilities, 30(3), 503–511. Willner, P. (2005). The effectiveness of psychotherapeutic interventions for people with learning disabilities: a critical overview. Journal of Intellectual Disability Research, 49(1), Zijlmans, L. J. M., Embregts, P. J. C. M., Gerits, L., Bosman, A. M. T. & Derksen, J. J. L. (2011). Training emotional intelligence related to treatment skills of staff working with clients with intellectual disabilities and challenging behaviour. Journal of Intellectual Disability Research, 55(2), 219–230.