1. The Role of the Learning Disability Clinical Psychologist Dr Alex Clark, Clinical Psychologist West Cornwall Community Learning Disability Team & Intensive Support Team Alex.Clark@cft.cornwall.nhs.uk

2. Aspects of the Role  Assessment  Formulation  Intervention - Service Users - Staff - The MDT  Consultation & Training  Service Development

3. Assessment  What is a Learning Disability? & Eligibility assessments (NOT just an IQ score!)  Functional Behavioural Analysis – observations, ABCs, interviewing - supervision and training  Specialist Assessment e.g. capacity/risk assessment (violence/sexual offending)/parenting.  Psychological assessment – e.g. neuropsychological, systemic, attachment/relational history.

4. Historical Context to Learning Disability  Many terms been used over the last 200 years (idiocy, feeblemindedness, mental deficiency, mental disability, mental handicap, mental subnormality, mental retardation)  Now: UK: Learning Disability US: Intellectual Disability

5. World Health Organisation and American Psychiatric Association definition of Learning Disability There are three core criteria:  Significant impairment of intellectual functioning  Significant impairment of adaptive/social functioning  Age of onset is before adulthood

6. Process of Learning Disability Assessment  Referral  Clinical Interview Consent Ethical considerations including current context Background information  Biological, psychological and social contexts  Psychometric Assessment (order decided by the person) Adaptive Behaviour Assessment System 2 nd Edition Weschler Adult Intelligence Scale- 4 th edition (new)  Report or letter written ideally with the client as the primary audience but considerations around other audience members.

7. Defining ‘Significant Impairment’  Both Intelligence and Adaptive/Social functioning have standardised measures, with a mean of 100 and 1 standard deviation of 15  Significant impairment = 2 standard deviations from the mean which equates to 70 or less, the lowest 2.2% of the general population  Working backwards this would mean that between 2% of the population have a learning disability, actually worked out as 2-3% of population 34% 2% Y axis (% of population) X axis (Scores) 100 8570115130 14% 34%

8. WAIS - IV UK  13 subtests assessing different aspects of the construct of ‘Intelligence’  Scores then compared with a general population providing: Full Scale IQ Verbal Comprehension Index Perceptual Organisation Index Working Memory Index Processing Speed Index

9. Significant impairment of adaptive/social functioning  Definition of adaptive/social functioning relates to a person’s performance in coping on a day to day basis with the demands of their environment  American Association on Mental Retardation (1992) further defined as impairments in at least two of the following:  Communication  Self care  Home living  Social Skills  Health and Safety  Community Use  Functional Academics  Work (if in a job)  Leisure  Self direction

10. Adaptive Behaviour Assessment System (ABAS II)  Scores then compared with a general population providing: General Adaptive Composite (GAC) Conceptual Composite (Communication, Functional Academics, Self Direction) Social Composite (Leisure, Social) Practical Composite (Community Use, Home Living, Health and Safety, Self Care, Work)  Significant Impairment is: a GAC of <70, one of the other Composite scores <70, or significant difficulty in 3 or more of the specific skill areas

11. Age of Onset  It is important that any significant impairments of intellectual and adaptive/social functioning occur before adulthood  Thus forming part of a developmental process (i.e. developmental disability)  General consensus is that this is before the person turns 18 years old  Therefore important that a developmental history be taken to provide context, including: Birth and pre birth information Developmental milestones and concerns about not achieving milestones Childhood diagnoses / illnesses School experiences / Statement of Educational Need Changes in ability during adulthood due to other events (e.g. head injury, dementia, mental health problems, reactions to medication etc)

12. Formulation  The 4 P’s –Predisposing, Precipitating, Perpetuating, Protective factors  Models of formulation – psychodynamic (Malan), systemic, CBT  Consulting to the system re: formulation

13. Intervention for Service Users- Aims of psychotherapy  The therapeutic relationship – establishing, maintaining and repairing  Meaning making – offering an explanatory framework/narrative to help the client make sense of their difficulties  Change promotion – acquiring new skills and trying them out in therapy and real life (e.g. how to repair relationship, experiencing oneself as different)

14. Intervention – Service Users  Cognitive Behavioural - thoughts, feelings, behaviour, beliefs and schemas (Stenfert Kroese, Dagnan, Willner)  Psychoanalytic – unconscious, transference, tactical defences, object relations (Beail, Sinason, Frankish)  Attachment – security and safety, exploration, internal working models, loss & separation (Holmes)  Systemic/Family Therapy – circularity, curiosity, homeostasis, family life cycle (Baum)  Social Constructionist – inequality, social structures, community psychology

15. Adaptations of Psychotherapy for people with Learning Disabilities  Pre-assessment re: cognitive level of understanding, TBF assessment (Reed & Clements), emotional awareness, labelling of emotions  Language use - person centred approach  Use of visual supports (photos, pictures, signing, availability of materials)  Level of directiveness (e.g. ASD)  Negotiation re: others’ presence  Communication with systems (family, staff teams)

16. Interventions-Staff Team  Formulation-co-construction and discussion  Training and consultation re: behavioural assessment/care planning/interventions (e.g. ASD & communication)  Systemic working to encourage team’s reflection around relationships with service user(s) and conflicts, considering emotional needs of staff

17. Interventions-The MDT  Reflective Practice sessions – “stuck” situations, team difficulties, emotional support  MDT meetings - encouraging reflection on service users’ relational and psychological context in considering mood and behaviour  Consultation role

18. Any questions?