Putting the usability of wearable technology in forensic psychiatry to the test: a randomized crossover trial.

Introduction: Forensic psychiatric patients receive treatment to address their violent and aggressive behavior with the aim of facilitating their safe reintegration into society. On average, these treatments are effective, but the magnitude of effect sizes tends to be small, even when considering more recent advancements in digital mental health innovations. Recent research indicates that wearable technology has positive effects on the physical and mental health of the general population, and may thus also be of use in forensic psychiatry, both for patients and staff members. Several applications and use cases of wearable technology hold promise, particularly for patients with mild intellectual disability or borderline intellectual functioning, as these devices are thought to be user-friendly and provide continuous daily feedback. Method: In the current randomized crossover trial, we addressed several limitations from previous research and compared the (continuous) usability and acceptance of four selected wearable devices. Each device was worn for one week by staff members and patients, amounting to a total of four weeks. Two of the devices were general purpose fitness trackers, while the other two devices used custom made applications designed for bio-cueing and for providing insights into physiological reactivity to daily stressors and events. Results: Our findings indicated significant differences in usability, acceptance and continuous use between devices. The highest usability scores were obtained for the two fitness trackers (Fitbit and Garmin) compared to the two devices employing custom made applications (Sense-IT and E4 dashboard). The results showed similar outcomes for patients and staff members. Discussion: None of the devices obtained usability scores that would justify recommendation for future use considering international standards; a finding that raises concerns about the adaptation and uptake of wearable technology in the context of forensic psychiatry. We suggest that improvements in gamification and motivational aspects of wearable technology might be helpful to tackle several challenges related to wearable technology.

Factors affecting the feelings of safety among individuals with mild intellectual disabilities and severe challenging behaviour in residential care: A qualitative study of professional and service users' perspectives.

Background: This study focuses on what feeling safe means for people with mild intellectual disabilities and severe challenging behaviour, and which factors affect their sense of safety. Method: Thematic analysis was used to analyse data collected during (1) ethnographic longitudinal research and (2) interviews and focus groups among professionals and service users. Results: Feelings of safety can relate to three main themes: (1) a physical environment that reduces risks and temptations; (2) a reliable, predictable, and supportive environment; and (3) an accepting environment that enables service users to establish a normal life. An analysis of which factors affect service users' sense of safety identified 20 themes (e.g. team climate) and 34 subthemes (e.g. interactions with other service users). Conclusions: A range of interconnected factors can affect service users' feelings of safety. Future research should explore what organisations and external actors (e.g. the police) can do to promote those feelings.

Cultural and Religious Equity and Disparity in the Group Climate Experience of Moroccan Girls in Dutch Residential Youth Care Settings.

BACKGROUND: The group climate within residential youth care institutions is considered a transactional process, both within a group of youth from various cultural backgrounds and between them and their group workers. The ongoing interaction between the cultural characteristics of these girls may influence the quality of the group climate. This study aimed to provide an in-depth account of the living group climate experiences and perceptions of Dutch girls with a Moroccan cultural background in Dutch residential groups. METHOD: Interpretative phenomenological analysis was employed to explore the girls' group climate experiences. RESULT: Three major themes emerged, namely (a) level of involvement of Moroccan girls in their living group, (b) perceptions of Moroccan girls' sense of belonging in a living group, and (c) cultural and religious equality or disparity results in two interaction patterns. The findings revealed that equality or disparity in language, culture, and religion affect Moroccan girls' experiences and perceptions of the living group climate. A crucial finding was that cultural and religious disparity leads to interaction patterns wherein the girls pre-emptively exclude themselves from receiving support from native group workers. CONCLUSION: Professionals must be aware of the cultural and religious dynamics, including the interplay and impact of cultural and religious equality and disparity, influencing Moroccan girls' group climate experiences.

Dog-Assisted Therapy in Mental Health Care: A Qualitative Study on the Experiences of Patients with Intellectual Disabilities.

(1) Background: Dog-assisted therapy (DAT) is an experiential intervention to promote psychological, physical, and social functioning in children and adults. Only few studies have been conducted on DAT in adults with a mild intellectual disability or borderline intellectual functioning (MID-BIF). The purpose of this study was to explore the experiences of patients with MID-BIF undergoing DAT in a mental health care facility. (2) Method: Seven patients completed 13 to 15 sessions of DAT. Within two weeks of completing the program, they were interviewed using a semi-structured interview. The transcripts of the interviews were analysed using interpretational phenomenological analysis. In addition, the patients' relatives and the DAT therapist were interviewed, and a focus group discussion took place with each patient's treatment team. (3) Results: The patients' experiences were predominantly positive. Physical contact with the dog calmed them down. The dog offered them emotional support and helped them to make contact inside and outside the therapy and the setting where they lived. The patients also liked the fact that DAT focused on the dog rather than their problems, that the therapy was experiential and using a positive approach, and that, during the therapy, they did not feel like a patient but a human being. DAT is a promising therapy for patients with MID-BIF in mental health care facilities, but more research into its effectiveness and cost-effectiveness and ways to implement DAT in clinical practice is needed to make more definitive statements.

Evaluating the Effectiveness of Take it Personal!+ in People With Mild Intellectual Disability or Borderline Intellectual Functioning and Substance Use Disorder: A Multiple Baseline Single-Case Experimental Study.

Individuals with mild intellectual disabilities or borderline intellectual functioning are at increased risk to develop a substance use disorder-however, effective treatment programs adapted to this target group are scarce. This study evaluated the effectiveness of Take it Personal!+ in individuals with mild intellectual disabilities or borderline intellectual functioning and substance use disorder. Take it Personal!+ is a personalized treatment based on motivational interviewing and cognitive-behavioral therapy supported by an mHealth application. Data were collected in a nonconcurrent multiple baseline single-case experimental design across individuals with four phases (i.e., baseline, treatment, posttreatment, and follow-up). Twelve participants were randomly allocated to baseline lengths varying between 7 and 11 days. Substance use quantity was assessed during baseline, treatment, and posttreatment with a daily survey using a mobile application. Visual analysis was supported with statistical analysis of the daily surveys by calculating three effect size measures in 10 participants (two participants were excluded from this analysis due to a compliance rate below 50%). Secondary, substance use severity was assessed with standardized questionnaires at baseline, posttreatment, and follow-up and analyzed by calculating the Reliable Change Index. Based on visual analysis of the daily surveys, 10 out of 12 participants showed a decrease in mean substance use quantity from baseline to treatment and, if posttreatment data were available, to posttreatment. Statistical analysis showed an effect of Take it Personal!+ in terms of a decrease in daily substance use in 8 of 10 participants from baseline to treatment and if posttreatment data were available, also to posttreatment. In addition, data of the standardized questionnaires showed a decrease in substance use severity in 8 of 12 participants. These results support the effectiveness of Take it Personal!+ in decreasing substance use in individuals with mild intellectual disabilities or borderline intellectual functioning.

Measurement invariance of the group climate inventory across adults with and without mild intellectual disability in secure residential facilities.

BACKGROUND: The Group Climate Inventory (GCI) was tested for measurement invariance across 332 adults with and 225 adults without mild intellectual disabilities in Dutch forensic treatment, and for latent mean differences on its Support, Growth, Repression, and Atmosphere subscales. METHOD: Multigroup confirmatory factor analysis was used to evaluate the configural, threshold, and loading and threshold invariance of the GCI across both groups, and to compare group latent means on each subscale. RESULTS: Measurement invariance was found across groups. Latent mean group comparisons showed small but significant differences reflected in lower scores on Support and Atmosphere in the group with mild intellectual disabilities. CONCLUSION: The GCI allows meaningful comparisons between clients with and without mild intellectual disabilities in secure facilities. Results from the between-group comparisons suggest that consideration should be given as to whether, and why, the support and atmosphere perceptions of clients with mild intellectual disabilities might be less good.

Qualitative Analysis of Severe Incidents in Forensic Psychiatric Hospitals: Toward a Model of Forensic Vigilance.

Forensic vigilance is a hypothesized specialty of forensic mental health professionals which seems to play a role in maintaining safety in forensic hospitals. It is unclear exactly how forensic vigilance relates to preventing incidents. We used standardized reports of severe incidents that occurred in forensic hospitals to investigate how forensic vigilance plays a role in the occurrence of incidents. Eight forensic psychiatric hospitals in the Netherlands contributed 69 anonymized incident reports, which were investigated by means of thematic analysis and interpretative phenomenological analysis. Analysis revealed five important themes. Four core skills needed by professionals, namely observation, integration, communication and action, which each need a number of prerequisites (e.g., knowledge). The fifth theme specifies that the professional needs to "connect the dots" meaningfully. This is a highly cyclical process in which the core four skills are steps. The process is unique to the forensic context in terms of how the "dots" are connected and weighed, and which risks need to be considered. We present a model of this process and prerequisites needed in professionals. This model can inform policy makers, aid assessment of and communication between forensic professionals and can form the basis of a training for forensic mental health professionals.

The adaptive ability performance test (ADAPT): A factor analytic study in clients with intellectual disabilities.

BACKGROUND: The adaptive ability performance test (ADAPT) was developed to assess adaptive skills in individuals with intellectual disabilities and borderline intellectual functioning, with or without mental disorders. As a follow-up to earlier research on the ADAPT, a factor analytic study was conducted. METHOD: One thousand and sixty six ADAPTs from clients with (suspected) intellectual disabilities or borderline intellectual functioning and 129 ADAPTs from participants from the general population were collected along with other characteristics (e.g., IQ, psychiatric classifications, living situation). RESULTS: An exploratory factor analysis (EFA) was performed and resulted in good fit indices. Subsequent confirmatory factor analysis (CFA) and multigroup CFA showed acceptable to good fit indices. This resulted in an instrument with eight factors and 62 items. CONCLUSION: Factor analytic results suggest that the ADAPT is a valid instrument that measures adaptive skills in individuals with intellectual disabilities or borderline intellectual functioning.

Dietary supplements for aggressive behaviour in people with intellectual disabilities: A randomised controlled crossover trial.

BACKGROUND: Aggressive incidents are common in people with intellectual disabilities. Therefore, we aimed to assess whether supplementation of multivitamins, minerals, and omega-3 fatty acids (FA) reduces aggressive incidents. METHODS: We conducted a randomised, triple blind, placebo controlled, single crossover intervention trial. People with intellectual disabilities or borderline intellectual functioning, between 12 and 40 years of age, and showing aggressive behaviour were included. Participants received either a daily dose of dietary supplements, or placebo. Primary outcome was the number of aggressive incidents, measured using the Modified Overt Aggression Scale (MOAS). RESULTS: there were 113 participants (placebo, n = 56), of whom 24 (placebo, n = 10) participated in the crossover phase of the trial. All 137 trajectories were included in the analyses. There was no significant difference in mean number of aggressive incidents per day between those assigned to supplements and those who received placebo (rate ratio = 0.93: 95% Confidence Interval [CI] = 0.59-1.45). CONCLUSION: In this pragmatic trial, we did not find significant differences in the outcomes between the supplement and placebo arms. The COVID-19 pandemic started midway through our trial, this may have affected the results.

Setting up a new team of support staff for people with mild intellectual disability or borderline intellectual functioning and severe challenging behaviour: A concept mapping study.

BACKGROUND: Studies about teams of staff supporting people with intellectual disability have focused on team performance of existing teams. This study aimed to examine important factors in the process of setting up a new team of support staff. Specifically, we considered the process for a team that supports service users with mild intellectual disability or borderline intellectual functioning who display severe challenging behaviour from the orthopedagogical perspective (i.e., with a focus on contextual factors). METHOD: Three participant groups (service users, support staff, and professionals supporting a team) participated in a concept mapping procedure, including generating statements in interviews and focus groups, sorting, and rating. An expert group interpreted the results. RESULTS: Important factors to one or more groups were: service users and support staff getting acquainted early, team safety, social support, a shared vision, and a positive reputation of the new home. CONCLUSIONS: Four core outcomes were addressed that may help service organisations to provide an environment matching the needs of service users who show severe challenging behaviour from the start.

Eudaimonic well-being in individuals with mild to moderate intellectual disability.

BACKGROUND: Subjective well-being research in individuals with intellectual disability (ID) has a large hedonic focus and eudaimonic well-being is understudied in this population. Knowledge on eudaimonic well-being of individuals with ID is however necessary to improve their experienced well-being and support them in leading meaningful and flourishing lives. AIMS: The current study adopted a qualitative design to examine whether and how people with ID experience elements of eudaimonic well-being. METHODS AND PROCEDURES: Eleven adults with mild to moderate ID participated in individual semi-structured interviews about their subjective well-being. Interviews with their relatives and their direct support providers were conducted to contextualize the data. OUTCOMES AND RESULTS: By means of an interpretative phenomenological analysis, social relationships, accomplishment, purpose and balance, individuality, autonomy, and growth could be identified as relevant elements of eudaimonic well-being. Eudaimonic well-being of individuals with ID seemed to be mediated by acceptance of others. CONCLUSIONS AND IMPLICATIONS: The results provide insight in eudaimonic indicators of well-being, expanding the current view on well-being in individuals with ID. Efforts to use these elements in the care and support for individuals with ID are discussed.

Victimization history in female forensic psychiatric patients with intellectual disabilities: Results from a Dutch multicenter comparative study.

BACKGROUND: Victimization is highly prevalent in individuals with mild intellectual disability (MID) or borderline intellectual functioning (BIF) and is an important risk factor for mental health problems and violent behavior. Not much is known, however, about victimization history in women with MID-BIF admitted to forensic mental health care. AIMS: The aim of this multicenter study is to gain insight into victimization histories and mental health problems of female forensic psychiatric patients with MID-BIF. METHODS: File data were analyzed of 126 women with MID-BIF who have been admitted to one of five Dutch forensic psychiatric hospitals between 1990 and 2014 and compared to data of 76 female patients with average or above intellectual functioning and to a matched sample of 31 male patients with MID-BIF. RESULTS: All forensic patients had high rates of victimization, but women with MID-BIF showed an even higher prevalence of victimization during both childhood and adulthood and more complex psychopathology compared to female patients without MID-BIF. Compared to male forensic patients with MID-BIF, women with MID-BIF were more often victim of sexual abuse during childhood. During adulthood, the victimization rate in these women was more than three times higher than in men. CONCLUSIONS: Victimization is a salient factor in female forensic patients with MID-BIF and more gender-responsive trauma-focused treatment is needed.

Lessons learned from two clinical trials on nutritional supplements to reduce aggressive behaviour.

BACKGROUND: Setting up and conducting a randomised controlled trial (RCT) has many challenges-particularly trials that include vulnerable individuals with behavioural problems or who reside in facilities that focus on care as opposed to research. These populations are underrepresented in RCTs. APPROACH: In our paper, we describe the challenges and practical lessons learned from two RCTs in two care settings involving long-stay psychiatric inpatients and people with intellectual disabilities. We describe five main difficulties and how these were overcome: (1) multisite setting, (2) inclusion of vulnerable participants, (3) nutritional supplements and placebos, (4) assessment of behavioural outcomes, and (5) collecting bio samples. CONCLUSIONS: By sharing these practical experiences, we hope to inform other researchers how to optimally design their trials, while avoiding and minimising the difficulties that we encountered, and to facilitate the implementation of a trial. Both trials were registered in the Clinical Trials Register (RCT A: NCT02498106; RCT B: NCT03212092).

Diet quality among people with intellectual disabilities and borderline intellectual functioning.

BACKGROUND: We sought to assess diet quality among people with intellectual disabilities or borderline intellectual functioning, living in residential facilities or receiving day care. METHODS: We measured diet quality using the Dutch Healthy Diet Food Frequency Questionnaire (DHD) and compared this between participants with (n = 151) and controls without intellectual disabilities (n = 169). Potential correlates of diet quality were explored. RESULTS: We found lower mean diet quality among people with intellectual disabilities (M = 80.9) compared to controls (M = 111.2; mean adjusted difference -28.4; 95% CI [-32.3, -24.5]; p < .001). Participants with borderline intellectual functioning and mild intellectual disabilities had lower diet quality and higher body mass index than individuals with severe to profound intellectual disabilities. Being female was a predictor of better diet quality. CONCLUSIONS: Overall, we found that diet quality was low in the sample of people with intellectual disabilities or borderline intellectual functioning.

Heart rate and skin conductance associations with physical aggression, psychopathy, antisocial personality disorder and conduct disorder: An updated meta-analysis.

The associations between physiological measures (i.e., heart rate and skin conductance) of autonomic nervous system (ANS) activity and severe antisocial spectrum behavior (AB) were meta-analyzed. We used an exhaustive partitioning of variables relevant to the ANS-AB association and investigated four highly relevant questions (on declining effect sizes, psychopathy subscales, moderators, and ANS measures) that are thought to be transformative for future research on AB. We investigated a broad spectrum of physiological measures (e.g., heart rate (variability), pre-ejection period) in relation to AB. The search date for the current meta-analysis was on January 1st, 2020, includes 101 studies and 769 effect sizes. Results indicate that effect sizes are heterogeneous and bidirectional. The careful partitioning of variables sheds light on the complex associations that were obscured in previous meta-analyses. Effects are largest for the most violent offenders and for psychopathy and are dependent on the experimental tasks used, parameters calculated, and analyses run. Understanding the specificity of physiological reactions may be expedient for differentiating between (and within) types of AB.

Development and psychometric assessment of a psychological well-being instrument for adults with mild intellectual disability or borderline intellectual functioning.

BACKGROUND: Measuring eudaimonic well-being is important to gain a complete picture of the well-being of individuals with mild intellectual disabilities or borderline intellectual functioning (MID-BIF), but there is no measurement instrument available for this population coding for multiple dimensions of eudaimonic well-being. AIMS: The current study developed and piloted a new instrument coding for eudaimonic well-being in individuals with MID-BIF. METHODS AND PROCEDURES: The instrument (SPWB-ID) was adapted from Ryff's scales of psychological well-being, including subscales addressing purpose in life, environmental mastery, positive relationships, self-acceptance, personal growth, and autonomy. Adaptations were based on the literature and interviews with people with MID-BIF and experts in the field. The SPWB-ID was piloted among 103 adults with MID-BIF. OUTCOMES AND RESULTS: The trimmed version of the SPWB-ID showed sufficient to good internal consistency and test-retest reliability. Hypothesis testing for construct validity suggested the subscales of the SPWB-ID measured well-being, showing moderate to high correlations with quality of life, and differences in eudaimonic well-being between participants with and without clinically relevant depression scores. CONCLUSIONS AND IMPLICATIONS: The SPWB-ID reliably measures eudaimonic well-being in individuals with MID-BIF. This enables support providers to collect information on eudaimonic well-being, providing input for person-centred care and support for individuals with MID-BIF.

EMDR therapy for PTSD symptoms in patients with mild intellectual disability or borderline intellectual functioning and comorbid psychotic disorder: A case series.

BACKGROUND: Little is known about the effectiveness of EMDR therapy for PTSD symptoms in persons with mild intellectual disability or borderline intellectual functioning (MID-BIF, IQ 50-85) and psychosis. AIMS: To examine effectiveness, feasibility, and safety of eye movement desensitization and reprocessing (EMDR) therapy in six patients with MID-BIF, PTSD and psychotic disorder. METHODS AND PROCEDURES: Data were collected in a multiple baseline across-subjects design. Before, during and after treatment, weekly assessments on PTSD symptoms and adverse events were carried out. PTSD classification was assessed, and severity of hallucinations, delusions, and general psychopathology were measured at pretreatment, posttreatment and three-month follow-up. OUTCOMES AND RESULTS: There were no dropouts and five of the six participants completed treatment early. They showed a decrease in PTSD symptom severity and did no longer meet DSM-5 PTSD criteria at posttreatment. Results were maintained at follow-up. Symptoms did not exacerbate as indicated by a significant decrease in general psychopathology (in five participants) and an improvement in general functioning. In five participants severity of psychotic symptoms decreased. CONCLUSIONS AND IMPLICATIONS: EMDR therapy is safe and feasible and the results suggest that it can be an effective treatment for PTSD in patients with triple mental health problems in a tertiary mental health treatment setting.

Intensive clinical trauma treatment for children and adolescents with mild intellectual disability or borderline intellectual functioning: A pilot study.

BACKGROUND: Children and adolescents with mild intellectual disability (MID) or borderline intellectual functioning (BIF) are at increased risk for posttraumatic stress disorder (PTSD) or trauma-related symptoms due to adverse childhood experiences (ACEs). Weekly provided treatment sessions and/or outpatient treatment may not be effective enough. AIMS: Investigate feasibility, safety and potential effectiveness of an intensive clinical trauma treatment in children and adolescents with MID-BIF and trauma-related symptoms as a result of ACEs or PTSD. METHODS AND PROCEDURES: Thirty-three participants between 6 and 17 years of age received intensive clinical treatment after experiencing multiple ACEs (most commonly physical abuse, emotional neglect or abuse, sexual abuse, domestic violence and bullying). Treatment lasted 8.4 days on average and consisted of a daily program of prolonged exposure, eye movement desensitisation and reprocessing and physical activation, embedded in a trauma-sensitive environment. Data were collected at intake, first day of treatment, last day of treatment and at follow-up. OUTCOMES AND RESULTS: There was a significant reduction of trauma-related symptoms and emotional and behavioral problems after treatment. In addition, the number of participants fulfilling the DSM-5 criteria of PTSD decreased from 24 at intake to 8 at the end of treatment. There was no drop out and no adverse events were seen. CONCLUSIONS AND IMPLICATIONS: The results of this pilot study suggest that an intensive clinical trauma treatment is a potentially effective and safe option for children and adolescents with MID-BIF.

Usability and Acceptance of Wearable Biosensors in Forensic Psychiatry: Cross-sectional Questionnaire Study.

BACKGROUND: The use of wearable biosensor devices for monitoring and coaching in forensic psychiatric settings yields high expectations for improved self-regulation of emotions and behavior in clients and staff members. More so, if clients have mild intellectual disabilities (IQ 50-85), they might benefit from these biosensors as they are easy to use in everyday life, which ensures that clients can practice with the devices in multiple stress and arousal-inducing situations. However, research on (continuous) use and acceptance of biosensors in forensic psychiatry for clients with mild intellectual disabilities and their caretakers is scarce. Although wearable biosensors show promise for health care, recent research showed that the acceptance and continuous use of wearable devices in consumers is not as was anticipated, probably due to low expectations. OBJECTIVE: The main goal of this study was to investigate the associations between and determinants of the expectation of usability, the actual experienced usability, and the intention for continuous use of biosensors. METHODS: A total of 77 participants (31 forensic clients with mild intellectual disabilities and 46 forensic staff members) participated in a 1-week trial. Preceding the study, we selected 4 devices thought to benefit the participants in domains of self-regulation, physical health, or sleep. Qualitative and quantitative questionnaires were used that explored the determinants of usability, acceptance, and continuous use of biosensors. Questionnaires consisted of the System Usability Scale, the Technology Acceptance Model questionnaire, and the extended expectation confirmation model questionnaire. RESULTS: Only the experienced usability of the devices was associated with intended continuous use. Forensic clients scored higher on acceptance and intention for continuous use than staff members. Moderate associations were found between usability with acceptance and continuous use. Staff members showed stronger associations between usability and acceptance (r=.80, P<.001) and usability and continuous use (r=.79, P<.001) than clients, who showed more moderate correlations between usability and acceptance (r=.46, P=.01) and usability and continuous use (r=.52, P=.003). The qualitative questionnaires in general indicated that the devices were easy to use and gave clear information. CONCLUSIONS: Contrary to expectations, it was the actual perceived usability of wearing a biosensor that was associated with continuous use and to a much lesser extent the expectancy of usability. Clients scored higher on acceptance and intention for continuous use, but associations between usability and both acceptance and continuous use were markedly stronger in staff members. This study provides clear directions on how to further investigate these associations. For example, whether this is a true effect or due to a social desirability bias in the client group must be investigated. Clients with mild intellectual disabilities might benefit from the ease of use of these devices and their continuing monitoring and coaching apps. For these clients, it is especially important to develop easy-to-use biosensors with a minimum requirement on cognitive capacity to increase usability, acceptance, and continuous use.