A preliminary controlled trial of a trans-diagnostic programme for cognitive behaviour therapy with adults with intellectual disability.

BACKGROUND: Several studies have found a heightened prevalence of mental health disorders in people with intellectual disabilities (ID). There have been a number of successful case series and two promising controlled treatment trials of cognitive behaviour therapy (CBT) for emotional disorders (excluding anger) for people with ID. Several authors have promoted the development of trans-diagnostic approaches to cognitive treatment. The present study extends this work with the development and evaluation of a trans-diagnostic treatment manual for CBT in people with ID. METHOD: A controlled treatment trial was conducted with 12 participants in treatment and waiting list control data. Each treatment participant was matched to a control on age, IQ, presenting problem, and Brief Symptom Inventory (BSI) global severity index (GSI) score. The treatment group was also evaluated on the Glasgow anxiety and depression scales and was followed up for 3 to 6 months after treatment. RESULTS: There were no significant differences between groups at baseline. Following treatment, the CBT group was significantly improved when compared with the control group on the GSI scale of the BSI. The ancovas for all other measures were not significant but there were significant improvements for the treatment group on all scaled except BSI depression from pre to post-CBT. Gains were maintained to follow up, and changes were associated with large effect sizes. CONCLUSIONS: It was possible to treat a range of symptoms and psychiatric diagnoses with a general trans-diagnostic CBT manual. The effects of therapy were promising, suggesting that the participants could respond to treatment in a meaningful and helpful manner and supporting the case for further evaluation of the trans-diagnostic approach in ID.

How do static and dynamic risk factors work together to predict violent behaviour among offenders with an intellectual disability?

BACKGROUND: Research on risk assessment with offenders with an intellectual disability (ID) has largely focused on estimating the predictive accuracy of static or dynamic risk assessments, or a comparison of the two approaches. The aim of this study was to explore how static and dynamic risk variables may 'work together' to predict violent behaviour. METHODS: Data from 212 offenders with an ID were analysed. Risk assessment tools included one static measure (Violence Risk Appraisal Guide), and two dynamic measures (Emotional Problems Scale and the Short Dynamic Risk Scale). Six-month concurrent prediction data on violent behaviour were collected. A structured methodology was employed to explore putative relationships between static and dynamic factors. RESULTS: Static risk factors temporally preceded dynamic ones, and were shown to dominate both dynamic measures, while there was a non-zero relationship between the static and the two dynamic measures. According to Kraemer et al., these findings suggest that dynamic risk factors function as proxy risk factors for static risk. CONCLUSIONS: Dynamic and static risk factors appear to capture elements of the same underlying risk associated with violent behaviour in individuals with an ID. This is the first study to empirically explore risk interrelationships in the forensic ID field. We discuss the importance of the contribution of dynamic variables in the prediction and management of risk.

Responsivity to criminogenic need in forensic intellectual disability services.

BACKGROUND: Research has shown for some time that addressing criminogenic need is one of the crucial aspects of reducing reoffending in all types of offenders. Criminogenic need such as anger or inappropriate sexual interest is considered to be crucial in the commission of the offence. The aim of the present study is to investigate the extent to which forensic services address the needs of those accepted into services. METHOD: This study reviews the treatment for 197 offenders with intellectual disability accepted into a range of services. Participants' case files were examined to ascertain the extent to which need was addressed through recognised therapies. A standard pro forma was used on which we had established good reliability across four research assistants. RESULTS: The most frequently referred problems were violence and sexual offending. Specialist forensic intellectual disability community services were significantly more likely to provide treatment specifically designed to address index behaviours when compared to generic community services and secure services. CONCLUSIONS: Various possible explanations of these findings are explored including staffing levels, diagnosed mental illness, expertise of staff and clarity of purpose in services.

Structure, fit and coherence of two circumplex assessments of personality in a population with intellectual disabilities.

BACKGROUND: Little research has been conducted investigating the way in which personality constructs relate to people with intellectual disabilities. The small amount of research that does exist suggests that underlying personality structure may be considerably different to that found in mainstream research. This hypothesis is, however, untested because so little work has been conducted with this population. METHOD: Two circumplex models, the Interpersonal Adjective Scales and the CIRCLE, were employed to explore the factor structure, coherence and fit of these models with this population. One hundred and twenty-three participants from forensic intellectual disability services were rated by staff on the assessments, although not all assessments were completed for all participants. RESULTS: The factor structures for both assessments conform broadly with a theoretical structure. Hypotheses concerning the magnitude and direction of Spearman's correlations both within and between assessments were generally confirmed. CONCLUSION: While results would support the applicability of mainstream personality assessments to this client group, cautions were expressed in relation to the source of the sample and to the method of data collection.

Emotional and behavioural problems in offenders with intellectual disability: comparative data from three forensic services.

BACKGROUND: Despite an increasing knowledge base concerning the assessment of emotional and behavioural problems in people with intellectual disabilities (ID), relatively little research has examined such problems in offenders with ID. METHODS: The study assessed 172 male offenders with ID in three service settings (high, medium-low security and community) using the Behaviour Rating Scale of the Emotional Problem Scales (EPS), with the aim of assessing differences in Externalizing and Internalizing Behaviour Problems. RESULTS: Normative information is presented on the Behaviour Rating Scale of the EPS across three levels of forensic ID care. It was found that offenders in higher secure care scored higher on sub-scales reflecting physical aggression than those in lower secure care. However, there was no difference in terms of other Externalizing Behaviour Problems, such as verbal aggression, non-compliance or hyperactivity. In addition, those offenders in higher secure care scored significantly higher on all Internalizing Behaviour Problems sub-scales, including anxiety, depression and low self-esteem. CONCLUSIONS: Implications for research and clinical practice are discussed, including the utility of the EPS as a measure of clinical need and treatment outcome.

Women with intellectual disability who have offended: characteristics and outcome.

BACKGROUND: There have been a few reports describing the characteristics and outcomes of male offenders with intellectual disability (ID). Therefore, while we are building up a reasonable picture of this client group, there are almost no reports of female offenders with ID. This paper is a preliminary attempt to present information on a small cohort of female offenders. METHODS: Characteristics of female offenders are presented including information on age, IQ, mental illness, referring agents, crimes committed, problems identified, sexual and physical abuse and outcome. Some comparisons are made with corresponding descriptions of male cohorts in Lindsay et al. (2004). RESULTS: The main result is that females constitute 9% of referrals to the service. Other notable results are that: at 61% sexual abuse in the cohort of female offenders is higher than in male cohorts but at 38.5% physical abuse is no higher than in appropriate comparison groups; as with mainstream female offenders identification of mental illness is high at 67%; and total re-offending over 5 years was 22% but, excluding prostitution, was only 16.5%. CONCLUSIONS: In some respects, this cohort of female offenders shows similar characteristics to their male counterparts. However, there are higher levels of mental illness, higher levels of sexual abuse and lower levels of re-offending. It is hypothesized that as females constitute such a low percentage of referrals, it suggests that women with ID do not show the same levels of sexually abusive behaviour or aggressive behaviour--the two most frequent reasons for male referral. Therefore, an intervening variable such as mental illness may indeed be a significant factor. Lower re-offending rates may indicate the success of interventions directed at psychological problems and mental illness.

Development and preliminary evaluation of a questionnaire on cognitions related to sex offending for use with individuals who have mild intellectual disabilities.

BACKGROUND: A number of authors note that distorted cognitions may play a significant role in sex offending behaviour in both the people with intellectual disability (ID) and general populations. However, no scales have been specifically developed for use with individuals with ID. To date, there is no valid, reliable, self-report questionnaire that assesses cognitive factors in these individuals. This paper aims to develop a valid, reliable self-report questionnaire to assess antisocial attitudes consistent with sex offending behaviour in individuals who have mild ID. METHODS: Seventeen male individuals with ID who had sexually offended were compared with two non-sex offender groups: 19 males with and 36 males without ID. The Questionnaire on Attitudes Consistent with Sex Offending (QACSO) measure was used to establish sexual attitudes in the three groups. The reliability and validity of the QACSO was examined. RESULTS: The groups were compared and results demonstrated that the QACSO is a promising tool in terms of providing an internally consistent, reliable and valid indicator of cognitive distortions/attitudes held by sex offenders with ID. CONCLUSIONS: The limitations, suggestions for modification, potential uses of the questionnaire and directions for further research are proposed.

Impulsiveness as a factor in sexual offending by people with mild intellectual disability.

BACKGROUND: It has been suggested that sexual offending by people with intellectual disability (ID) results from a pattern of impulsive behaviour that is consistent with psychosocial disadvantage, rather than sexual deviancy. This study aimed to explore this hypothesis by assessing levels of impulsiveness in sexual offenders, non-sexual offenders and non-offenders with mild ID. METHOD: Impulsiveness was assessed using a modified version of the Barratt Impulsiveness Scale (11th edition). Total impulsivity scores were compared between sexual offenders, non-sexual offenders and non-offenders, all with mild ID. RESULTS: There was a significant difference in the levels of impulsiveness between sexual offenders and non-sexual offenders with ID (t=2.83, P<0.01). The sexual offenders were less impulsive than non-sexual offenders. CONCLUSIONS: This study did not support the hypothesis that sexual offending by people with ID is better explained by impulsive behaviour rather than sexual deviancy. It supports recent findings that among the general population, sexual offenders are less impulsive than controls and violent offenders.

Research and literature on sex offenders with intellectual and developmental disabilities.

The present paper sets out to review the literature on several aspects of sex offenders with intellectual and developmental disabilities, including the relationship between sex offending and developmental disabilities, the prevalence and characteristics of sex offenders in this client group, assessment, treatment, and outcome of intervention. Several important variables were identified as influencing the disparate results found in different prevalence studies. These include variations in inclusion criteria, differences in the source of the sample, differences in determination of IQ, the impact of deinstitutionalization, and the effect of changing social and penal policies in the area where studies have been conducted. Although some studies have suggested an increasing incidence, there is no clear evidence for the over- or under-representation of people with developmental disabilities amongst sex offenders. One of the main methodological flaws in several reports listing the characteristics of sex offenders is that considerations are based on clinical samples. Therefore, there is no control group to show that these characteristics do not exist in other samples of individuals with intellectual disability (ID). It does appear that sex offenders with ID are more likely to commit offences across categories and to be less discriminating in their victims. There may also be an association with sexual abuse in childhood. The primary issue considered has been assessment of competency, in that people with ID are considered to be disadvantaged by the criminal justice process. While several authors have delineated the important areas for assessment, there are few assessment measures with robust psychometric properties. Pharmacological, behavioural, educational and cognitive treatments are reviewed. Several comprehensive treatments which include all of the aforementioned methods are also considered. Although most studies do not report particularly positive outcomes, several authors have found better outcomes with treatment lasting at least 2 years.

A comparison of physical and sexual abuse: histories of sexual and non-sexual offenders with intellectual disability.

OBJECTIVES: To review patterns of physical and sexual abuse in cohorts of sexual offenders and nonsexual offenders with intellectual disability. METHOD: Forty-six sexual offenders were compared with 48 male nonsexual offenders in relation to their experiences of sexual and physical abuse in childhood. Comprehensive assessments were taken over a period of at least one year, and were conducted independently by a range of professionals. RESULTS: Thirty-eight percent of the sexual offenders and 12.7% of the nonsexual offenders had experienced sexual abuse, while 13% of the sexual offenders and 33% of the nonsexual offenders had experienced physical abuse. CONCLUSIONS: Sexual abuse seems a significant variable in the history of sexual offenders, while physical abuse seems a significant variable in the history of nonsexual offenders. The results support the view that the "cycle of abuse" is neither inevitable nor an adequate explanation of future offending.

Treatment of adolescent sex offenders with intellectual disabilities.

The problems of male adolescent sex offenders with intellectual disabilities were described and issues for treatment reviewed. A group treatment based on cognitive therapy was offered. Treatment methods and assessment of attitudes related to commission of sexual offenses were described. Four case studies of teenage male adolescent sex offenders with intellectual disabilities were presented. All subjects responded to treatment. Their individual differences related to their responses were discussed in the context of the type of denial exhibited by each subject. At the time of this study, 3 years had elapsed for 2 subjects and 4 years for the other 2 without a recurrence of an offense.

Responses to treatment for sex offenders with intellectual disability: a comparison of men with 1- and 2-year probation sentences.

The present study compares the responses to treatment of sex offenders with intellectual disability receiving 1- and 2-year probationary sentences. There were seven subjects in each group. There were no differences between subjects with regard to age, IQ or previous offences. All subjects received group treatment which addressed issues of: denial, minimization and responsibility for the offence; harm done to the victim; behaviour consistent with offending; and victim awareness and confidentiality. The subjects were assessed on a standard questionnaire designed to assess attitudes consistent with sex offending. All subjects were convicted of either indecent exposure or offences against children. There was a significant difference between the groups at the end of the probation period with subjects sentenced to 2 years' probation showing greater improvement. Subjects receiving 1 years' probation retained a number of attitudes consistent with denial and minimization of their offence. Furthermore, follow-up data underlined the poorer response to treatment for the 1-year probation group in terms of re-offending rates and assessment of attitudes consistent with sex offending. The authors recommend that a court order for a 1-year period of probation with treatment is of little value when dealing with sex offenders with intellectual disability. Rather, a period of at least 2 years' probation with a treatment recommendation is suggested.

The treatment of men with a learning disability convicted of exhibitionism.

This paper reviews work on the treatment of men convicted of exhibitionism or indecent exposure. Recidivism is extremely high after treatments, with true figures on recidivism unavailable until 4 years after conviction. It is extremely difficult to control for treatment effects because of the ethical issues surrounding withholding of treatment, but cognitive techniques provide a promising treatment approach. The present study attempted to address all these issues for men with a learning disability. A cognitive treatment is presented and data are available for at least 5 years after conviction. An AB design was used and treatment effects were monitored carefully. Treatment dealt with the issues of accepting that the offense took place, taking responsibility for the offense, accepting the intention of the offending behavior, victim awareness, and behavior consistent with offending for four offenders. All the men responded to treatment, although one offender with only 1 year of probation responded less convincingly than others. Beliefs relating to indecent exposure being fun or not causing harm to women seemed most open to alteration. The beliefs in which the perpetrator thought that the victim shared responsibility for the offense and that women may take a long while to recover from such an incident, seemed the most difficult to alter. Individual characteristics of the case examples are discussed in terms of these general trends.

The treatment of six men with a learning disability convicted of sex offences with children.

This paper describes a cognitive therapy for men with a learning disability convicted of sex offences against children. Methods are described which focus the session, emphasize confidentiality, ensure that the patient accepts responsibility for the offence, and deal with issues of intent, harm done to the victim and sequences of offending behaviour. Methods for producing cognitive change are described. Patients were assessed regularly and data are presented in detail. While all six men showed improvement, there were several variables which interfered with the course of treatment. The study attempts to address two major problems in work with sex offenders: the difficulty of employing a controlled treatment design and the importance of a long follow-up period.

Changes following community living skills training: a controlled study.

Fifty-seven adults with mild to moderate learning disability served as participants in a community living skills training programme. Twenty-nine were trained using in vivo techniques, 13 were taught using classroom techniques and 15 acted as a no treatment control group. Assessments of community living skills and adaptive behaviour found those receiving in vivo training performed significantly better than the other groups. Eventual placement in the community reflected this superiority.

A comparison of the effects of four therapy procedures on concentration and responsiveness in people with profound learning disabilities.

This paper is an investigation into the efficacy of four therapeutic treatment procedures increasingly used with people with profound learning disabilities: snoezelen, hand massage/aromatherapy, relaxation, and active therapy (a bouncy castle). In particular, the effects of these procedures on concentration and responsiveness were examined. Eight subjects with profound learning disabilities took part in the study and each subject received each of the treatments. To assess the effects of the treatments, simple concentration tasks were administered and the subjects' responsiveness to each treatment was rated by independent observers. The results suggest that both snoezelen and relaxation had a positive effect on concentration and seemed to be the most enjoyable therapies for clients, whereas hand massage/aromatherapy and active therapy had no or even negative effects on concentration and appeared less enjoyable.

The Chief Scientist reports... A controlled investigation of changes following a programme of community living, skills training and the validation of these changes through relocation.

Fifty-seven adults with mild to moderate learning disabilities served as subjects in a community living skills training project. Twenty-nine subjects were trained using in vivo techniques, 13 were taught using classroom techniques and 15 subjects acted as a no-treatment control group. The effects of the training programme were assessed using videotaped assessments rated by independent observers and the in vivo techniques were found to be significantly superior to the teaching and no-treatment control conditions. These effects were still evident at one year and two year follow-up assessments. Two years after the final follow-up, eventual relocation was examined and the in vivo group were found to have significantly more independent living circumstances than either of the two control groups.

The effects of behavioural relaxation on cognitive performance in adults with severe intellectual disabilities.

Behavioural relaxation training has been found to be effective in the treatment of generalized anxiety in people with intellectual disability. The present study is designed to assess whether or not these techniques can help individuals in more generalized aspects of their life. Two groups of 10 adults with a severe intellectual disability formed a relaxation group and a control group. The relaxation group were given a course in behavioural relaxation training and the control group were given a quiet reading period for the same amount of time. Each subject was given a digit span test, a test of long-term memory and an incidental learning test after each session. Results suggest behavioural relaxation training has a beneficial effect on performance on tests of short-term memory and incidental learning, but no effect upon long-term memory.

The effects of cue control relaxation on adults with severe mental retardation.

This study was designed to assess two aspects of behavioural relaxation training with subjects who have severe mental retardation. The first was whether or not cue words could be linked effectively to training so that they would eventually produce a relaxation effect in the absence of a full relaxation procedure. The second was to determine the effects of relaxation training and subsequent cue control on concentration and attention to an occupational task. Five subjects participated, and individual case designs were used. Cue Control, behavioural relaxation training (BRT), and new therapists were introduced at different times for each subject to ascertain the effects of each variable. Subjects were assessed at baseline and following each training session on a behavioural relaxation scale to judge the direct effects of relaxation training and on the amount of time spent concentrating on an occupational task. BRT produced reductions in rated anxiety and improvements in concentration for all subjects. The cue control words were effective only after they had been linked to BRT. In most cases, the introduction of a new therapist had no appreciable effect on anxiety or concentration. There was some suggestion that in the final cue only phases concentration was better and more consistent than during the BRT phases of the study.

The consistency of reports about feelings and emotions from people with intellectual disability.

Sixty-seven subjects with mild or moderate intellectual disability were assessed on a variety of measures of emotion. All of the measures were self-report measures and all of the data is based on reports by the subjects' themselves. The battery included the Zung Self-Rating Anxiety Scale, the Zung Depression Inventory, the General Health Questionnaire and the Eysenck-Withers Personality Test. The results reveal an impressive amount of convergent validity in the subjects' emotional systems.