The Role of the Learning Disability Clinical Psychologist

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 2nd Edition • Weschler Adult Intelligence Scale- 4th 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 100 70 85 115 130 Y axis (% of population) X axis (Scores) 34% 34% 14% 2% 14% 2%

8. WAIS - IVUK • 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:

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?