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_at_cft.cornwall.nhs
.uk
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Aspects of the Role

• Assessment
• Formulation
• Intervention - Service Users
• - Staff
• - The MDT
• Consultation Training
• Service Development

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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/relationa
  l history.

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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

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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

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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.

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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
85
70
115
130
Y axis ( of population)
X axis (Scores)
34
14
34
2
2
14
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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

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Significant impairment of adaptive/social
functioning

• Definition of adaptive/social functioning relates
  to a persons 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
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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 lt70,
• one of the other Composite scores lt70,
• or significant difficulty in 3 or more of the
  specific skill areas

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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)

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Formulation

• The 4 Ps Predisposing, Precipitating,
  Perpetuating, Protective factors
• Models of formulation psychodynamic (Malan),
  systemic, CBT
• Consulting to the system re formulation

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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)

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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

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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)

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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 teams reflection
  around relationships with service user(s) and
  conflicts, considering emotional needs of staff

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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

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• Any questions?