Group-based CBT effective in improving anger control by people with learning disabilities

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Cognitive behavioural therapy (CBT) is an approach used to help people manage problems by changing the way they think and behave. It is a talking therapy designed to help examine they way in which their actions can affect they way they think and feel. It looks for practical ways to improve states of mind on a daily basis.

It has been shown to be effective in helping people control their anger and the researchers in this study were particularly interested in looking whether this approach could be effective when used with people with learning disabilities.

Controlling anger is a problem faced by many people with learning disabilities and can lead to acts of aggression that may seriously impact on their quality of life and is a major cause of breakdown of support in mainstream services.

What they did was work with 30 day services providers in Scotland, England and Wales, recruiting four to eight service users  from each centre, up to a total of 179 people, all of whom had been identified as having problems with anger control. They then randomly allocated half the participants to a treatment intervention group and half to a ‘treatment as usual’ waiting list control group.

Those in the CBT treatment group had CBT sessions every week for 12 weeks which were delivered by staff in day services who had been trained to follow a manual based treatment intervention.

Those in the waiting list group who acted as a control group for the study got the treatment intervention at the end of the twelve week period.

They took a number of baseline measures of intellectual and receptive language abilities. As an outcome measure, they used the Provocation Index which was completed by the service user at 10-month follow-up. This is a measure of felt response to hypothetical, potential anger provoking situations. This index was also completed by a keyworker and a home carer.

They also used the Profile of Anger Coping Skills (PACS) which was also completed by service user, keyworker and home carer, and was used to assess the development of functional coping skills.

Self-reported quality of life was assessed using the Comprehensive Quality of Life Scale – Intellectual Disability (ComQoL-ID) and they asked keyworkers and home carers to assess challenging behaviour using the Hyperactivity and Irritability domain items of the Aberrant Behavior Checklist (ABC-H/I) and the Modified Overt Aggression Scale (MOAS). They also looked at the economic implications of the treatment intervention to identify treatment costs.

What they found was that those in the treatment group did not report any significant reductions in their anger responses to hypothetical triggers. However, they did report a decrease in their anger response to real triggers. Interestingly keyworkers reported that their anger had decreased significantly compared with the controls, at both 16 week and 10 month follow-ups.

The researchers point out that many service users had difficulty in imagining some of the hypothetical situations in the Provocation Index so might not have been the ideal primary outcome measure.

As keyworkers and home carers both reported decreases in challenging behaviour, the authors suggest that this study may be the first to controlled study to suggest improved self-management of aggressive challenging behaviour by people with learning disabilities themselves.

They identified the overall excess cost of the treatment intervention to be around £296 per person.  However, they also found that the total adjusted mean cost of health and social care service use at the 10-month follow-up was lower for the intervention group by £22.46 per person per week. Although this cost was almost  equivalent to the weekly excess cost of the intervention itself, it was not statistically significant.

Professor Willner, lead author of the study said:
“CBT is the treatment of choice for common mental health problems, and widening access to CBT is seen as a major policy priority. However, the delivery of CBT to people with intellectual disabilities is underdeveloped, and there is limited evidence of its effectiveness for this client group.

“Our study clearly shows that group-based CBT was effective in improving anger control by people with intellectual disabilities. The CBT intervention also decreased challenging behaviour, as rated by both keyworkers and home carers. Overall, this study provides evidence of the effectiveness of CBT for this client group, and demonstrates that the staff who work with people with intellectual disabilities can be trained and supervised to deliver such therapy effectively.”

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John Northfield

After qualifying as a social worker, John worked in community learning disability teams before getting involved in a number of long-stay hospital closure programmes, working to develop individual plans for people moving into their own homes. He worked for BILD, helping to develop the Quality Network and was editorial lead for the NHS electronic library learning disabilities specialist collection. This led him to found the Learning Disabilities Elf site with Andre Tomlin as a way of making the evidence accessible to practitioners in health and social care. Most recently he has worked as part of Mencap's national quality team and also been involved in a number of national website developments, including the General Medical Council's learning disabilities site.

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