Supporting affect regulation in children with multiple disabilities during psychotherapy: a multiple case design study of therapeutic attachment.

In a controlled multiple case design study, the development of a therapeutic relationship and its role in affect regulation were studied in 6 children with visual disabilities, severe intellectual disabilities, severe challenging behavior, and prolonged social deprivation. In the 1st phase, children had sessions with an experimental therapist stimulating therapeutic attachment, alternating with a control therapist providing positive personal attention only. In the 2nd phase, both therapists applied behavior therapy. Clients sought more proximity to the experimental therapist compared with the control therapist. Psychophysiological arousal (respiratory sinus arrhythmia and pre-ejection period) was lower when the experimental therapist applied behavior modification than when the control therapist did. Despite prolonged social deprivation, the attachment behavioral system appeared responsive to stimulation. The effects on affect regulation may explain the synergy between psychotherapy based on interpersonal and behavior modification approaches.

Visual impairments in people with severe and profound multiple disabilities: an inventory of visual functioning.

BACKGROUND: The prevalence of visual impairments in people with severe and profound multiple disabilities (SPMD) is the subject of considerable debate and is difficult to assess. METHODS: In a typical Dutch care organization, all clients with SPMD (n = 76) participated in the study and specific instruments adapted to these clients (requiring a minimum of cooperation) were used to measure visual acuity, the visual field, binocular vision, contrast sensitivity, refractive errors and visual functioning behaviour. RESULTS: We found an unexpected 92% of clients with SPMD to have visual impairments. Previously, only 30% were known to have visual problems. None of the persons observed had normal visual acuity. Subnormal visual acuity was the best result. The severity of the visual impairment was related to the severity of the intellectual disability. In addition to the problem of acuity, impairments in the visual field, impaired contrast sensibility and impaired binocular functioning were found, as well as impaired visual attention, fixation and following. In 22% of the clients observed, refractive errors were found and glasses were advised. CONCLUSIONS: Consequences for caregiving and for modifications of the environment were discussed.

Perspectives on quality of life of people with intellectual disabilities: the interpretation of discrepancies between clients and caregivers.

Large discrepancies have sometimes been found between the quality of life (QOL) experienced by clients with intellectual disabilities and their QOL as described by their caregivers. Olsen and Schober (Soc Indi Res 1993; 28: 173-193) may have provided a framework useful to conceptualize such discrepancies. They suggested that lack of concordance between objective circumstances (i.e. poverty) and perceived QOL must not be treated as measurement noise, but as a source of information. They speculated on the psychological processes that underly and explain this lack of concordance; particularly processes that try to deal with the stress induced by cognitive dissonance and learned helplessness. In this study low to moderate agreement was found between caregivers judgement of QOL of individual clients and clients' own perception of QOL. In some areas and for some clients the discrepancies indicated dissonance (caregivers are satisfied, clients are not) and in other areas and for other clients adaptation (clients are satisfied, caregivers are not). There were systematic differences between clients falling in these groups with respect to their personal characteristics and with respect to factual conditions of care. These outcomes are interpreted with respect to Olson and Schober's contentions regarding the psychological processes that underly a person's experience of QOL. The Olson and Schober framework appears to be a fruitful way to combine different sources of information regarding QOL.

Understanding challenging behaviour in people with severe and profound intellectual disability: a stress-attachment model.

BACKGROUND: Advances in our knowledge of attachment, stress and coping may foster new explanations for the development of challenging behaviour in people with intellectual disability (ID). METHOD: Research on stress and coping among people with ID was reviewed initially, and then studies on the security of the attachment relationships of people with ID with their caregivers were analysed. RESULTS: There is evidence that people with ID are more vulnerable to stress and use less effective coping strategies. Furthermore, the body of studies on attachment indicates that people with ID are at risk for developing insecure, especially disorganized attachment. There is evidence from other populations that the combination of stress, and insecure or disorganized attachment may put people at risk for developing behaviour problems. CONCLUSION: A stress-attachment model of the development of challenging behaviour among people with ID shows promise as an explanatory framework. The uncovering of these developmental mechanisms may be particularly useful for the prevention of behavioural problems.