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
Aspects of the Role
 Assessment
 Formulation
 Intervention
- Service Users
- Staff
- The MDT
 Consultation & Training
 Service Development
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.
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:
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UK: Learning Disability
US: Intellectual Disability
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
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.
Defining ‘Significant Impairment’

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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)
2%
14%
34%
34%
14%
2%
X axis
(Scores)
WAIS - IVUK
 13 subtests assessing different aspects
of the construct of ‘Intelligence’
 Scores then compared with a general
population providing:

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Full Scale IQ
Verbal Comprehension Index
Perceptual Organisation Index
Working Memory Index
Processing Speed Index
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:
 Communication
 Community Use
 Self care
 Functional Academics
 Home living
 Work (if in a job)
 Social Skills
 Leisure
 Health and Safety
 Self direction
Adaptive Behaviour
Assessment System (ABAS II)
 Scores then compared with a general population
providing:

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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:


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a GAC of <70,
one of the other Composite scores <70,
or significant difficulty in 3 or more of the specific skill
areas
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:
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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)
Formulation
 The 4 P’s –Predisposing, Precipitating,
Perpetuating, Protective factors
 Models of formulation – psychodynamic
(Malan), systemic, CBT
 Consulting to the system re: formulation
Intervention for Service UsersAims 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)
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
Adaptations of Psychotherapy for
people with Learning Disabilities
 Pre-assessment re: cognitive level of

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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)
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
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
Any questions?