Posted: April 24th, 2025

Education EDF 621 Week 1 Assignment

NO PLAGIARISM

Educational Psychology Introduction & Research

Choose a topic related to Educational Psychology. Break down the topic into 3 main ideas and research Educational Psychology literature to support your ideas (2-3 articles per idea). Write a 2-3 paragraph introduction and include a reference page of 6–9 sources.

You may select from the following examples or choose your own:

Cognitive Disabilities

Module 1: Lecture Materials & Resources

Challenges & History, Using Science, & Social-Emotional Development

Read and watch the lecture resources & materials below early in the week to help you respond to the discussion questions and to complete your assignment(s).

(Note: The citations below are provided for your research convenience. Students should always cross-reference the current APA guide for correct styling of citations and references in their academic work.)

Read

· Durwin, C. C., & Reese-Weber, M. J. (2020).
EdPsych Modules (4th ed.). SAGE Publications.

· Chapter 1: Using Science to Inform Classroom Practices

· Chapter 2: Contexts of Development

· Chapter 3: Social-Emotional Development

· Heller, R. (2017). On the science and teaching of emotional intelligence: an interview with Marc Brackett.
Phi Delta Kappan,
98(6), 20-24.

On the science and teaching of

Download On the science and teaching of

· As part of your readings in this Module, please also review the following:

Syllabus

APA and Research Guides

Watch

·
Comparing descriptive, correlational, and experimental studies (10:44)
Miller, B. (2014, June 6).
Comparing descriptive, correlational, and experimental studies [Video]. YouTube.

Comparing Descriptive, Correlational, and Experimental StudiesLinks to an external site.

·
Quasi-Experimental Designs (3:13)
Miller, B. (2014, June 6).
Quasi-Experimental Designs [Video]. YouTube.

Quasi-Experimental DesignsLinks to an external site.

·
Inside Chicago Public Schools: SEL at Marcus Garvey Elementary (4:47)
CASEL. (2013, January 11).
Inside Chicago Public Schools: SEL at Marcus Garvey Elementary [Video]. YouTube.

Inside Chicago Public Schools: SEL at Marcus Garvey ElementaryLinks to an external site.

·
Daniel Goleman introduces emotional intelligence (5:31)
Big Think. (2012, April 23).
Daniel Goleman introduces emotional intelligence [Video]. YouTube.

Daniel Goleman Introduces Emotional Intelligence | Big ThinkLinks to an external site.

Supplemental Materials & Resources

Robert Gagne Hierarchies of Learning PDF

Module 1 Assignment

· Topic: Cognitive Disabilities

Educational Psychology Paper Introduction & Research

You may select from the following examples or choose your own:

· Theories

· Testing

· Policies (e.g. No Child Left Behind)

· Cognitive Disabilities

· Behavioral Issues

· Digital Instruction/Remote Learning

Submission Instructions:

· Your paper should be formatted per current APA and should include a 2-3 paragraph introduction and references page with 6-9 sources.

· The paper is to be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.

· The reference page is to show you have researched your topic. You are not required to cite all of them in the introduction.

References

Li, S., Yong, Y., Li, Y., Li, J., & Xie, J. (2024). Cognitive-Based Interventions for Improving Psychological Health and Well-Being for Parents of Children with Developmental Disabilities: A Systematic Review and Meta-analysis.
Journal of Autism & Developmental Disorders,
54(9), 3316–3335.

https://doi.org/10.1007/s10803-023-06063-x

Fynn, G., Porter, M., Borchard, T., Kazzi, C., Zhong, Q., & Campbell, L. (2023). The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and anxiety: a systematic review.
Journal of Intellectual Disability Research,
67(9), 816–841.

https://doi.org/10.1111/jir.13046

Miller, A. L. (2022). Reconceptualizing Education Grounded in the Multimodal Discourses of Girls of Color Labeled with Significant Cognitive Disabilities.
Research and Practice for Persons with Severe Disabilities,
47(3), 158–175.

https://doi.org/10.1177/15407969221119848

Kulnazarova, G., Namazbaeva, Z., Butabayeva, L., & Tulepova, L. (2023). Cognitive Therapy for Children with Intellectual Disabilities: A New Look at Social Adaptation Skills and Interpersonal Relationships.
Occupational Therapy International, 1–8.

https://doi.org/10.1155/2023/6466836

Barclay, L. (2023). Cognitive Disability and Social Inequality.
Social Theory & Practice,
49(4), 605–628.

https://doi.org/10.5840/soctheorpract2023817200

Hronis, A., Roberts, R., Roberts, L., & Kneebone, I. (2020). Potential for children with intellectual disability to engage in cognitive behaviour therapy: the parent perspective.
Journal of Intellectual Disability Research,
64(1), 62–67.

https://doi.org/10.1111/jir.12694

Giannaki, R., & Hewitt, O. (2021). A multiple methods evaluation of a cognitive behavioural therapy group for people with learning disabilities and anxiety.
British Journal of Learning Disabilities,
49(1), 87–99.

https://doi.org/10.1111/bld.12344

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Received: 11 December 2019 | Revised: 21 August 2020 | Accepted: 24 August 2020

DOI: 10.1111/bld.12344

O R I G I N A L A R T I C L E

A multiple methods evaluation of a cognitive behavioural
therapy group for people with learning disabilities and anxiety

Rengina Giannaki1,2 | Olivia Hewitt1,2

1Learning Disability Services, Berkshire, UK
2Healthcare NHS Foundation Trust, Reading,
UK

Correspondence
Rengina Giannaki, Psychology Service,
Learning Disabilities, 7-9 Cremyll Road,
Reading RG1 8NQ, UK.
Email: Rengina.Giannaki@oxfordhealth.nhs.
uk

Accessible summary
• Cognitive Behavioural Therapy (CBT) can help individuals with learning disabilities

and anxiety.
• A group was run to help people to manage their anxiety and to feel better.
• At the end participants and their supporters fed back their experiences of the

group and filled in questionnaires to measure their anxiety and psychological
distress.

• The group seems to reduce people’s anxiety.
• This report adds to a growing body of existing literature demonstrating some ben-

efits of CBT for people with learning disabilities and anxiety.

Abstract
Background: Existing studies show mixed results of the effectiveness of CBT for
people with learning disabilities and anxiety.
Method: A CBT group was run for people with learning disabilities and anxiety, who
attended with a supporter. Qualitative interviews were conducted post-group and
analysed using thematic analysis. Standardised questionnaires measuring anxiety,
psychological distress and overall functioning were administered at pre- and post-
group, and at follow-up.
Results: Participants’ anxiety decreased overall post-group, which remained largely at
follow-up. The group and the supporters’ involvement was helpful. Both supporters
and participants recalled coping strategies that were presented in the group. Three
out of four participants found attending a group challenging initially. The supporters
seem to have specific expectations about the impact of the group.
Conclusions: The results of the study are consistent with the existing, growing body
of evidence which supports the use of CBT for people with learning disabilities and
anxiety.

K E Y W O R D S

clinical psychology, intellectual disability, learning (intellectual) disabilities, mental health,
Psychological therapy, stress

www.wileyonlinelibrary.com/journal/bld

mailto:

https://orcid.org/0000-0002-1807-1347

https://orcid.org/0000-0002-6393-2388

mailto:Rengina.Giannaki@oxfordhealth.nhs.uk

88 | GIANNAKI ANd HEWITT

1 | INTRODUC TION

Mental health issues including anxiety are common in people with
learning disabilities (Bowring, Painter, & Hastings, 2019; Cooper
et al., 2015; NICE, 2016). Reid, Smiley, and Cooper (2011) found that
3.8% of people with a learning disability have an anxiety disorder
with generalised anxiety disorder as the most common (1.7%), and
then agoraphobia (0.7%). Physical health issues, sensory impairment,
specific syndromes and lower cognitive abilities might be associated
with the high rates of anxiety in people with learning disabilities (e.g.
Austin, Hunter, Gallagher, & Campbell, 2018; Bowring et al., 2019;
Dykens, 2003). Anxiety might impact on the quality of everyday life
(Bowring et al., 2019) by hindering the social integration (Totsika &
Hastings, 2009) and safety of people with learning disabilities. It
might be manifested through self-injurious, aggressive or avoidance
behaviours (Stavrakaki, 2002).

NICE (2016) indicates that psychological interventions such as
cognitive behavioural therapy (CBT) are effective treatments for
anxiety within the general population that CBT should be consid-
ered to treat depression in people with mild learning disabilities, and
that relaxation therapy and graded exposure should be considered
to treat anxiety symptoms.

1.1 | The effectiveness of CBT for anxiety in people
with learning disabilities

The existing literature shows mixed results for CBT interventions on
anxiety in people with learning disabilities. Dagnan’s, Jackson, and
Eastlake (2018) systematic review reported positive outcomes of
CBT interventions on anxiety for people with learning disabilities,
although much of the current literature consists of single case re-
ports. Unwin, Tsimopoulou, Kroese, and Azmi (2016) systematically
reviewed the literature around the effectiveness of CBT and con-
cluded that there is equivocal evidence for improving anxiety with
some uncontrolled studies demonstrating some positive results, and
with the qualitative data consistently reflecting a positive percep-
tion of the treatment. Both authors concluded that the area needs
further research.

Some studies show limited or no effectiveness of CBT on anxi-
ety. Hassiotis et al. (2013) conducted a randomised control trial to
study the effectiveness of a 16-week manualised individual CBT on
anxiety and depression. Sixteen adults with mild to moderate learn-
ing disabilities were randomly allocated in the CBT group and six-
teen in the control group. No statistically significant difference was
found. However, the approach of intervention was generalised and
not anxiety-focused (Unwin et al., 2016).

Other studies indicate a more promising impact of CBT on anxi-
ety. Ghafoori, Ratanasiripong, and Holladay (2010) reported a signif-
icant reduction in anxiety, following a 9-week generalised approach
of CBT group which included eight participants, but that phobic anx-
iety was not reduced. Quantitative analysis showed that the anxi-
ety remained roughly decreased at 4-month follow-up but without

statistical significance. However, the participants were young stu-
dents which limits the generalisability.

Lindsay (1999) used individual Beck’s CBT adapted to anxiety
and found that the fifteen participants’ anxiety scores decreased by
35%, which persisted at follow-up. However, the study comprised
a brief case report and presented little methodological information
(Unwin et al., 2016).

Lindsay et al. (2015) conducted a matched control trial employing a
quasi-experimental design. The CBT group involved twelve adults with
mild learning disabilities with their supporters. The author developed a
CBT manual containing a generalised approach targeting mixed presen-
tations, anxiety, depression and anger. Significant decrease in anxiety
was found post-group which remained at 6-month follow-up. However,
no between group treatment effects on anxiety were reported.

Douglass, Palmer, and O’Connor (2007) studied the effective-
ness of a CBT group for anxiety. Outcome measures demonstrated
that after a 12-week intervention, two out of six participants noted a
significant reduction in anxiety. All group members developed cop-
ing strategies. Four participants reported decreased anxiety and all
supporters a better understanding of anxiety. The study used both
quantitative and qualitative data, but did not present quotes sup-
porting the qualitative analysis.

In Marwood and Hewitt’s (2012) study, quantitative data sug-
gested that two out of eight participants with mild learning disabil-
ities noted a significant decrease of anxiety after a 6-week CBT
group. Qualitative data analysis reported positive experiences of
attending the group and of supporters’ inclusion. However, the num-
ber of participants who noted a decrease of anxiety remains small
compared to the total number of participants, though each partici-
pant reported finding the group beneficial.

Given the limited existing literature and the ambiguity of results,
an evaluation of a CBT intervention seems to be appropriate in de-
termining its efficacy on anxiety. According to NICE (2016), further
research is needed to evaluate the effectiveness of CBT in people
with learning disabilities and anxiety. Due to the limited qualitative
data and the limited opportunities that people with learning dis-
abilities have to express their views on interventions, a qualitative
methodology in addition to a quantitative one could enrich the data
and enable the voices of people with learning disabilities to be heard
allowing a deeper understanding of participants’ experience in the
group. It will also increase insights into helpful components of the
intervention and into the process of change (MacMahon et al., 2015).

This study aims to evaluate the effectiveness of a CBT group for
adults with learning disabilities who present with anxiety symptoms
impacting on their everyday life to the extent that psychological
input is sought. A secondary objective is to investigate if the inter-
vention will help participants to feel better by reducing their psycho-
logical distress.

2 | METHODOLOGY

A service evaluation was carried out using multiple methods.

| 89GIANNAKI ANd HEWITT

2.1 | Participants

The participants who attended the group consisted of four indi-
viduals with mild learning disabilities and anxiety symptoms (see
Table 1 for demographic information). All of them were presenting
with symptoms related to generalised anxiety and specific fears.
Each participant was asked to attend the group with a supporter,
either family member either carer, who could commit to the group.
Previous research reported benefits of supporters’ inclusion by
generalising the learned skills in other areas of participants’ life and
maintaining long-term treatment effects (e.g. Crossland, Hewitt, &
Walden, 2017).

Participants were referred to the psychological service for peo-
ple with learning disabilities within the NHS Trust and were assessed
for suitability for the group. Inclusion criteria were being over the
age of 18 years, presenting with anxiety symptoms, having mild to
moderate learning disabilities, being willing to participate in the
group, and a supporter’s inclusion. No formal, psychiatric diagno-
sis of anxiety was required. Exclusion criteria were receiving other
psychological therapy during the group or having severe learning
disabilities.

All group members gave informed consent both to participate in
the group and in its evaluation. They were informed about the ano-
nymity of the information they provided. The project was reviewed
and registered with the research department of the NHS Trust,
which approved it as a service evaluation without warranting review
by the research ethics committee.

2.2 | Group content

The group content consisted of basic CBT concepts based on Beck’s
(1987) model. The material was developed in the service (see Table 2
for outline of group sessions). Cognitive and behavioural compo-
nents were introduced in the group as guided by previous research
(e.g. Dagnan et al., 2018; Douglass et al., 2007 for review; NICE
Guideline 54, 2016).

Cognitive behavioural therapy is often adapted for use with peo-
ple with learning disabilities. Adaptations include using visual aids
and prompts, using diary sheets requiring only tick box responses,
shorter sessions with slower pace, using concrete examples, re-
peating information (Haddock & Jones, 2006). Such adaptions were

included in the present group. Previous research suggests includ-
ing supporters improves outcomes (e.g. Douglass et al., 2007).
Therefore, each participant was encouraged to bring a supporter to
the group to support generalising new skills.

The programme consisted of a 7-week CBT group targeting anx-
iety and one follow-up session taking part one month after the last
of the 7-week sessions. Two trainee clinical psychologists and two
assistant psychologists facilitated the group receiving weekly super-
vision by a clinical psychologist.

2.3 | Measures

Three standardised measures were administered by a trainee clini-
cal psychologist and an assistant psychologist to the individuals with
learning disabilities who attended the group at three time points. A
range of measures comprising specific and generic scales were em-
ployed in support of the aims of the study. All three detect changes
of both anxiety and overall mental health as interventions in an area
can lead to changes in several areas of functioning (Roy, Matthews,
Clifford, Fowler, & Martin, 2002; Unwin et al., 2016). These meas-
ures were chosen for their psychometric properties and were used in
previous research (e.g. Douglass et al., 2007). One additional ques-
tionnaire, the PTOS-ID, was administered to participants’ supporters
at three time points to capture supporters’ perceptions of partici-
pants’ level of distress and to identify any discrepancies among par-
ticipants’ and supporters’ perception.

The Glasgow Anxiety Scale for people with an Intellectual
Disability (GAS-ID; Mindham & Espie, 2003) is a measure designed
for people with mild learning disabilities. It has good reliability and
internal consistency. The 27-item self-rating scale evaluates the
level of anxiety and comprises of cognitive, behavioural and somatic
symptoms that the person experiences over the past week. The au-
thors suggest a cut-off score of 13 as a threshold value to identify
a possible anxiety disorder. Higher score shows higher degree of
anxiety. The three-option response format, “never,” “sometimes,”
“always”, makes the measure sensitive to changes over time.

The Health of the Nation Brief Outcome Measure for People
with Learning Disabilities and Mental Health Needs (HoNOS-LD;
Roy et al., 2002) rates the mental health needs and global function-
ing for people with all levels of learning disabilities. The 18-item in-
strument has good reliability and validity, and can measure changes

TA B L E 1 Demographic data

Pseudonym Age Ethnicity Gender Living situation Diagnosis
Supporter’s pseudonym
and relationship

Alice 21 British-White Female Family home Mild LD, anxiety Sylvia, mother

Colin 56 British-White Male Independent living with
support staff

Mild LD psychosis,
anxiety

Ivor, paid support worker

Mary 48 British-White Female Supported
accommodation

Mild LD, anxiety Jacob, partner

Sally 55 British-White Female Family home Mild LD, anxiety Erica, mother

90 | GIANNAKI ANd HEWITT

over time. The clinician rates each item over the past four weeks
according to the level of severity of the problem scoring from 0 to
4. Higher level of wellbeing is indicated by lower total score. The
measure can detect changes over time.

The Psychological Therapy Outcome Scale-Intellectual Disabilities
(PTOS-ID; Vlissides, Beail, Jackson, Williams, & Golding, 2017) is a
30-item self-rated scale designed to measure anxiety, anger, depres-
sion, interpersonal wellbeing and psychological wellbeing in people
with mild to moderate learning disabilities. Each item is rated on a
4-point Likert scale anchored by “not at all” to “a lot.” The measure as-
sesses two dimensions over the past week: the index of psychological
distress and the index of wellbeing. The psychological distress score
equals the sum of anxiety, depression and anger scores. Higher score
of the psychological distress index indicates higher level of distress.
The wellbeing score equals the sum of interpersonal wellbeing and
psychological wellbeing. A parallel PTOS-ID form can be completed by
supporters and captures supporters’ perception about the distress and
wellbeing of the person with a learning disabilities. The measure has
high internal consistency of the psychological distress index (α = 0.85)
and high reliability of the wellbeing index (α = 0.81). Full evaluation of
its psychometric properties has yet to be carried out.

2.4 | Qualitative method

Qualitative data were derived from semi-structured interviews
which were conducted post-group in order to obtain group members’
experiences of the group. The interviews were conducted at par-
ticipants’ homes, separately for each participant and each supporter.
This allowed all group members’ voices to be heard independently
and to compare participants’ and their supporters’ experience. A
trainee clinical psychologist and two assistant psychologists carried

out the interviews after receiving participants’ and supporters’ writ-
ten, informed consent.

The interviews included questions related to the aims of the
study: participants’ experience of the group, their interaction with
others, group content, what participants learned, helpful and un-
helpful things from the group. An interview schedule contained
questions which were used in similar studies. A pilot interview took
place among the interviewers who provided with feedback to each
other. Alongside a discussion with the supervisor ensured the appro-
priateness of the questions and of the interview process. The ques-
tions were open-ended with prompts, and they were used flexibly as
a guide allowing a natural flow of conversation.

The interviews lasted between 13 and 30 min. They were audio
recorded using digital voice recorder as explained in the information
provided. The recordings were transcribed verbatim by the same
interviewers respectively. Identifying information in the transcripts
was anonymised.

The transcripts were analysed by the first author using the-
matic analysis. Thematic analysis is a method for identifying, an-
alysing and reporting patterns (themes) within data. It organises,
describes the data and interprets various aspects of the research
topic. Six stages of thematic analysis were used in the current
study (Braun & Clarke, 2006). The first author was familiarised
initially with the data by listening to the audio recordings and
reading the transcripts repeatedly; the author created initial codes
involving collating and coding quotes (coding); the author looked
for similar themes in the transcript and grouped them based on
the similarity (searching for themes); the author reflected on the
themes, discussed them in the supervision and edited them (re-
viewing themes). The fifth stage of “defining and naming themes”
was achieved by creating broader superordinate themes of similar
themes. The qualitative data were divided into participants’ data
and into supporters’ data to ensure that participants’ voice is heard
and to achieve a broader understanding of the group members’
experience. The sixth stage included the writing of this report,
reflecting, receiving feedback from the supervisor and making
choices about the quotes presented.

To ensure credibility, detailed notes were undertaken for all the
processes by the first author throughout the study. Regular supervi-
sion of the analysis also provided by OH, a clinical psychologist with
experience in conducting qualitative research. To ensure validity and
trustworthiness, the first author was repeating detailed readings of
the verbatim transcript. The first author’s role as co-facilitator of the
group allowed an early familiarity with the concepts of the group and
the establishment of a relationship of trust with the interviewees
ensuring validity as well (Shenton, 2004).

2.5 | Attendance and missing data

All four participants completed the group. All measures were
completed for all participants at all three time points (pre-, post-
intervention and at follow-up). Three out of four participants

TA B L E 2 Group session outline

Week Topic

1 Introduction, creating a safe environment, overview
of the programme, supporters’ role

Introducing what anxiety means, anxiety provoking
situations, helpful coping skills

2 Identifying emotions. hometask: recording emotions

3 Identifying unhelpful thoughts and their impact on
emotions and actions. Setting optional hometask:
breathing relaxation

Three weeks Christmas break

4 Recap of first three sessions

5 Identifying body reactions of anxiety

6 Identifying actions. Five senses self-soothing activity

One week break

7 Linking emotions, thoughts and behaviours

8 One month follow-up. Recap of the programme.
Completing measures

| 91GIANNAKI ANd HEWITT

completed the measures at 1-month follow-up after the end of the
group. Due to Colin’s physical health issues, the administration
of his follow-up measures took place 2-month post-group. One
participant, Mary, joined the group from the fourth group session
and she was not administered the HoNOS-LD at pre-group. Alice’s
interview was not recorded due to technological issues thus her
interview is missing.

3 | RESULTS

3.1 | Quantitative results

The group mean and the standard deviation for the three measures
are displayed in Table 3. All participants’ pre-group mean score of
anxiety for all three measures decreased by nearly half following
the intervention. The group mean of anxiety for GAS was 25.25
at intake and 13 post-group. The pre-group mean of distress for
PTOS-ID was 25.25 and 13.75 post-group. The mean for three out
of four participants on HoNOS-LD was 16.33 initially and 8.25
post-group. The reduced scores remained at follow-up (Figure 1).
The group mean of participants’ distress on PTOS-ID as perceived
by supporters was 19.5 at intake and became 5.25 at post-group,

which was not maintained at follow-up, where it reverted to base-
line levels (Table 3).

Due to the small number of participants, a Reliable Change
Analysis (RCI) was carried out for the three time points. This analysis
compares each participant’s individual scores over time to see if the
changes are significant (Table 3).

3.1.1 | Alice

Alice’s post-group anxiety score on GAS decreased (RCI = −2.20,
p < .05) which remained at follow-up (RCI = −1.69, p < .05) compared
to pre-group. Alice's post-group score on HoNOS-LD decreased
meaningfully (RCI = −1.88, p < .05), which persisted at follow-up de-
spite a slight increase (RCI = −1.61, p < .05).

The Figure 2 shows a significant reduction of distress post-
group both on PTOS-ID for Alice (RCI = −2.24, p < .05) and on
PTOS-ID completed by her supporter (RCI = −1.36, p < .05). Alice's
score of distress on PTOS-ID at follow-up (RCI = −0.46, p < .05)
remained at low level though it was slightly equivalent to the post-
group score. Alice maintained a meaningful low score on support-
er's PTOS-ID at follow-up (RCI = −0.24, p < .05) despite a slight
increase.

Measure/Time Alice Colin Mary Sally
Mean
score

Standard
deviation

GAS pre 23 21 23 34 25.25 5.90

GAS post 10 10 18 14 13 3.82

GAS F/U 13 12 15 12 13 1.41

GAS RCI pre-post −2.20* −1.86* −0.84* −3.38*

HoNOS-LD pre 29 8 – 12 16.33 11.15

HoNOS-LD post 8 0 2 23 8.25 10.40

HoNOS-LD F/U 11 14 3 16 11 5.75

HoNOS-LD
RCI pre-post

−1.88* −0.71* – 0.98

PTOS
Distress pre

41 21 17 22 25.25 10.71

PTOS
Distress post

17 18 10 10 13.75 4.34

PTOS
Distress F/U

36 22 12 8 14 4.96

PTOS
Distress RCI pre-post

−2.24* −0.28* −0.27* −0.47*

Supporter’s PTOS
Distress pre

20 22 12 8 19.5 12.47

Supporter’s PTOS
Distress post

3 12 0 6 5.25 5.12

Supporter’s PTOS
Distress F/U

17 16 30 11 18.5 8.1

Note.: Higher scores indicate increased impairment.
Abbreviations: F/U, follow-up; Post, post-intervention; Pre, pre-intervention; RCI, reliable change
index.
*Statistically significant at α = 0.05.

TA B L E 3 Participants’ pre-post reliable
change index (RCI) scores

92 | GIANNAKI ANd HEWITT

3.1.2 | Colin

A RCI analysis demonstrated that Colin’s GAS score lowered signifi-
cantly post-group (RCI = −1.86, p < .05) and at follow-up (RCI = −1.52,
p < .05). Colin's score on HoNOS-LD decreased immediately post-
group scoring 0 (RCI = −0.71, p < .05) indicating a meaningful im-
provement in his global functioning post-group. Colin's post-group
reliable change on HoNOS-LD was not maintained at follow-up
showing a decrease of his global functioning (RCI = 0.53) compared
to pre-group. This might be attributed to Colin receiving fewer inter-
personal interactions post-group or to a physical condition.

A RCI analysis showed a meaningful reduction of distress on
the index of distress on PTOS-ID for Colin post-group (RCI = −0.28,
p < .05) which was not maintained at follow-up (RCI = 0.09). Colin's
score of distress on supporter's PTOS-ID at follow-up was reduced
significantly (RCI = −0.80, p < .05) post-group despite a slight in-
crease of distress at follow-up compared to post-group (Figure 3).

3.1.3 | Mary

Mary noted a reliable reduction of her anxiety level (RCI = −0.84,
p < .05) on GAS at post-group, which decreased further at follow-
up (RCI = −1.35, p < .05). Mary did not fill in the HoNOS-LD before
the group thus it was not possible to track any change of her overall
functioning over time.

Mary’s score of distress for PTOS-ID demonstrated reliable
change and her level of distress decreased post-group (RCI = −0.27,
p < .05) and remained at a lower level at follow-up (RCI = −0.46,
p < .05) despite a slight increase. Mary's score on supporter's PTOS-ID
noted a reliable change post-group (RCI = −0.96, p < .05) indicating
a significant decrease of her distress. Mary showed a high increase
of distress on supporter's PTOS-ID at follow-up (RCI = 1.44) which
was higher than the pre-group score (Figure 4). This might be because
the measure was administered to two different persons. Alongside
her partner reported in the interview no improvement for Mary. This
might be because Mary joined the group after the other participants
and she did not apply the coping strategies outside the group.

3.1.4 | Sally

From the RCI emerged that Sally’s anxiety score for GAS de-
creased meaningfully post-group (RCI = −3.38, p < .05) which
remained almost equivalent at 1-month follow-up (RCI = −3.22,
p < .05). Sally's score on HoNOS-LD was increased post-group
(RCI = 0.98) indicating an increased impairment in her global func-
tioning. There was a slight improvement in her functioning at fol-
low-up (RCI = 0.35) compared to the post-group which remained
lower than the pre-group (Figure 5). Sally's post-group score on
HoNOS-LD was increased showing decreased functioning, possi-
bly due to a physical condition that Sally developed whilst attend-
ing the group.

Sally’s score on PTOS-ID noted a reliable decrease (RCI = −1.12,
p < .05) immediately after the intervention showing an improvement
of her distress. The post-group reliable change remained at follow-up
(RCI = −1.30, p < .05) showing a slight higher level of improvement
compared to the intake. Sally's score for supporter's PTOS-ID noted
a reliable reduction of distress (RCI = −0.16, p < .05) at post-group
but was slightly increased at follow-up (RCI = 0.24) compared to pre-
group. This might be due to the ending of the group, which was a
positive experience for Sally.

Clinical significance was used to examine the pre- and post-
group changes for each participant. Clinical significance is

F I G U R E 1 Participants’ changes for HoNOS-LD, GAS, PTOS-ID
index of distress and supporter’s (S/R) PTOS-ID index of distress
at pre-, post-group and follow-up. Higher scores on all measures
indicate an increase of impairment and vice versa

0
5

10
15
20
25

Group’s mean scores over time

F I G U R E 2 The graph displays Alice’s scores at pre, post and
follow-up intervention for the measures GAS, HoNOS-LD, index
of distress on PTOS-ID and index of distress on supporters’ (S/R)
PTOS-ID. Higher scores indicate increased level of impairment

0
10
20
30
40

Alice’s scores over time

F I G U R E 3 The graph displays Colin’s scores at pre-, post- and
follow-up intervention for the measures GAS, HoNOS-LD, index
of distress on PTOS-ID and index of distress on supporters’ (S/R)
PTOS-ID. Higher scores indicate increased level of impairment

0
5

10
15
20
25

Colin’s scores over time

| 93GIANNAKI ANd HEWITT

routinely defined as returning to normal functioning, and occurs
when post-intervention scores are more than two standard de-
viations above or below the mean score of the pre-intervention
sample (Jacobson, Roberts, Berns, & McGlinchey, 1999). Alice’s
and Colin’s post-group improvement on all measures were clini-
cally significant. This is supported for Alice by subjective reports.
Mary’s and Sally’s improvement on two measures were clinically
significant, which is in line with subjective reports for Sally; how-
ever, this is contradicted for Mary by her supporter’s subjective
reports.

3.2 | Qualitative results

The quotes below indicate text taken directly from the transcripts.
The number in brackets indicates the line location within the data.
The “P” refers to participants’ and “S” to supporters’ quote.

3.2.1 | Results from participants

Four superordinate themes were identified from the participants’
interviews (Table 4).

Superordinate theme 1: How things were before the group
The first superordinate theme described participants’ pre-existing
issues and helpful coping skills which were used before starting the
group.

All participants identified emotional difficulties, such as fears,
frustration and family problems. Mary and Colin expressed concerns
around medical appointments. Sally said:

You get headaches. Bad headaches sometimes.
(P, 133)

Colin described:

Years ago I used to be a little bit scared of dogs… If we
go to the doctor and somebody does not explain me
the reason that bothers me.

(P, 52)

All participants described how they coped with anxiety before the
group. Mary engaged in helpful activities such as reading and writing.
Two participants used physical activity to help them to relax. Collin
said:

I use my exercise bike… sometimes I do jogging. And
I count up to ten. And I jump up until twenty… it gets
out my stress.

(P, 88)

Superordinate theme 2: Participants’ perceived positive and
negative aspects of the group
This theme considered participants’ positive experience in the
group, how they benefited from the group and things they did not
like about the group.

All participants held a generally positive view of the group. Two
participants enjoyed the group content and activities. Sally found
the group “interesting” and said:

it was all good. That was a nice change. I enjoyed it. It
was good to do things. I had a nice time.

(P, 171)

Most participants learned helpful coping strategies to manage anx-
iety. Two participants found it helpful to talk about their problems in
the group. Mary said that she learned:

to talk about my anxiety, the appointment at the hos-
pital that I didn’t like.. I have to go for that… to talk
about to my sister, and feel better…talk about your
problems, anxiety it helped me too.

(P, 8)

F I G U R E 4 The graph displays Mary’s scores at pre-, post-
intervention and follow-up for GAS, HoNOS-LD, index of distress
on PTOS-ID and on supporters’ (S/R) PTOS-ID. Higher scores
indicate increased level of impairment. Mary’s HoNOS score at pre-
group is missing

0
5

10
15
20
25
30
35

Mary’s scores over time

F I G U R E 5 The graph displays Sally’s scores at pre-, post- and
follow-up intervention for GAS, HoNOS-LD, index of distress on
PTOS-ID and on supporters’ (S/R) PTOS-ID. Higher scores indicate
increased level of impairment

0
10
20
30
40

Sally’s scores over time

94 | GIANNAKI ANd HEWITT

Two participants described difficulties they experienced in the
group. One participant found the room “dark” and the venue too small.
Another participant found it difficult initially to be in a group with
others.

Superordinate theme 3: Participants’ perceived positive interactions
with other group members
This theme incorporates participants’ positive experience of inter-
acting with other participants, supporters and facilitators.

Sally and Colin enjoyed talking to other group members. Colin
described:

I‘ve enjoyed having a chat. And, I‘ve enjoyed explain-
ing about myself. I really enjoyed the group.

(P, 16)

Sally liked learning from others and said that it was “nice” to “talk
to your friends.” She liked the communication among group members:

[liked] listening and hearing things. Stick to other peo-
ple’s conversations. Taking in turns. Well done.

(P, 11)

All participants expressed their appreciation about the facilitators
describing them as “helpful” and “nice.” For example, Colin said: “I‘ve
enjoyed having a chat with them” (P, 38). One participant, Colin, ex-
pressed a positive view of his supporter’s inclusion: “I really enjoyed it
with Ivor in group.” (P, 234).

Superordinate theme 4: Group content
This theme reflects topics that were presented in the group, activities
that were practised in the group to deal with anxiety and the hometask.

All participants recalled some of the group topics such as feel-
ings, behaviours and bodily sensations. Sally recalled that “we talked
about heart” and about:

the very happy face on the board. That‘s a good one…
It is funny that.

(P, 53)

She also recalled an activity involving writing anxiety provoking
thoughts on a picture of a head. She liked the “nice big circle eyes…you
could draw it.” (P, 90).

Two participants talked about their positive contribution to the
group being a model for others as they presented their pre-existing
helpful coping strategies. For example, Sally shared with others what
she described as “stretching”:

Looking up to the ceiling, and then looking down.
That’s good. You have to be careful with your neck…I
did it in the anxiety group. It is good Sally because you
move and your little fingers as well.

(P, 145)

All participants completed the hometask at least once with their
supporters’ help. Most liked the hometask. Sally found it “quite good”
although Mary said that she did not find it helpful.

3.2.2 | Results from supporters

Five superordinate themes were identified from the supporters’ in-
terviews (Table 5).

Superordinate theme 1: How things were before the group
The first theme captures supporters’ account of both participants’
and their own emotional issues, coping skills, positive things in eve-
ryday life before the group and expectations about the group.

Most supporters said that the participants were encountering
emotional difficulties in their everyday life before starting the group.
Jacob said:

Superordinate theme Subordinate theme Endorsed by

1. How things were before the
group

Participants’ pre-existing emotional
difficulties

Participants’ pre-existing coping skills

Colin, Mary,
Sally

2. Perceived positive and negative
aspects of the group

Participants’ positive experience in
the group

How the group helped participants
Participants’ difficulties in the group

Colin, Mary,
Sally

3. Participants’ perceived positive
interactions with other group
members

Participants’ positive experience
of interacting with other group
members

Colin, Mary,
Sally

4. Group content Topics and activities in the group
Participants’ presentation of coping

skills
Hometask

Colin, Mary,
Sally

TA B L E 4 Summary of superordinate
and subordinate themes for participants

| 95GIANNAKI ANd HEWITT

Mary gets worried sometimes. She wants me to go
always out and get her stuff… (S, 13). When she does
things, when she goes somewhere, she always likes
somebody with her.

(S, 213)

Sylvia talked about Alice’s social withdrawal and Erica about Sally’s
fears. Most supporters described their own worries. Erica expressed
her initial hesitation to attend the group:

I wasn’t very keen on going to the group first of all. I
couldn’t believe that [Sally] would change.

(S, 5)

Superordinate theme 2: What supporters found helpful about the
group
This theme captures group aspects which supporters perceived as
helpful for the participants and themselves, such as the group envi-
ronment and content, the hometask, the interactions among group
members, practical things.

All supporters described the group as “relaxed,” “interesting”
and “friendly” reporting an overall positive experience. For example,

Erica felt “happy”. They appreciated the safe and non-judgemental
environment where people felt free to express their views and
needs.

All supporters recalled topics from the group and most of them
endorsed the group content reporting its positive impact on them-
selves, despite materials being targeted to participants. They found
the strategies to deal with anxiety and the activities that were prac-
tised in the group helpful and enjoyable. Introducing coping strate-
gies from the first sessions helped Alice to manage her anxiety as
she became familiar with the group, her mother said. Erica found
everything was helpful:

it did really sink in all those things for her [Sally]. And
she does talk about those things, when she gets home.

(S, 6)

Half of supporters found the hometask which was completed by all
participants at least once as helpful. Sylvia recognised that this activity
is a “massive help.” Jacob found it “good” and that it “helps me under-
stand the feelings what is like.”

Most supporters found the social aspect helpful. Ivor empha-
sised the opportunity of making friendships and the usefulness of

Superordinate theme Subordinate theme Endorsed by

1. How things were
before the group

Participants’ and supporters’ emotional difficulties
in life

Participants’ and supporters’ coping strategies and
positive things in life

Supporter’s initial hesitation to attend the group

Erica, Jacob,
Ivor, Sylvia

2. What supporters
found helpful about
the group

Supporters’ perceived positive aspects of the
group

Supporters’ perceived positive group environment
Supporters’ perceived positive group topics and

coping strategies
Supporters’ perception about the hometask
Social aspects of the group are helpful
Others as a source of learning
Practical aspects of the group are not an issue

Erica, Jacob,
Ivor, Sylvia

3. Supporters’
perceived negative
aspects of the group

Participant’s initial expectation about the group is
not met

Supporters’ perceived negative social aspects of
the group

Supporters’ perception about participants’
difficulties in the group and after the termination
of the group

Supporter’s negative experience about the
hometask

Supporter’s negative experience about practical
aspects of the group

Erica, Jacob,
Ivor, Sylvia

4. Supporters’
perceived positive
impact of the group
on participants and
themselves

Supporters’ perceived positive impact of the group
on participants’ emotions in the group

Supporters perceive a positive impact of the group
on participants which lasts after its termination

Erica, Jacob,
Ivor, Sylvia

5. Looking to the future Supporters’ constructive feedback about the group
Participant’s care plan after the group
Supporters’ hopes for the future

Erica, Sylvia,
Ivor

TA B L E 5 Summary of themes from
supporters’ interviews

96 | GIANNAKI ANd HEWITT

discussions. Most supporters perceived their role as active and helpful.
All supporters expressed their appreciation for the facilitators. Sylvia
said:

the way you did it passing the bottle and that that
helped that helped Alice as well. Alice came out of her
shell in the last week… which was good to see what a
difference.

(S, 112)

Supporters felt participants benefited from learning through oth-
ers’ experiences and skills. Colin got help hearing that “other people
have anxieties,” Ivor said. Erica said: “listening to those she [Sally] got
confidence from those how to answer questions.” (S, 24). Sylvia said: “it
was good to get different perspectives.”

Superordinate theme 3: Supporters’ perceived negative aspects of
the group
Supporters described negative aspects of the group and members’
difficulties in the group and after the end.

Sylvia felt the facilitators should have been more aware of par-
ticipants’ needs before starting the group. Talking about the range of
participants’ age Sylvia said:

She [Alice] was running off, she was getting very frus-
trated and anxious, but I think that was because Alice
was expecting it to be her age range and it wasn’t, it
was her and two 50 plus year olds and she found that
difficult…That was a shame because there was no-
body that she could become friends with afterwards.

(S, 7)

Jacob expressed his preference for an individual intervention.
Half of supporters expressed their dissatisfaction at one participant’s
dominance of the conversation. Two participants, Sally and Mary, felt
uncertainty about what to say. With regards to the hometask, Erica
felt initially “a little bit muddled” on “how to fill those spaces [on the
worksheets].” Parking was a “big issue” for one supporter. Jacob said
that Mary has not used the coping strategies from the group and that:

She [Mary] still gets worries and stress. Because she
came back and then in few days, she is worrying about
things again.

(S, 230)

Superordinate theme 4: Supporters’ perceived positive impact of
the group on participants and themselves
The theme captures supporters’ perception about the positive out-
come of the group on participants’ feelings and behaviours in the
group and after the end of the group.

Half of supporters talked about participants’ positive feelings
and changes in the group over time. Sylvia noticed that Alice became
“relaxed” and that she had a “massive difference” at the end with

“fully engagement.” Erica mentioned Sally “found so happy to speak
to other people.”

Ivor noticed two participants’ progress: “in a very short space of
time, she [Alice] grew to trust the group and enjoyed interacting. I
thought that was really impressive.” (S, 10).

Supporters described participants’ feelings and behaviours
which lasted after the termination of the group. Erica noticed Sally’s
“tremendous difference” as she “talks more,” “won’t worry about
anything” and “feels happier.”

But the happiness she got at the group was really,
helped her down there [day centre] really. Because
she kept saying I am a nice person, I am strong, I am
gonna be all the things that you said at the group, she
is taking that on board and repeats that.

(Erica, 11)

Sylvia commented that the “healing process” started early and that
the group helped Alice:

definitely one hundred percent… she doesn’t get as
anxious anymore, she’s now started going out more
with her friends. She went to the pub last night with
a few friends.

(S, 234)

Superordinate theme 5: Looking to the future
This theme incorporated suggestions for future groups, plans for on-
going psychological support and hopes for the future. Sylvia would
prefer the group content to be tailored to each participant’s needs:

what’ s the requirement for the individual, what is it
that they need from the group, you need to find that
out.

(S, 179)

Erica expressed her hope that Sally’s progress will last in long-term:

I am hoping now, that we can go forward back to how
it used to be one time, when she [Sally] was going to
shopping.

(S, 28)

4 | DISCUSSION

This study aimed to evaluate the effectiveness of a 7-week CBT
group intervention for adults with learning disabilities and anxiety
using a multiple methods design, combining standardised measures
with qualitative analysis.

Quantitative results show that the CBT group had an overall
positive impact on most participants’ anxiety, distress and global
functioning, which was maintained for most at follow-up. This study

| 97GIANNAKI ANd HEWITT

replicated findings that CBT might be helpful for people with learn-
ing disabilities and anxiety (Dagnan et al., 2018).

Participants’ mean and individual GAS scores decreased post-
group, which remained at follow-up as shown previously (e.g. Lindsay
et al., 2015). Participants’ HoNOS-LD scores improved post-group in
line with Marwood and Hewitt’s study (2012).

All participants’ post-group level of distress decreased, which
remained at follow-up despite a slight higher score of distress for
most of them, as supported by Crossland et al.’s study (2017).
The post-group level of distress on supporter’s PTOS-ID for all
participants lowered, and the level of distress at follow-up re-
mained at low level for three out of four participants despite a
slight increase.

The scores of measures are fairly consistent with the qualitative
results. The qualitative analysis showed that the group intervention
was largely a positive experience for participants who reported get-
ting help from the group and from interacting with others, possibly
through normalising their own experiences (Marwood & Hewitt,
2012). Based on supporters’ narratives, half participants reported
a decrease of anxiety and increase of wellbeing which is supported
elsewhere (e.g. Bouvet & Coulet, 2015).

The qualitative data showed that most supporters worried
about participants’ wellbeing, as reported elsewhere (e.g. Mansell
& Wilson, 2010). Supporters helped participants to manage their
initial worries, generalise skills outside the group (e.g. Douglass
et al., 2007) and engage with the group (Willner, 2006). Supporters
benefited from learning coping strategies for themselves as well, as
shown previously (Crossland et al., 2017).

Regarding the group content, participants recalled some anx-
iety-related feelings, behaviours and body reactions. Most par-
ticipants recalled the skills practised in the group (mindfulness
and relaxation skills), in line with similar studies (e.g. Bouvet &
Coulet, 2015). Participants presented their own pre-existing coping
skills in the group. Using visual aids appears to have aided recollec-
tion of the content (Haddock & Jones, 2006).

Some participants recalled anxiety-related situations and be-
haviours. This is in line with Tsimopoulou, Stenfert Kroese, Unwin,
Azmi, and Jones (2018) study demonstrating that people with a
learning disability learned to link activating situations to emo-
tions. None of the participants discussed the impact of unhelpful
thoughts on anxiety, which is a core concept of cognitive therapy
(Beck, 1987), which was found elsewhere (Vereenooghe, Reynolds,
Gega, & Langdon, 2015) suggesting that people with learning dis-
abilities did not learn to link thoughts to emotions. This might reflect
participants’ difficulty in perceiving or recalling abstract concepts.
Problems recalling theoretical elements are replicated by other re-
search (e.g. Hewitt, Atkisnon-Jones, Gregory, & Hollyman, 2019).

4.1 | Clinical implications

The CBT group had an overall positive impact on participants. The
quantitative analysis showed improvement whilst the qualitative

analysis showed that the group was largely beneficial for partici-
pants. Current findings have implications for services working with
people with learning disabilities.

From the qualitative data, it seems that group aspects that
helped achieving positive results are the visual presentation of con-
cepts, the presentation of basic CBT concepts such as situations,
behaviours, body reactions that are related to anxiety, the practice
of skills in and outside the group and modelling participants’ own
pre-existing skills to others, all enhanced learning. An environment
promoting safety, the social interaction and supporters’ involvement
helped too.

Exploring individuals with learning disabilities unhelpful thoughts
eliciting anxiety, participants’ and supporters’ initial expectations
about the intervention might be helpfully integrated in the assessment
session. Setting any unrealistic initial expectations might be of benefit
before starting the group. Given the supporters’ self-reported anxiety,
additional sessions could focus on supporters’ anxiety, which might
enhance participants’ progress over time. Encouraging participants’
regular attendance could enhance participants’ learning.

4.2 | Research implications

This study suggests promising results around the benefits of a CBT
group for people with learning disabilities, adding to the growing lit-
erature. Use of multiple methods allowed tracking the improvement
with regards to anxiety and psychological distress. Standardised
measures were used to ensure validity. A qualitative results both
from participants and their supporters allowed in depth exploration
of what aspects of the group were most helpful for participants. A fol-
low-up evaluation helped to identify if the gains remained over time.

However, the results following the intervention should be inter-
preted with caution. Supporters reported external factors that may
have impacted on measures of anxiety. The first author held the role
of group facilitator and interviewer holding possibly biases around
the results. A lack of control group limits the reliability of the study.
The small sample and large standard error limit the generalisability
of the results. The specific cognitive changes linked to participants’
anxiety have not been captured over time. Administering outcomes
measures at three time points to the same person with consistency
could reduce any errors. Future research should be more rigorous,
using more robust methodologies with larger samples of people to
ascertain which aspects of CBT are effective and the generalisability
of the results.

ACKNOWLEDG EMENTS
R.G. would like to thank Iman Hassan, trainee clinical psychologist,
Katie Ash and Nerissa Grant, assistant psychologists for their help
throughout the process.

DATA AVAIL ABILIT Y S TATEMENT
The data that support the findings of this study are available on re-
quest from the corresponding author, Rengina Giannaki. The data

98 | GIANNAKI ANd HEWITT

are not publicly available due to their containing information that
could compromise the privacy of research participants.

ORCID
Rengina Giannaki https://orcid.org/0000-0002-1807-1347
Olivia Hewitt https://orcid.org/0000-0002-6393-2388

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| 99GIANNAKI ANd HEWITT

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Social Theory and Practice
Vol. 49, No. 4 (October 2023): 605–628
DOI: 10.5840/soctheorpract2023817200

Cognitive Disability and Social Inequality

Linda Barclay

Abstract: Individuals with ‘severe’ cognitive disabilities are primarily discussed in
philosophy and bioethics to determine their moral status. In this paper it is argued that
theories of moral status have limited relevance to the unjust ways in which people with
cognitive disabilities are routinely treated in the actual world, which largely concerns
their relegation to an inferior social status. I discuss three possible relationships
between moral and social status, demonstrating that determinate answers about the
moral status of individuals with ‘severe’ cognitive disabilities are neither necessary
nor sufficient for defending the imperative that they be treated as our social equals.

Keywords: cognitive disability, moral status, social status

I. Introduction

Individuals with what are usually referred to as ‘profound’ or ‘severe’ cogni-
tive disabilities have notoriously been discussed in philosophy and bioethics
to determine whether their moral status is higher than that of many nonhu-
man animals (McMahan 2002; Singer 2011).1 Disability advocates vehement-
ly contest claims that such individuals don’t share the same moral status as
other human beings, and moreover argue that suggestions to the contrary are
harmful and dangerous (Kittay 2010). Although this debate about the moral
status of individuals with cognitive disabilities is very well-rehearsed, nothing
approaching a consensus view has emerged. Yet debates about moral status
continue to dominate philosophical discussion of people with ‘severe’ or ‘pro-
found’ cognitive disabilities, with all sides assuming that the outcomes of such
debates are pivotal for determining how we ought to treat such people.

1. From here I will usually just refer to such individuals as ‘people with cognitive disabili-
ties.’ It should be understood that debates about the moral status of such people are only
relevant to those individuals with the most ‘severe or ‘profound’ disabilities, who consti-
tute only a very small proportion of people with cognitive disabilities. There is little con-
sensus about the exact nature of the categories ‘severe’ and ‘profound’ cognitive disability,
nor exactly which individuals fall into that category. At the very least it is to be understood
that I am referring to people with reported very low IQ, who have little to no facility with
language (they are unable to speak, read or write) and who need constant daily care with
eating, personal hygiene, and avoiding basic threats to safety. For more detail about the
broad and diverse group of people often identified as having ‘severe’ or ‘profound’ cogni-
tive disability see Vorhaus 2017, Carlson 2019.

Linda Barclay606

In this paper I will argue that theories of moral status have quite limited
relevance to the unjust ways in which people with cognitive disabilities are
routinely treated in the actual world. What I will show is that this routine un-
just treatment threatens the social status of people with cognitive disabilities.
After explaining the difference between moral status and social status, I will
argue that fixing on moral status plays only a limited role in helping us to un-
derstand and respond to the injustice of pernicious social status hierarchies. As
such, if we are concerned to address the injustices perpetrated against people
with cognitive disabilities, we need to focus much more on neglected issues of
social inequality.

My arguments in this paper are a clarion call for us to focus discussion of
cognitive disability on issues of injustice. Other philosophers have persuasive-
ly argued that we can neither understand nor address racial and sexual injustice
by focussing solely on the bad attitudes of individual actors, whether explicit
or implicit (Anderson 2010; Haslanger 2015). The sources of injustice and the
causal mechanisms that sustain it are far more complex than an individualis-
tic focus on the beliefs or other attitudes of agents would suggest. This paper
furthers this structural focus by applying some of its insights to the sphere of
disability: the sources of injustice and the causal mechanisms that sustain it are
far more complex than the almost exclusive focus on beliefs about moral status
would lead us to suppose.

In sections II and III I will explain what is meant by moral status and so-
cial status respectively. In discussing the nature of moral status in section II,
I will explain that the possession of moral status is necessary in order to be
harmed by pernicious social hierarchy. As such, establishing that people with
‘profound’ cognitive disabilities have moral status is of first importance to any
discussion of the injustice of social status hierarchies. If an individual has no
moral status, they cannot be a victim of social injustice either. Beyond that
important role, debates about moral status have very little further to add. In
section IV I will reject the conventional view which holds that when people are
treated as social inferiors it is because they are assumed to have lower moral
status. I will argue that there can be a number of reasons for why social hier-
archies emerge that have nothing to do with individuals’ beliefs about moral
status, and this can certainly be the case with disability.

In section V I will argue that even if social status hierarchies are morally
impermissible because they violate respect for people’s moral status, it is still
the case that theories of moral status are very uninformative in terms of ex-
plaining the nature, function and ultimate impermissibility of social hierarchy.
In this sense, fixing on the moral status of people with ‘profound’ cognitive
disabilities does little explanatory work in determining how they ought to be
treated.

607Cognitive Disability and Social Inequality

In section VI I will suggest something that is perhaps more confronting:
that we do not need to demonstrate that people with ‘profound’ cognitive dis-
abilities possess equal moral status with other human beings in order to de-
nounce the unjust ways they are treated in the actual world. The overwhelming
majority of us will agree that much of treatment I discuss in this paper is wrong
and must be rectified. Yet we can agree on that quite independently of whether
we also agree that people with cognitive impairments share exactly the same
moral status with more typical adult human beings. To a large extent, that par-
ticular issue is entirely orthogonal.

In sum, if we want to understand how people with cognitive disabilities
are treated unjustly, understand why they are so treated, and what we must do
better, then we must pay far more attention to the nature and function of perni-
cious social hierarchies.

II. Moral Status and Its Necessity

Our widespread practices and behaviour suggest that most of us believe that
all human beings have a higher moral status than (almost all) animals. Philo-
sophical justification for this belief has proven elusive. It is helpful to begin
by distinguishing two broad approaches to the question of moral status (cf.
Jaworska and Tannenbaum 2014).

Threshold accounts. Questions about the moral status of individuals with
‘severe’ or ‘profound’ cognitive disabilities are unavoidably vexing for any
view that designates high level, typically human cognitive wherewithal—ra-
tionality, the capacity for moral agency—as a necessary condition for moral
status. Moral status is a threshold concept for such views: individuals who fall
below some minimal threshold have no moral status at all, and individuals who
are at or above the minimal threshold enjoy equal moral status. Human and
non-human individuals who lack rationality, the capacity for moral agency,
etc., have no moral status at all. We are permitted to treat them as we will, as
long as we do not violate any moral requirements towards those who do have
moral status (including oneself).

Interest accounts. On these accounts, the concept of moral status, if it is
relevant at all (Sachs 2011), refers to identifying the specific individual inter-
ests which must be considered in determining how we ought to treat others.
In developing a version of this approach, Peter Singer notoriously compares
human beings with very ‘severe’ or ‘profound’ cognitive disabilities to non-
human animals (Singer 2011: 135–36). Non-human animals and severely cog-
nitively disabled humans share many of the same interests, such as that of
avoiding pain. Whether individual humans with severe cognitive disabilities
have an interest in continued living has also been extensively discussed under

Linda Barclay608

this approach. Following Michael Tooley (Tooley 1972), Singer argues that
only persons can claim such an interest, and most non-human animals, human
infants, and some individuals with severe cognitive disabilities are not persons
(Singer 2011: 160–67). The wrongness of (painlessly) killing such individu-
als, according to Singer, is to be entirely explained by its negative effects on
overall utility, that is, on the interests of others, such as parents, would-be
parents and so on. Hence interest accounts, like threshold accounts, assuage
our shocked sensibilities by suggesting that we have indirect reasons for not
wantonly killing (for fun, say) individuals who are not persons.

Despite the obvious differences between threshold and interest accounts
of moral status, it is what they share in common that is of interest here: neither
draws the boundaries of moral status to include all and only human beings. On
the interest approach, there is no compelling reason to deny that most animals
will share some of our most important interests, such as avoiding pain and
suffering. Equally, not all humans will have the same interests: some humans
who are persons will have more and perhaps weightier interests than those
humans who are not persons. Most threshold accounts of moral status propose
criteria for moral status that will exclude most animals, but also many human
beings. In response to the concern of exclusion, one can propose a less de-
manding threshold: the capacity for sentience for example, rather than capaci-
ties for rationality or moral agency. A criterion like sentience would helpfully
include virtually all human beings, but would include nearly all animals as
well. Thus, neither approach to moral status defends our common intuitions
about the equal moral status of all human beings, and lesser moral status (if
any) for most animals. While those who advocate for the interests or rights of
animals might embrace this conclusion, it is considered a wholly unacceptable
outcome by those who advocate for people with disability: ‘reducing’ people
with cognitive disabilities to the status of animals exemplifies everything we
rail against.

More recently new theories about the criteria for moral status have been
developed with the aim of defending the common belief that all human be-
ings share a higher moral status than (most) non-human animals. The various
theories are well-rehearsed, such as genetic species membership (Liao 2012),
or the capacity to participate in person-rearing relationships (Jaworska and
Tannenbaum 2014). All such proposals remain deeply controversial. As Ag-
nieszka Jaworska and Julie Tannenbaum argue, “providing an adequate theory
to account for the FMS [full moral status] of unimpaired infants and cogni-
tively impaired human beings (whether infants or adults) without attributing
the same status to most animals has proven very difficult . . . this challenge
has not been fully met by any of the existing accounts of the grounds of moral
status” (2018).

609Cognitive Disability and Social Inequality

This challenge is particularly acute for theories of moral status that focus
on the capacities or properties of individuals as grounds for moral status. I
will not focus further on the details of such approaches to moral status, nor
on whether they succeed in meeting the challenge described by Jaworska and
Tannenbaum. Of somewhat more relevance to my argument are alternative
approaches to moral status which shift the focus away from the capacities of
individuals and on to more social features characteristic of the relations be-
tween human beings. There are a range of such views, including those identi-
fied as Wittgensteinian in nature (cf. Diamond 1978); those which argue that
moral status can be bestowed on human beings (but not animals) by virtue of
being taken into the life of the human community (Vehmas and Curtis 2017);
and those which argue that what we owe other human beings is related to their
participation in characteristically human forms of social life (Vorhaus 2017).
As I will argue in Section V, some of these theories do indeed identify some-
thing morally crucial, but mistakenly attribute it to the issue of moral status.
Understanding the moral importance of participating in specifically human
forms of social life does not lead us to conclusions about the bestowment of
moral status, but about the need to identify and oppose social hierarchy. This
latter conclusion can be reached whilst remaining largely silent on the vexed
question about the precise nature of the moral status of people with ‘profound’
cognitive disabilities.

Before proceeding with this discussion, I acknowledge that it is certainly
true that the arguments to follow presuppose that people with cognitive dis-
abilities have some moral status. Put somewhat differently, the possession of
moral status is necessary in order for a person to be wronged by social hierar-
chy: if a person has no moral status, nor can they be wronged by social status
hierarchies either.

As we have seen, this is a vexing result for many threshold accounts
of moral status centred on individual capacities, as many people with very
‘severe’ or ‘profound’ cognitive disabilities will not meet many nominated
thresholds. If an individual does not meet whatever threshold is posited for
possessing any moral status at all, then we can never have any direct reasons
to avoid treating them as social inferiors. I can hardly take on the task here of
showing why demanding threshold views are wrong. I hope my discussion of
the obvious harms inflicted on people with cognitive disabilities when they are
treated as social inferiors acts as a kind of reductio of demanding threshold
views. If not, I concede that my audience is restricted to the vast majority of
us who believe that people with ‘severe’ or ‘profound’ cognitive disabilities do
indeed possess at least some moral status.

In contrast to threshold views, interest accounts of moral status have little
difficulty in accepting that people with even the most ‘severe’ cognitive dis-

Linda Barclay610

abilities have interests and therefore moral status: on virtually all interest ac-
counts any individual who is sentient has some interests. Most of my claims
about the harms caused by social hierarchy will be accepted by those who
hold interest accounts of moral status, including utilitarians, as I will indicate
throughout: indeed, for most such accounts, it is precisely in identifying the
harms of various forms of social hierarchy that we establish an individual’s
interest against them.

On the other hand, as I have mentioned, it is certainly not clear that interest
accounts would recognise that newborns have an interest in continued living.
Singer has denied that newborns (disabled or not) have a direct interest in
continued living (Singer 2011: 135–36). I acknowledge that it is precisely this
position that motivates many people to develop alternative accounts of moral
status—so that they can demonstrate that it is directly wrong to kill newborns,
including disabled newborns. While I agree that it is, all of the harms that I
identify in this paper apply only to those who are living among us as socially-
engaged individuals. As such, my arguments about social hierarchy do not
obviously apply to the case of newborns. I must confess, I am not overly con-
cerned by this limitation. While I appreciate the motivation some have to ad-
dress utilitarian views about the moral status of newborns, part of my motiva-
tion in this paper is to address what I take to be the comparative neglect of the
way we engage with the millions of people with cognitive disability who live
among us, and always will. For example, we don’t talk nearly enough about
the dirty business of residential facilities in moral philosophy.

III. Social Status

According to distributive theories of justice, equality consists of people hav-
ing an equal amount of something, such as resources, capabilities or opportu-
nity for welfare (Arneson 1989; Cohen 1989; Dworkin 2000). Numerous and
elaborate theories of distributive justice have been developed as answers to the
‘equality of what’ challenge since the 1980s.

Social egalitarianism has emerged partly in response to the dominance of
distributive approaches to equality. Social egalitarians deny that equality ex-
clusively concerns what one gets in the form of individual holdings. Equality
also, or perhaps more fundamentally, concerns the quality of the relationships
between individuals, including between individuals and those who govern
them. It has been argued not only that distributive approaches have ignored
these relational considerations, but that numerous distributive theories propose
conceptions of equality that promote the kinds of relations that social egalitar-
ians oppose. For example, both Elizabeth Anderson and Jonathan Wolff argue
that the focus on individual responsibility in many distributive theories would

611Cognitive Disability and Social Inequality

endorse disrespectful and disparaging judgments which promote social hierar-
chies (Wolff 1998; Anderson 1999).

What exactly are the kinds of relations that exemplify social equality ac-
cording to social egalitarians? To a large extent, social egalitarians develop
their case by way of negative example, where we are encouraged to share their
intuitions that a particular form of relationship is at odds with social equality.
Moreover, social egalitarians have been slow to develop their own systematic
accounts of equality with the detail and complexity characteristic of distribu-
tive approaches.2 As such, we’ll begin with some of the paradigmatic examples
that social egalitarians offer as exemplifying problematic instances of social
hierarchy. Examples of hierarchical social status relations typical in class and
caste societies are commonly cited. Social inferiors might be expected to en-
gage in explicit acts of deference and submission, such as tugging at the fore-
lock, bowing and avoiding eye contact, whilst superiors might condescend,
sneer and belittle and expect to receive various social privileges. Members of
highly stratified societies also tend to lack easy, fraternal relations when their
tastes, leisure pursuits, consumption patterns, assumptions, stereotypes and
sources of information are strongly divided according to location in the social
hierarchy. The vision expressed by recent social egalitarians “identifies a so-
cial ideal, the ideal of a society in which people regard and treat one another as
equals, in other words a society that is not marked by status divisions such that
one can place different people in hierarchically ranked categories, in different
classes for instance” (Miller 1997: 224).

Social status hierarchies are also connected to domination. Some exercise
considerable control over others, including decision-making authority at work
and in the provision of public services, decisions over what is produced and
consumed, what achievements are celebrated and how prizes are distributed.
Social inferiors are often marginalised from society in various ways, either
locked out of highly rewarded and esteemed productive activity, or isolated
from valuable forms of social and cultural life. Individuals in highly stratified
societies also experience radically different access and success with respect to
political power (Young 1990). The effects of domination, marginalisation and
unequal power can range from feelings of worthlessness and shame, lack of
access to opportunities for esteem and personal autonomy, lack of opportunity
for economic, social, political and cultural engagement and influence, to sig-
nificantly poorer health outcomes (O’Neill 2010).

We can render some of this somewhat abstract discussion more concrete
with an example. My focus is on the case of people with cognitive disabilities,
but examples abound of groups stratified by gender, class, race or other mark-

2. In section V I will argue that these are not flaws of social egalitarianism, but indicate a pur-
poseful methodological approach with superior capacity to address real world inequality.

Linda Barclay612

ers of social hierarchy. People with cognitive disabilities often share many
core experiences of social status inequality. Imagine one such group of people
with a range of disabilities living in a supported residential environment. Some
of the care workers speak to them with a tone of condescension and infantiliza-
tion whereas others routinely express impatience and contempt. The privacy of
the residents is often violated, when staff walk into their rooms without knock-
ing, or assist them with personal care without ensuring others cannot interrupt
or observe. The food and recreational activities offered to the residents are of
poor quality, and inadequate staffing levels also contributes to residents often
missing out on showers, assistance with eating and participation is social and
cultural activities. To keep costs down, the facility is located on the outskirts of
town and difficult to access via public transport. To meet their safety reporting
targets, residents are not permitted to leave the facility on their own or even to
wander the gardens unattended. Many of the residents therefore have little to
no contact with close friends or family members, nor are they able to engage
in the life of their community. Many of the residents are terribly lonely, bored
and frustrated, are sometimes hungry, and suffer occasional medical problems
associated with a lack of hygiene and prompt medical attention. No one takes
initiative to ensure that residents have a genuine opportunity to vote in elec-
tions. While much of this story will resonate with those familiar with residen-
tial care for people with cognitive disabilities, it will also be familiar to many
older people living in supported accommodation.

Does the treatment the residents are exposed to—the behaviours, the prac-
tices, the policies—ensure that they enjoy equal social status with those they
routinely engage with? I don’t think so. Those who are charged with support-
ing them often act as social superiors, free to express scorn, and to infantilise.
Given the vulnerability of the residents with respect to accessing the most ba-
sic of requirements such as food, personal care and social contact, it is unsur-
prising that some of them who are less disabled might tend towards deference
and servility and a general desire to please. The residents are marginalised,
or indeed segregated, from the broader life of the community, its cultural, so-
cial and political activities. They can be aptly described as dominated when
they have no security in staying clean, or consuming nutritious meals, but are
instead at the mercy of others’ decisions around staffing levels, staff qualifica-
tions and institutional priorities. The residents and those who have such ex-
tensive control over their lives do not “stand in front of each other as equals”
(Bidadanure 2016: 236).

The kind of social status hierarchy I have described is very widespread in
residential care settings (Gjermestad, Luteberget et al. 2017; Steele, Swaffer
et al. 2019; Murphy and Bantry-White 2021). As Kieran Murphy and Elea-

613Cognitive Disability and Social Inequality

nor Bantry-White state, their evaluation of over 620 inspection reports of care
homes in Ireland demonstrates

that people with an intellectual disability were not regarded as citizens capable
of inclusion in society. If they were, people would not have had to experience
daily restrictions on their lives, be subjected to abuse and be segregated,
isolated and neglected. . . . The findings depicted a system of residential care
that disempowered, controlled and monitored people. The combined findings
demonstrated that the system of residential care for people with an intellectual
disability was one of total control as described by Altermark in his work
Citizenship Inclusion and Intellectual Disability, namely a system designed
to monitor behaviour; dependant on a hierarchy between staff and residents;
constant control; with the control being individualised to micromanage every
aspect of people’s lives. (Murphy and Bantry-White 2021: 763–64)

Moreover, it is plausible that such extensive status differences render residents
vulnerable to further forms of maltreatment and abuse. We know that vulner-
able people in residential care suffer high levels of sexual and physical abuse
(Baladerian 1991; Horner-Johnson and Drum 2006; Murphy and Bantry-White
2021). Condescension, neglect, powerlessness and infantilization, contribute
to an environment where people relegated to an inferior position in a social
hierarchy are prey to violence and egregious forms of harm. I will elaborate on
this claim in more detail in the next section.

It emerges from this picture that one’s location in a social hierarchy is
constituted by the nature of the relationships one has with others. One occupies
a lower position in the social hierarchy because of the way one is regularly
treated by others, and the decision-making power they yield. The ideas of reg-
ularity and scope are important here. Everyone can be occasionally subject to
sneering and condescension by particular others. This is not sufficient to make
one an inferior in a social status hierarchy. Such inferiors are regularly subject
to a range of convention and norm-driven behaviours of this type. Similarly,
each of us can occasionally find ourselves marginalised or excluded from a
valuable opportunity through happenstance, bad luck, our own earlier deci-
sions, etc. Social inferiors are marginalised and excluded from a wide range of
economic, social, political and cultural opportunities which has a very signifi-
cant impact on the course of their lives.3

Having now outlined the basic contours of both moral status and social
status, questions arise as to the nature of the relationship between them. Given
that most philosophical debate about people with ‘profound’ cognitive dis-
abilities concerns moral status, it would be natural to assume that questions
3. It follows that there can be vagueness and disagreement in some cases as to where people

are located in social hierarchies, or whether there are any hierarchies at play. I think this
is just what we should expect. In marginal cases, there can be genuine disagreement as to
whether social hierarchies exist and as to where people are located. I discuss some of this
complexity in (Barclay 2020).

Linda Barclay614

about the nature and permissibility of social status hierarchies are subordinate
to the question of moral status. In one respect, this is true: as I have explained
in Section II, people with ‘profound’ cognitive disabilities must possess some
moral status in order for these behaviours to be directly morally troubling. The
possession of moral status is a necessary condition for the impermissibility of
social hierarchy. Those who subscribe to demanding threshold views of moral
status will find no direct reasons to morally condemn the harms and suffering
inflicted on the residents. As I have stated, those who hold such views are not
my audience here. On the other hand, most interest accounts of moral status
will surely believe that significant interests are at stake in these examples.
People with cognitive disabilities can be lonely, bored, frustrated, agitated,
humiliated, hungry, and vulnerable to the harms of abuse and medical neglect.
As such, some of their significant interests are at stake in pernicious social
hierarchies. Utilitarians like Singer certainly agree that individuals with cog-
nitive impairments can suffer in the ways I have described, and as such they
have morally-considerably interests that must be taken into account. They
have moral status.

Beyond recognising that people with ‘profound’ cognitive disabilities do
possess moral status, theories of moral status have little further to add to ques-
tions about the nature, function and permissibility of social hierarchies, as I
will argue in the next three sections.

IV. The Conventional View

The most straightforward way to suggest a more significant role for theories
of moral status in addressing the morality of social hierarchy is by adoption of
what I will call the conventional view. According to the conventional view, it
is the belief that some people have lower moral status that causes social hier-
archy: in other words, the various attitudes and behaviours that constitute so-
cial status hierarchies express people’s beliefs that social inferiors have lower
moral status.

The conventional view is perhaps the simplest way to understand some
of the following claims by prominent social egalitarians. Anderson states that
“Inegalitarianism asserted the justice or necessity of basing social order on a
hierarchy of human beings, ranked according to intrinsic worth. . . . Egalitar-
ian political movements oppose such hierarchies. They assert the equal moral
worth of persons” (Anderson 1999: 312). Similarly, Christian Schemmel sug-
gests that “[egalitarian] movements generally demand treatment that affirms
their equal moral status. What they are after is the confirmation that the people
they represent are not, by virtue of belonging to a group such as women or
gays, of inferior moral worth, and, accordingly, they demand state action that

615Cognitive Disability and Social Inequality

makes this clear” (Schemmel 2011: 134). I suspect the conventional view un-
derpins much of the objection to social status hierarchies, taken as they are as
expressions of the belief that some people have lower moral status or worth.
Indeed, so widespread is this view that most people do not typically distinguish
between moral and social status when denouncing inequality and hierarchy.

I certainly have no wish to deny that some of the most egregious social
status hierarchies have been built upon and sustained by widely shared beliefs
that those at the bottom of such hierarchies have lower moral status. This is
certainly the case for disability: people with disabilities have been treated in-
tolerably because of widespread dehumanising stigma around disability. Noth-
ing in what follows should be taken to deny this fact. Nevertheless, there are
numerous factors that sustain hierarchical social relations which cannot be re-
duced to the existence of widespread beliefs about inferior moral status, and
this is also the case for disability. I will argue that beliefs about low moral sta-
tus are not necessary for social hierarchies to emerge; indeed, social hierarchy
can emerge even when people sincerely disavow the view that some people are
of lesser moral worth.

To begin with the relatively mundane, social hierarchy can sometimes
emerge for reasons that are themselves morally acceptable. Decisions about
the allocation of limited resources, planning decisions, health care priorities
and the like can all have the unintended and often unforeseen effect of con-
tributing to social status hierarchies. Consider a concrete example of children
with cognitive disabilities who are taught separately from children without
such disabilities. Segregated schooling might be a response to concerns from
parents and educators about the failure of children with disabilities to thrive in
mainstream schools. There may be some evidence to support this claim, and
concern from parents about the bullying and social exclusion their children
have been subjected to. Evidence might suggest that educating some children
with cognitive disabilities in specialist schools improves their educational and
social outcomes. Nonetheless, the evidence might also show that segregated
education is a contributing factor to longer-term marginalisation, as people
without disabilities remain ignorant of the capabilities of people with disabili-
ties, as well as insecure and uncomfortable in interacting with them.

Consider also the case of residential aged or disability care located on the
outskirts of major cities. Planners and policies makers have to allocate scarce
resources, and residential homes in the inner city might be prohibitively ex-
pensive. Planners may also be rightly concerned that the high cost might put
inner-city facilities out of reach of all but the wealthy. As explained above,
locating residential facilitates far from city centres or from public transport can
lead to marginalisation, but in this case being marginalised would not neces-
sarily be caused by the belief that people in need of residential care have lower

Linda Barclay616

moral status. These examples—and there are many just like them—support the
contention that social status hierarchy can sometimes arise from a combina-
tion of factors other than a widespread belief that some people have low moral
status.

More generally, individuals’ beliefs often do not provide the best explana-
tion for the persistence of social status hierarchies. Sally Haslanger has argued
that ‘social meanings’ can create social injustice, where those meanings con-
sist of more than beliefs (Haslanger 2015; Haslanger 2017a). She argues that
the way we think and act is shaped by culturally-shared meanings—“cultural
schemas”—beyond and sometimes prior to propositional attitudes. They can
include things like culturally shared propositions, but also norms and concepts
that when internalised by individuals become the basis of various behavioural
and emotional dispositions. They highlight some parts of the world and ob-
scure others, thus partly shaping our perception; they also link some things
to others, conceptually, or through shared narratives and stories. “Thought,
perception, emotion and other psychological states depend on a public ‘field of
preexisting meanings’ . . . this ‘field’ shapes and conditions our experience and
agency, and provides a kind of palette of psychological content” (Haslanger
2017a: 154). Such cultural schemes function to provide us with the ‘tools’ for
interpretation, interaction and coordination that enables social fluency with
respect to our shared practices. Cultural schemas shape the way we respond
to the world, how we organise ourselves, distribute resources, use implements
and objects, relate to one another, formulate rules and policies. The effect is
that our social arrangements and practices reinforce the social meanings that
produced them, making it seem as though our cultural schemas interpret and
value the world the way it really is. Culture is a source of beliefs, not just an
effect of them (Haslanger 2017b).

One upshot of Haslanger’s view is that we underestimate the resilience
of social injustice if we characterise it simply as an effect of pernicious or
false beliefs. Injustice can be sustained by practices, and the social structures
they constitute. Returning to the example of residential care, care staff im-
mersed in shared practices of caring for the disabled and the very old often
take themselves to be acting in the best interests of those they care for, fully
dedicated to securing their well-being, avoiding risk, improving accessibility
and showing kindness. The social meanings at play are internalised by carers
to shape their shared understandings of what constitutes good caring, allowing
a degree of fluency in their coordination. Challenging some of their beliefs (for
example, about risk, privacy, dependency, appropriate tone of voice) is likely
to be of limited benefit when the practices they engage in reinforce the inter-
nalised social meanings that inform them. To overemphasise the role of perni-
cious beliefs in producing or sustaining social hierarchy is to ignore the more

617Cognitive Disability and Social Inequality

complex structural story which can explain the way an unjust social system
reinforces itself. It can do so even in cases where people disavow pernicious
beliefs about the moral inferiority of others. As Haslanger argues, changing
patterns of thought, both explicit and implicit, often requires changes to social
structures and the schemas that inform them (Haslanger 2015).

Indeed, insofar as people may hold beliefs about the moral inferiority of
disabled people using residential care, such beliefs might be an effect of wide-
spread practices which perpetuate social status hierarchies, rather than their
cause. It is plausible to suppose that the creation of social hierarchies between
people with cognitive disabilities and those who interact with them is some-
thing that can contribute to shaping even more unjust practices. We cannot
ignore not only the long history, but also contemporary evidence of the sheer
extent of injustice to which people with cognitive disabilities are exposed,
including violence, extreme physical, medical and emotional neglect, sexual
abuse, institutionalisation in squalid and unsafe environments and involuntary
medical experimentation, are just some examples (Baladerian 1991; Horner-
Johnson and Drum 2006; Troller, Srasuebkul et al. 2017). The construction of
people with cognitive disabilities as social inferiors surely plays some explan-
atory role in such maltreatment (cf. Carlson 2019). To routinely engage with
people with cognitive disabilities as social inferiors can contribute to dehu-
manising social meanings around disability that in turn shape practices that all
of us should recognize as profoundly unjust—those characterised by violence,
sexual abuse, severe neglect, and distributive injustice.

I have argued in this section that beliefs about lower moral status do not
necessarily explain the emergence or persistence of social inequality. Social
hierarchies can emerge from and be sustained by a range of beliefs and broader
social meanings, some of which may not themselves be morally troubling, or at
least not obviously so. The emergence and persistence of social status inequal-
ity is often not aptly described as an expression of widespread beliefs about
inferior moral status, although the existence of widespread social status hier-
archies can itself play a causal role in producing and perpetuating views about
the inferior moral status of people with cognitive disability. It is of course true
that some of the most egregious social hierarchies have been undergirded by
widespread beliefs about the inferior moral status of some groups of human
beings. Nothing argued here should be taken to deny that fact. What is being
argued is that the conventional view is too limited to fully explain the extent
of the social hierarchy characteristic of the relationship between people with
and without disabilities.

One implicit upshot of the argument so far is that we need to be far more
attentive to the social facts before any conclusions can be drawn about the
role of moral status claims in perpetuating social hierarchies. Only by paying

Linda Barclay618

attention to the actual history, cause, nature and justification of various social
relations can we make judgements about what role, if any, beliefs about moral
status are playing. This appeal to the importance of social facts is central to the
methodology of much recent social egalitarian theorising, which I will elabo-
rate upon in the next section.

V. The Impermissibility View

I have rejected the view that social status inequality is always just an effect or
expression of the belief that those at the bottom of the hierarchy have lower
moral status. Another possible relationship between moral status and social
status is what I will call the impermissibility view. According to the imper-
missibility view, social status hierarchies are morally impermissible because
they fail to respect our moral status. When Anderson claims that egalitarian
movements “assert the equal moral worth of persons” and Schemmel says
that they “demand treatment that affirms their equal moral status” they might
be interpreted as stating that social status hierarchies are morally wrong be-
cause incompatible with our equal moral status. This normative claim does not
presuppose the conventional view, which I criticised in the previous section.
One can accept that social status hierarchy might arise from factors other than
beliefs that some have inferior moral status, but nevertheless argue that social
hierarchy must be eliminated because it is in conflict with our moral status. In
other words, the fact that all human beings have moral status is sufficient to
denounce social status hierarchy, whatever its causal origins, and whatever the
forces that sustain it.

I am largely sympathetic to this claim. I think many cases of social hier-
archy are morally impermissible because they do not respect our moral status,
even if they happen to have arisen from reasons or circumstances that are in
themselves morally acceptable. However, I shall develop two arguments in
what follows. Firstly, in this section I will show that facts about moral status
do very little explanatory work in establishing this case against social status
hierarchies. In terms of identifying morally unacceptable social hierarchies,
and knowing how to rectify them, philosophical views about moral status are
largely uninformative. To understand when social hierarchies are wrong be-
cause in conflict with moral status, we need to pay much more attention to
the nature and function of social inequality. In this sense, further theorising
about the grounds for moral status is rather irrelevant. Secondly, in section
VI I will also argue that it is not necessary to establish that all participants in
social relations must share equal or the same moral status in order to plausibly
denounce social status hierarchies. Even if some people have different or even
‘lower’ moral status than others, social status inequality can still be morally

619Cognitive Disability and Social Inequality

impermissible. As such, we can reject much of the injustice inflicted on people
with ‘profound’ cognitive disabilities in the actual world without establishing
that we all share the same moral status.

What would be required to determine whether social hierarchies are mor-
ally impermissible? Certainly not all social hierarchies strike us as impermis-
sible. Social relations are replete with behaviour that expresses social hierar-
chy. When a judge enters a courtroom, we stand for her; we address her only
by title, never by name; we respect her almost unlimited authority in the court
to dictate when we may or may not speak, stand, and so on. Another example:
in most countries, there are numerous ways in which children and the young
are expected to behave deferentially toward (some) adults. They too might be
required to use titles when addressing others, or to ask permission to speak or
leave a room. Perhaps they have to stand when a teacher enters the room. Most
of us consider it acceptable to talk about babies to others even when the baby
is in the room, to ignore adult standards of privacy when bathing the baby, and
to use a tone of voice that would be regarded as shockingly condescending if
used in conversation with an adult.

Are these instances of morally unacceptable social hierarchy? We will not
get far in answering this question by arguing that non-judges, young people
and babies have full moral status, for example because they are members of
the human species, or are sentient, or can participate in person-rearing rela-
tionships, or because they are rational (admittedly a stretch in the case of ba-
bies!). So what? What we need to know is whether non-judges, young people
and babies have a significant interest in not being treated in the manner de-
scribed, and it strikes me as fairly obvious that the answer to this question
must be determined by careful attention to the social facts. Most obviously,
we would need to be attentive to various facts about whether these modes
of treatment cause harm to the recipients; whether broader social damage is
wrought by allowing relations marked by such status differences to flourish;
or whether these particular behaviours and norms interact with other aspects
of social relations to generate harmful and damaging outcomes. For example,
we might ask whether our norms in the courtroom hinder fair trials; whether
such norms contribute to judges wielding disproportionate political power,
or whether they create or reinforce expectations that others should defer and
grovel to judges in a wide range of social settings outside of the court room.
We might ask whether such norms induce feelings of shame and humiliation
in other participants in court cases, and whether they contribute to widespread
stigma against lawyers, jurors and defendants who are required to stand for the
judge and refer to her as ‘Your Honour.” Even if the answers to some of these
questions are affirmative (which I very much doubt), the case against our court
room norms of status hierarchy is not established. For we would still have to

Linda Barclay620

ask whether there are compelling reasons for the norms, and whether it is pos-
sible to abolish or modify them without jeopardising respect for those reasons.

Similar questions arise in scrutinising the behaviour between adults and
children. Does bathing babies naked in front of other people undermine mor-
ally valuable relations between babies and adults? Is it likely to induce shame
and humiliation, or contribute to a broader pattern of social meaning and be-
haviour which render babies vulnerable to physical and psychological neglect
and harm? Posing questions such as these takes us deep into an exploration of
the nature of babies, how they flourish, and facts about how our social norms
and patterns of behaviour might stunt or facilitate such flourishing. It requires
attention to the construction of social meaning and how cultural schemas can
sustain our participation in social injustice.

Theories of moral status are almost entirely irrelevant to this task. Take
the threshold account of moral status. Let’s grant for the sake of argument that
all non-judges and all young people and babies meet the threshold for moral
status. That starting place affords no guidance as to whether the behaviours
we are discussing are morally acceptable or not. Jaworska and Tannenbaum,
address head on the question of what follows from any given threshold ac-
count of moral status in terms of how we should treat one another. They come
up with the following suggestions, all of which they concede are contentious,
some highly so: a moral presumption against certain types of interference,
such as killing and medically experimenting on the being in question; a strong,
but not necessarily stringent reason to aid; a strong reason to treat fairly, with
the caveat that what counts as ‘fairly’ is highly contentious (Jaworska and Tan-
nenbaum 2018). None of these questions figure directly in a serious explora-
tion as to which of our social status examples are impermissible.

An interest approach to moral status will have a much more direct path to
acknowledging that all nonjudges have an interest in avoiding stigma, humili-
ation, and harm. We still do not know whether the norms of the courtroom are
morally bad or suspect: only close attention to the social facts can guide us. To
repeat, we’d have to explore whether the hierarchical norms of the courtroom
contribute to harm outside of it, by, for example, contributing to social mean-
ing about the comparative worthlessness of nonjudges which ultimately harms
their interests. With babies, the questions are more complex still: whether they
even have an interest in avoiding powerlessness and marginalisation, what
their actual interests might be, and what patterns of behaviour are consistent
with promoting them. To reach any conclusions on these vexed questions re-
quires that we pay attention to how social hierarchies actually function in real-
world cases. Knowledge about how social hierarchies function is essential to
reaching any normative conclusions about when we need to avoid them, which
ones specifically we need to avoid, and how we might do so. In this sense, un-

621Cognitive Disability and Social Inequality

derstanding that we have the moral status granted to us on an interest account
is not sufficient to establish the moral impermissibility of social hierarchy, or
even throw much light on why it is so.

Critics of social egalitarianism have accused it of being vague and impre-
cise in its approach to equality. The accusation is based in a number of reasons,
including the tendency of social egalitarians to eschew ideal theories of justice
of the type that have dominated distributive approaches to equality. Instead of
engaging in endlessly complex specifications of an ideal conception of equal-
ity, social egalitarians often proceed by highlighting actual cases of manifest
injustice: indeed, they are often very sceptical that ideal theories of justice
shed much explanatory light on, or prescriptive guidance with respect to, ac-
tual cases of injustice (Anderson 2010; Anderson 2012; Wolff 2015). Their
preferred methodological approach is to scrutinise the nature and function of
actual instances of social inequality as an essential step in proposing effective
solutions. As such, social egalitarians have typically been highly attentive to
the actual ‘sociology of disadvantage’ (Axelsen and Bidadanure 2019). As Da-
vid Axelsen and Juliana Bidadanure argue, the diagnostic precision attained by
social egalitarians (their ability to identify ills within the actual world) “stems
from constructing their account around, and not abstracting from, the most sa-
lient features of how inequalities and disadvantages actually appear and func-
tion” (2019: 344, emphasis in the original). Or as they put it, the normative
significance of equality is tied to the sociology of actual disadvantages.

If we return to the cases which are the focus of this paper, we need to
ask a range of questions about how inequalities function. Does speaking with
condescension to adults with cognitive disabilities, or ignoring privacy norms,
humiliate them? Even if some such people are impervious to feelings of hu-
miliation and shame it is equally crucial to know whether such behaviours
contribute to pernicious social meanings around disability that can render dis-
abled people vulnerable to neglect and harm. Does housing people with cogni-
tive disabilities away from the centre of communities lead to social isolation,
loneliness and vulnerability to abuse? Do paternalistic policies in residential
settings rob people of the opportunity to develop independence skills, and
thus decrease their opportunities for self-esteem and the satisfaction of their
preferences? Does the inability to contribute to the life of the community—
through work, social, cultural and political engagement—render them prey to
the preferences and choices of others in which their own needs are likely to
be overlooked? I am confident that the answers to these questions are often af-
firmative, and that as such any interest approach to moral status will grant that
important interests are at stake. But it is not my intention to prosecute this case
here. What, instead, I have been arguing is that if philosophy is to contribute to
detecting and addressing the actual injustices to which people with cognitive

Linda Barclay622

disabilities are most often exposed, we need to spend much more time thinking
about the nature and function of social status rather than engaging in endless
abstract debates about the grounds for moral status.

As we know, many philosophers who focus on theories of moral status
trade heavily in comparing people with ‘profound’ cognitive disabilities to
animals. As such, they are likely to do so here as well by asking: if it is of-
ten wrong to treat people with cognitive disabilities according to hierarchical
social norms, doesn’t it follow that it must also be wrong to treat nonhuman
animals in similar ways? One of the most significant advantages of paying at-
tention to the actual facts of social inequality is that we can cut off any easy
comparison between animals and people at the pass. If we want to question the
moral acceptability of some of the standard ways we fail to treat animals as
our social equals—commanding them to sit when they’d rather stand; failing
to dress them; making them eat from a bowl on the floor—only attention to the
social facts will help us. My own view is that the sociology of disadvantage
and injustice is likely to reassure us that treating animals in these ways is com-
patible with respecting their interests: shame and humiliation are not likely
at stake, and nor are the social meanings reenforced by such behaviour likely
to lead to domestic pets being abused or neglected. But my aim here is not to
prosecute the details of this particular case. What I am pressing is that attention
to the nature and function of social relations is what will largely determine the
matter, rather than appeal to a theory of moral status. I am assuming that my
readers share some of my moral qualms about the cognitive disability cases. In
these cases it is clear that theories of moral status have marginal informational
importance in determining whether or not relations characterised by social hi-
erarchy are morally unacceptable, and nor do we need to rely on the develop-
ment of such a theory to tell us why we often have compelling reasons to treat
other human beings differently to how we treat domestic pets.

I flagged in section II that there is a degree of overlap between my argu-
ment in this paper and more recent theories of moral status that shift focus
away from the capacities of individuals toward the social relations between
human beings. For example Simo Vehmas and Benjamin Curtis argue that
moral status is bestowed on individuals with serious cognitive impairments
by virtue of their relationship to other human beings, specifically by being
taking in to the human community. Being taken into the human community
means being treated as a human within the human community (Vehmas and
Curtis 2017: 510), something usually not possible or desirable with animals.
Clearly I agree with them that human beings quite appropriately relate to each
other differently to how we relate to other animals. But while this aspect of
their view is compelling, what they fail to do is offer a convincing reason as to
why being taken into the human community in this way thereby bestows moral

623Cognitive Disability and Social Inequality

status on human individuals who would otherwise lack such status.4 On my
view, the connection between moral status and human relationships is quite
straightforward: as long as an individual can suffer harm or experience goods,
then we have strong reasons to denounce some forms of social relations and
promote other forms. For human beings, many goods or interests can only be
promoted within specific non-hierarchical types of human relationships. Moral
status comes first: because a human being (already) has various interests, we
need to assess which modes of human social interaction promote those inter-
ests and which jeopardise them. Because animals also have interests, we need
to do the same for them, although their interests are likely to be promoted
by very different types of relationships with humans. This is the relevance of
human relationships—their centrality to promoting or jeopardising interests—
not their ability to mysteriously bestow moral status on individuals who would
otherwise lack it.

Closer to my view is an argument developed by John Vorhaus (Vorhaus
2017). Vorhaus also connects moral status to participation in practices distinc-
tive of specifically human forms of life. He too defends a very rich account
of how our capacities—cognitive, social, emotional—are acquired within and
developed through participation in specifically human culture, including the
more specific norms and practices that distinguish one human culture from
another. What we owe one to one another is connected to such participation,
although exactly how participation grounds moral claims of this kind Vorhaus
does not say. His primary focus is to bolster the case that human beings par-
ticipate in characteristically enculturated human forms of life that animals do
not and cannot participate in (for the main), and this despite the fact that some
animals may have greater cognitive capacities (of some kinds) than some hu-
man beings.

Although he declines to develop a fulsome argument for how such partici-
pation is connected to moral status, I would argue that the reasons are already
embedded in his account, but that, as with Vehmas and Curtis, stirring the
idea of ‘moral status’ into the mix is needlessly obfuscating. In discussing the
case of human individuals whose capacities for participation in human culture
might be questioned, Vorhaus presents two compelling arguments for why we
should treat such individuals as though they have the potential to participate,
and thus engage them educationally, socially and in other ways characteristic
of human life, as far as possible. Most importantly he says that “there is a
large risk to people who are excluded or marginalised from the rest of their
society that they will become vulnerable to abuse or neglect, or that they will

4. In another article, Curtis and Vehmas deny that we are required to develop a theory of
moral status to defend out commonsense view that all human beings share a higher moral
status than animals (Curtis and Vehmas 2016).

Linda Barclay624

be stigmatised, or that they may be denied their lawful rights. The effects of
being treated as an outsider, or as sub-human, or as a non-citizen, are often
disastrous and lifelong” (Vorhaus 2017: 73). Secondly, he also argues that if
we treat people with cognitive disabilities as though they have the potential to
participate, then they are more likely to develop the capacities to do so, and
giving up on their potential means they will never develop such capacities.

I certainly agree with Vorhaus’ claims here, but what he doesn’t seem to
appreciate is that these arguments already explain why we should draw all
human beings, as far as possible, into morally worthy modes of social engage-
ment, whether their capacities are actual or merely potential: namely, failing
to do so will almost certainly jeopardise their most basic interests, in avoiding
harm, cruelty, medical neglect, social isolation, squalor and malnutrition, and
so on. Once again, moral status comes first: it is precisely because (nearly
all) human beings have such basic interests that their involvement in certain
social relations characteristic of human social life (and protection from other
relations) is so important for them. There is no additional, extra argument re-
quired to explain how participation of this kind grounds moral status. Talk of
moral status is obfuscating. We do better by thinking simply about what we
owe such people, as Vorhaus suggests: what we owe them is protection against
great harms and suffering, and it is by engaging in good social relations, and
being protected from bad social relations, that we go a long way to securing
such protection. Or so I have argued with respect to the ills of pernicious social
hierarchies.

VI. Equal Moral Status?

Much of the discussion so far has suggested a range of ways in which the
interests of people with cognitive disabilities can be threatened by relations
of social hierarchy. When such hierarchies can render them lonely, bored, dis-
tressed, agitated, hungry, vulnerable to abuse and medical neglect then pro-
ponents of interest accounts will accept my arguments that if social hierarchy
causes or contributes to such harms, then social hierarchy is (ceteris paribus)
wrong because it violates the interests and thus moral status of the individuals
involved. Utilitarians will accept these conclusions too, as long as the interests
at stake are not outweighed by the equally weighty interests of others.

However, such an interest-based argument against social hierarchy need
not presuppose that all individuals have equal moral status in the sense that
they have the same interests. As Singer has argued, equal interests must be
weighted equally, but this is compatible with different individuals having very
different interests and some having fewer than others.

625Cognitive Disability and Social Inequality

Given that the interest account of moral status is not a strict equality view,
it is also possible that not every individual has the same interests in always
avoiding hierarchical social relations. Indeed, that has been explicit, for ex-
ample, in the discussion of babies, where public naked bathing and a high-
pitched tone of voice may promote their interests, whereas we may have good
reason to suppose that the exact same behaviour may not promote the interests
of adults with cognitive disabilities, depending, as I have argued, on the ef-
fects and function of such relations. I certainly wouldn’t rule out that in order
to respect the interests of some individuals with cognitive disabilities we may
have to engage with them in a way that might resemble the way social inferiors
are treated. For example, it may be that a person with cognitive disabilities
is comforted by a tone of voice that might sound condescending, that such a
voice soothes and relieves agitation. A person with advanced dementia might
be wholly incapable of choosing what she wears, consenting to social activi-
ties and so on, such that carers make all of these decisions without consulting
with her. In cases like these, forms of interaction characteristic of that between
social equals may not be in the interests of the individuals concerned. As such,
whilst possessing moral status is a necessary condition for rejecting social hi-
erarchy, it is not sufficient: everything will depend on the social facts.

If this is right, then it indicates another way in which we have exaggerated
the importance of theories of moral status: it is not necessary to show that all
human beings share the exact same moral status to compellingly denounce
the morally unacceptable ways in which people with cognitive disabilities are
routinely treated. If we have good reasons to suppose that treating such indi-
viduals as social inferiors contributes to their being significantly harmed, then
any interest approach to moral status can recognise and morally reject such
treatment, including those interest accounts that would argue that people with
severe cognitive disabilities do not have all the same interests as more typical
adult human beings.

VII. Conclusion

I have suggested that many of the morally troubling ways we treat people
with cognitive disabilities in the actual world involves treating them as social
inferiors. I have argued that social status is distinct from moral status and that
to determine when relations of social hierarchy are morally impermissible we
need to scrutinise their function and effects rather than delve even deeper into
familiar debates about the moral status of people with ‘profound’ cognitive
disabilities. An appreciation of the fact that people with cognitive disabili-
ties have moral status—as they do—does not provide much information about
what causes and sustains social hierarchy, nor in what ways it damages, harms

Linda Barclay626

and oppresses people. That an individual has moral status is certainly a neces-
sary condition for the direct impermissibility of social hierarchy, but determin-
ing whether or not such hierarchy is actually morally impermissible requires
attention to the social facts. If philosophers want to contribute to addressing
the myriad of unjust ways that people with cognitive disabilities are so often
treated in the actual world, we should recognise that scrutiny of social sta-
tus will often be more fruitful than further engagement in intractable debates
about the best theory of moral status.

Monash University
linda.barclay@monash.edu

Acknowledgements
I would like to thank the referees for this journal as well as the participants at the “Dignity,
Equality and Social Status” conference (Monash University, December 2019) for their very
helpful feedback on earlier versions of this paper.

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Research Article
Cognitive Therapy for Children with Intellectual
Disabilities: A New Look at Social Adaptation Skills and
Interpersonal Relationships

Gulnaz Kulnazarova , Zhamiliya Namazbaeva, Laura Butabayeva , and Lazzat Tulepova

Department of Special Education, Abai Kazakh National Pedagogical University, Almaty 050010, Kazakhstan

Correspondence should be addressed to Gulnaz Kulnazarova; gukulnazarova@rambler.ru

Received 12 November 2022; Revised 26 January 2023; Accepted 4 March 2023; Published 3 April 2023

Academic Editor: Marta Pérez-de-Heredia-Torres

Copyright © 2023 Gulnaz Kulnazarova et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

The purpose of the study is to consider the factors influencing the development of the culture of interpersonal relationships and
the effectiveness of the influence of cognitive therapy on improving social adaptation skills. The method of cognitive therapy
included several types of activities. The first type of activities included group sessions, during which the weaknesses of the
interaction and their correction were identified. The second type was conducted in the format of teaching standard models of
interaction between people. The third type of activity aimed to teach children to build a dialogue with each other and express
their desires and emotions. Classes were held 3 times a week throughout the year. The study was attended by pupils of 5-7
grades of Zhanuya boarding school and special correctional boarding school No. 7 for children with intellectual disabilities.
The results of a randomized study demonstrated an increase in the indicators of teamwork skills, self-control, emotional
stability, and independent decision-making. The indicators of cheerfulness, openness, sociability, and logical thinking also
improved. But the factor of antisocial behavior decreased. All of these indicators directly affect socialization. This strategy can
be applied in practice in various specialized boarding schools and schools for children with intellectual disabilities.

1. Introduction

The study of the behavior of children with intellectual dis-
abilities is a rather relevant topic today. A decrease in intel-
lectual abilities can occur due to various diseases and factors.
The basis of pathogenesis is central nervous system disorders
[1]. These can be chromosomal pathologies such as Down,
Patau, and Edward syndromes. Also, chromosomal abnor-
malities include Angelman syndrome and Prader-Willi syn-
drome. The features of chromosomal abnormalities include
not only delayed intellectual development but also somatic
abnormalities. These include sinistral immunity, visual
problems, and abnormalities of the nervous system [2].
Abnormalities in mental development can also occur due
to complications during pregnancy and childbirth, as well
as due to external factors, for example, if the mother had
TORCH infections during pregnancy or was exposed to high
ionizing radiation doses. Quite often, birth trauma and fetal

asphyxia can be the causes of developmental delay. A nega-
tive factor can be the mother’s use of alcohol and drugs dur-
ing pregnancy [3]. Also, a decrease in the level of intelligence
is observed in the absence of proper education and training
of children in their first years of life, this often happens in
dysfunctional families [4]. These children often have com-
munication problems with the people around them. First,
due to a decrease in intelligence, children are not always able
to formulate and express their thoughts clearly, which often
leads to misunderstandings [5]. Secondly, emotional adapta-
tion is impaired, which is characterized by the inability of
children to adequately respond to various situations and
can also be manifested through isolation and avoidance of
social contacts [6]. Due to these factors, most children with
intellectual disabilities have problems with socialization
and self-realization in society. To help these children, pro-
grams are often used to develop their social and communica-
tion skills. They are usually implemented at specialized

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https://orcid.org/0000-0002-3758-8624

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https://doi.org/10.1155/2023/6466836

schools [7]. Due to the fact that the problem is global, there are
quite a lot of options for such training. Various cognitive behav-
ioral practices are very often used to teach interpersonal rela-
tionships [8]. For example, there are real-time play therapy
techniques: each participant must build a dialogue and learn
to solve various problems together with another person or a
group of people under the supervision of a teacher or psychol-
ogist [9]. Cognitive therapy options using various mobile appli-
cations are also being considered. These can be simple games
with cards that help children communicate with others and
by choosing one or another card, to show their emotions and
desires. This makes it easier to understand the needs of children
[10]. There are applications that simulate certain situations,
teach reactions, and, through repetition, reinforce the acquired
skill. For example, there are mobile phone applications that
match a word to an object or colour [11]. Currently, consider-
ation is being given to introducing a virtual universe using com-
puter technology. This makes it possible to expand the
variability of tasks and enhance visual fixation during trainings
[12]. Despite the positive dynamics and all possible options for
the socialization of children with intellectual disabilities, it
should be borne in mind that most studies have certain gaps.
Many of them require additional research in various focus
groups to obtain new results [13]. The problem of the culture
of relationships among people with intellectual disabilities is
quite relevant. Their inability to build social relationships
reduces the quality of life and prevents them from becoming
full-fledged members of society. Therefore, new training and
psychological assistance programs are constantly being devel-
oped in the world. This not only provides an opportunity for
socialization but also helps to change the attitude of society
towards people with impaired intellectual functions. More
research is required to understand the effectiveness of the
impact of cognitive techniques on interpersonal culture. It is
necessary to introduce similar experimental methods in schools
and boarding schools for children with intellectual disabilities.

2. Literature Review

Scientists from Sydney (Australia) conducted research on
impaired social interaction skills among children with intel-
lectual disabilities. They concluded that the main problem
lies in the impairment of the neuropsychological profile as
such children often have affective and comorbid disorders.
This leads to impaired memory, learning, and expression
of one’s own thoughts and emotions. In most cases, atten-
tion deficit hyperactivity disorder occurs. Due to this, com-
munication becomes difficult. It was also concluded that
there are very few methods for helping such children and
the best choice is cognitive behavioral therapy. However,
the data on the effectiveness of the influence turned out to
be rather controversial [14]. There was an experiment con-
ducted in the UK to introduce cognitive programs to help
people with congenital disabilities. The concept was to learn
to distinguish between behaviors, thoughts, feelings, and
emotions and to relate them to different situations. It was a
randomized study involving people with mild to moderate
mental retardation. These training sessions significantly
improved understanding of one’s own emotions, as well as

the ability to respond correctly to various life situations
[15]. Swedish researchers considered the impact of cognitive
group training on the socialization of children with autism
spectrum disorders. As part of the experiment, the effective-
ness of this method has been confirmed [16]. Studies by
South Korean researchers on the issue of socialization and
improvement of communication skills among people with
intellectual disabilities also confirmed their effectiveness.
The methodology aimed to teach people the rules of com-
munication, etiquette, and cultural characteristics of the
region. An intragroup study demonstrated a fairly high effi-
ciency [17]. In Victoria (Australia), researchers considered
the effects of cognitive behavioral therapy on the social skills
of children and adolescents. A randomized experiment,
which confirmed the positive impact of behavioral interven-
tions on children with socialization deficits, was carried out
[18]. Scientists from Maribor (Slovenia) considered play
intervention for children with developmental disabilities.
All games were built on the development of cognitive skills,
fine motor skills, social skills (adequate interpretation of
emotions), and expansion of vocabulary. All games were
played in a digital environment. The experiment studied
children with autism and attention deficit disorder. How-
ever, the results were controversial. While the serious play
method reduced anxiety and stress indicators and contrib-
uted to the recognition and management of emotions, clini-
cal evidence of the benefits of this strategy was not revealed
[19]. In Ireland, a strategy for the development of communi-
cation and language skills in children with Down syndrome
was considered. The study said that the development of the
social abilities in these children should start at a very early
age. This is associated with the fact that contact and commu-
nication with people around them affects the level of com-
munication skills of people with a similar disorder. Thus, it
was concluded that social skills should be improved not only
by the teacher but also by the parents or guardians. This
requires that parents are taught to find contact with their
children [20]. Indian researchers have studied the preoccu-
pation with activities in children with intellectual disabilities.
The experiment involved two focus groups, one of which
consisted of absolutely healthy children, and the second
one included children with various types of intellectual dis-
abilities. The researchers let the children play in the class-
room with ordinary toys (construction kits, figurines, cars,
dolls) and watched the process. As a result, they noticed that
the immersion and enthusiasm of children with mental dis-
abilities in the game is much higher than that of healthy chil-
dren. This should be taken into account as a psychological
feature of children with intellectual disabilities in order to
properly select a correction program [21]. Based on the data
obtained, some conclusions can be drawn about teaching
communication skills to people with intellectual disabilities.
First, it should be borne in mind that the main socialization
problems mainly occur due to the presence of comorbid and
affective disorders. It should be taken into account that ear-
lier development will determine the effectiveness of the
selected strategy. Secondly, there is a need to choose the
right approach for these children. One of the best options
is cognitive therapy. There are a lot of cognitive therapy

2 Occupational Therapy International

options: from individual sessions with a specialist to ready-
made mobile applications and computer games. Thirdly, it
is worth noting that most of the experiments are randomized
studies. Therefore, precisely accurate results cannot be con-
firmed and such strategies require further research.

2.1. Setting Objectives. The motivation is to conduct more
studies on the impact of cognitive therapy on the culture
of interpersonal relationships among children with intellec-
tual disabilities to understand the degree of effectiveness.
Cognitive therapy has not yet been completely studied, and
more research is needed. In the course of the study, it is also
worth finding out in which areas this technique can be
applied and how appropriate it is. The main goal was to
study the influence of cognitive behavioral therapy on the
socialization of children with intellectual disabilities aged
11-13. A randomized study was conducted at specialized
(correctional) boarding school No. 7 and Zhanuya boarding
school. A total of 350 children took part in the study. The
objectives included the introduction of cognitive therapy in
the education of children with intellectual disabilities. Also,
to clarify the degree of socialization problems and test the
effectiveness, specialized testing was used to assess commu-
nicative competence. This test was implemented to evaluate
the effectiveness of the integrated methodology. Further
prospects of using the cognitive therapy strategy were also
assessed. Specialized testing was used to analyze progress
in the study. This was carried out and evaluated by a special-
ist in psychology.

3. Methods

3.1. Research Design and Sample. A randomized study was
conducted to assess the impact of cognitive behavioral
therapy on children with intellectual disabilities. This study
looked at the uncontrolled before-after design. There was
no control group in the study. The experiment involved
students of specialized boarding school No. 7 and Zhanuya
boarding school (Almaty). These were 5-7 grade students.
The age of the respondents was 11-13 years old. The
experimental group consisted of 350 participants. There
were 180 boys and 170 girls among the respondents. The
objectives of the experiment were to introduce cognitive
therapy into the education of children with intellectual dis-
abilities. A specialized test to assess communicative compe-
tence was also used to clarify the extent of socialization
problems and to verify effectiveness. This questionnaire
was administered to evaluate the effectiveness of the com-
prehensive methodology. Further perspectives of the cogni-
tive therapy strategy were also evaluated. Specialized
testing was used to analyze the progress of the study. It
was conducted and evaluated by a specialist in psychology.
Outside the study, the children attended school in accor-
dance with their timetable. No additional psychological
therapy was performed.

3.2. Experiment. Prior to the experiment, all respondents
were tested to evaluate their communicative and social com-
petence. This is a multifactorial questionnaire that makes it

possible to assess the position of the individual in society
and make a probable forecast of their further social activity.
It includes 100 questions and the assessment of such criteria
as factor A (openness, sociability), factor D (assessment of
cheerfulness), factor K (desire to work in a team), factor P
(propensity for antisocial behavior), factor M (independence
and independence of other people’s opinions), factor N (self-
control), and factor V (developed logical thinking). Each
indicator is assessed on a 20-point scale except for factor P
that is evaluated on a 40-point scale. Psychometric proper-
ties of this test include reliability (0.94-0.90), validity (0.85-
0.8), and discriminability (0.33) [22]. The participants were
tested at the beginning, in the middle, and at the end of
the study. The experiment took place over four months.
The therapy sessions were carried out 3 times a week. Each
session lasted 3 hours. All training sessions were conducted
under the guidance of a psychologist and a supervisor. Each
of the three sessions that were carried out during the week
had its own specifics. As part of the first type of training, col-
lective therapy aimed at identifying the weaknesses of the
interaction and their correction was carried out. This
involved group sessions. Thus, a small group of children
was selected to find a way out of a simulated situation
through interaction with each other and teamwork. All
respondents had to solve at least one case problem, after
which they had to tell what emotions they experienced and
analyze them [23]. The second type of activity was held in
a training format. The children were shown standard models
of interaction between people in various situations and had
to repeat them to consolidate the material while acting out
the scenario with each other [9]. The third type of session
aimed to teach children to build a dialogue with each other
by expressing their emotions and requests with the simula-
tion of certain situations [24]. During these sessions, the
respondents were divided into pairs. At the end of each
month of the experiments, groups and pairs were disbanded
and new ones were created to increase the level of adaptation
of the respondents.

3.3. Statistical Processing and Data Analysis. The analysis
was carried out using a questionnaire on communicative
and social competence. It is a multifactor questionnaire
which includes a measurement on eight criteria. The test
itself consists of 100 questions. Seven of the criteria were
assessed on a scale of 0 to 20 points, and only factor P
(propensity for antisocial behavior) was assessed on a 40-
point scale. Psychometric properties of this test include
reliability (0.94-0.90), validity (0.85-0.8), and discriminabil-
ity (0.33) The multifactor questionnaire is validated by
Nikolai Petrovich Fetiskin (vice president of the Interna-
tional Academy of Psychological Sciences). This question-
naire was administered to all respondents three times:
before the experiment, in the middle (interim testing),
and at the end of the study.

To process the data of this study, a specialized program
for statistical analysis SPSS 26.0 was used. The results were
interpreted and visualized with the help of the Microsoft
Excel 2019 software package. Student’s t-test was used to
compare the effectiveness of the proposed teaching approach.

3Occupational Therapy International

To compare the mean result of the initial test with the results
of the posttest to identify significant differences in the learn-
ing process. The level of significance was set at (p ≤ 0:05).
95% confidence intervals (CI) were calculated for median
analysis.

3.4. Research Limitations. It should be noted that the degree
of intellectual disability was not taken into account; all
children were treated equally during the experiment. How-
ever, it should be taken into account that due to the vary-
ing degrees of intellectual disability, this therapy may not
affect the participants in the same way. Also, the disease,
which led to intellectual impairment, and its specificity
were not taken into account. The experiment involved
children with various pathologies. It should be noted that
this is a completely randomized trial, the purpose of
which is to determine the impact of cognitive behavioral
therapy on the socialization of children with intellectual
disabilities and teaching them communication skills. The
results of the study will be considered in terms of the
arithmetic mean of the sample. All these factors should
be taken into account when considering the results of
the experiment. It should also be noted that the study
was not carried out after the experiment had ended. It is
therefore not possible to say with certainty that the result
remains at a static level.

3.5. Ethical Issues. Such experiments require the consent of
the respondents. Due to the fact that the prospective par-
ticipants have not yet reached the age of majority, the
official decision can only be made by the persons respon-
sible for them. Parents and guardians were informed ver-
bally and in writing about the format of the experiment
and all its details. After that, they gave their written con-
sent for their children’s participation in the study. The
children gave their verbal consent to take part in the
study after having been told about the essence of the
experiment.

4. Results

Before the experiment began, a communicative competence
test was carried out. All the results of the respondents have
an average value for the study group and are described as
points and percentages. The preliminary result for factor A
(openness and sociability) was 8 points (40%)—the lowest
indicator of the average level of sociability. The result for
factor D (cheerfulness) was 13 points (65%). The indicator
of factor K (teamwork) turned out to be rather low -5 points
(25%). Factor P (propensity for antisocial behavior) result
was equal to 12 points out of 40 possible (30%). The score
for factor M (independent decision-making) turned out to
be rather low -6 points (30%). Factor N (self-control) also
showed a low value of -5 points out of 20 possible (25%).
Factor V (logical thinking) was equal to 4 points (20%).
The result of factor C (emotional stability) is 6 points
(30%), which is also a rather low indicator. The result is
shown in Table 1.

Intermediate testing was carried out 2 months after the
start of the experiment. The factor A results (openness and
sociability) were 11 points (55%). This indicates an increase
in sociability in the study group. In turn, factor D (cheerful-
ness) changed insignificantly; it increased by 1 point (70%).
The factor K indicator (teamwork) increased by 3 points;
thus, it was equal to 8 (40%). In two months, this indicator
moved from the low level to the average level. Factor P (pro-
pensity for antisocial behavior) decreased to 10 points out of
40 possible (25%). The result of factor M (independent
decision-making) increased to 9 points (45%). Factor N
increased by two points and was equal to 7 points (35%).
Logical thinking (factor V) also increased by 2 points and
was equal to 6 points out of 20 possible (30%). Emotional
stability (factor C) changed its value in a positive direction
-8 points (40%). The result of intermediate testing is shown
in Table 2.

At the end of the experiment, the final test was carried
out. According to its results, factor A (openness and sociabil-
ity) reached 13 points (65%). The factor D result (cheerful-
ness) was 15 points (75%)—the upper limit of the average
level. Factor K (teamwork) amounted to 10 points (50%).
The results of factor P (propensity to antisocial behavior)
were equal to 8 points out of 40 (20%). The factor M indica-
tor (independent decision-making) was 11 points (55%).
The factor N indicator (self-control) was equal to 9 points
out of 20 possible (45%). The result of factor V (logical
thinking) was 8 points (40%). Factor C (emotional stability)
reached 10 points (50%).

The result of the final testing is shown in Table 3.
After the final test was calculated, it was compared with

the preliminary results using Student’s t-tests (Table 4). The
significance level of A, K, and M is 0.008 (p ≤ 0:01). This
result demonstrates the exclusion of the null hypothesis
and acceptance of the alternative hypothesis. That is, it
shows that there is a sufficient statistical difference between
the “before” and “after” figures. The significance level of fac-
tor D is 0.005 (p ≤ 0:01). The significance level of factors P,
V, and C is equated to 0.011 (p ≤ 0:05). And factor N has a
significance level of 0.001 (p ≤ 0:001). It follows that all cri-
teria underwent statistically significant changes in the course
of the experiment.

Based on the data above, we can conclude that cognitive
therapy sessions have a positive effect on the development of
social skills in children with intellectual disabilities. This is
evidenced by an increase in the indicators of teamwork,
independent decision-making, self-control, logical thinking,
and emotional stability. The criteria, such as “cheerfulness,”
“openness,” and “sociability” also improved. It is worth not-
ing that the factor of the propensity for antisocial behavior
decreased due to the sessions of cognitive therapy. Also,
changes in the behavior of the students who took part in
the experiment began were noticed by their teachers.
According to one of the supervisors, the children have really
become more open in communication with each other and
teachers, in particular. They are more actively involved in
learning and open up to everything new with great interest.
It is also worth noting that their academic performance has
improved.

4 Occupational Therapy International

However, it should be considered that the study is
completely randomized and was conducted in a large focus
group. Also, the disease that provoked intellectual disability

and its degree were not taken into account. Therefore, the
absolute reliability of the results cannot be stated. In the
future, additional research may be required.

Table 2: Intermediate results.

Name of factor Points Standard deviation %

Factor A (openness, sociability) 11 points 1.1 55%

Factor D (cheerfulness) 14 points 1.4 70%

Factor K (teamwork) 8 points 1.2 40%

Factor P (propensity for antisocial behavior) 10 points 1.3 25%

Factor M (independent decision-making) 9 points 1.0 45%

Factor N (self-control) 7 points 0.8 35%

Factor V (logical thinking) 6 points 1.1 30%

Factor C (emotional stability) 8 points 1.0 40%

Table 3: Final results.

Name of factor Points Standard deviation %

Factor A (openness, sociability) 13 points 0.7 65%

Factor D (cheerfulness) 15 points 0.6 75%

Factor K (teamwork) 10 points 1.1 50%

Factor P (propensity for antisocial behavior) 8 points 0.9 20%

Factor M (independent decision-making) 11 points 1.0 55%

Factor N (self-control) 9 points 0.7 45%

Factor V (logical thinking) 8 points 0.6 40%

Factor C (emotional stability) 10 points 0.9 50%

Table 1: Preliminary results.

Name of factor Points Standard deviation %

Factor A (openness, sociability) 8 points 1.3 40%

Factor D (cheerfulness) 13 points 1.6 65%

Factor K (teamwork) 5 points 1.2 25%

Factor P (propensity for antisocial behavior) 12 points 1.8 30%

Factor M (independent decision-making) 6 points 1.5 30%

Factor N (self-control) 5 points 1.1 25%

Factor V (logical thinking) 4 points 1.2 20%

Factor C (emotional stability) 6 points 1.4 30%

Table 4: Comparison of the results.

Scales Preliminary results. Final results Empirical value Significance level (p value)

Factor A 8 ± 0:141 13 ± 0:283 -22.361 0.008∗∗

Factor D 13 ± 0:141 15 ± 0:141 -14.142 0.005∗∗

Factor K 5 ± 0:283 10 ± 0:141 -22.361 0.008∗∗

Factor P 12 ± 0:141 8 ± 0:283 17.889 0.011∗

Factor M 6 ± 0:283 11 ± 0:141 -22.361 0.008∗∗

Factor N 5 ± 0:141 9 ± 0:141 -28.284 0.001∗∗∗

Factor V 4 ± 0:141 8 ± 0:283 -17.889 0.011∗

Factor C 6 ± 0:283 10 ± 0:141 -17.889 0.011∗

∗p < 0:05; ∗∗p < 0:01; ∗∗∗p < 0:001.

5Occupational Therapy International

5. Discussion

In 2019, a study on the thinking and behavior of chil-
dren with intellectual disabilities was conducted in the
Netherlands. The emphasis was placed on the assump-
tion of the flexibility of behavior and personality factors.
A randomized trial was conducted. The results showed that
children with intellectual disabilities have more fixed think-
ing in terms of emotions and behavior. This suggests that
teaching positive attitudes towards the development of the
emotional sphere can be used to correct behavior and
improve mental state [25]. It is impossible to fully compare
this study with the present paper. This is due to the fact
that the experiment, which was carried out in the Nether-
lands, does not involve cognitive therapy. However, the
result obtained in the course of the Dutch research
describes and confirms the positive dynamics that were
obtained during the experiment described above in this
study. In 2018, Canadian scientists conducted an experi-
ment and studied the effect of cognitive behavioral therapy
on the behavior of children with autism. The study was
randomized. As a result, the scientists concluded that the
indicators of emotional state and socialization skills
improved in the focus group [26]. Comparing the results
obtained by Canadian scientists with the results of this
study, we can say that in both cases, there is a positive
trend. The only difference is that in Canada, the focus
group consisted exclusively of children with autism while
this study looked at intellectual spectrum disorders more
extensively. In 2018, there was an American study of the
effect of cognitive therapy on children with self-regulation
problems, namely, with social, executive dysfunction, and
emotional spectrum disorders. The results proved the effec-
tiveness of the impact of cognitive behavioral therapy on
these areas of life [27]. This also confirms the feasibility
of the application of this type of therapy to solve the prob-
lem of socialization in children with intellectual disabilities.
Scientists from the UK have studied the effect of cognitive
behavioral therapy on people with intellectual disabilities.
They conducted a randomized trial. The results showed
improved cognitive functions and improved quality of life
[28]. The experiment by British researchers has confirmed
the results of this study. Joint developments of scientists
from China and the United States were based on studying
the effectiveness of the use of cognitive therapy for resis-
tance to various social situations in people with neurocog-
nitive disorders. The results were ambiguous. Resistance
to various social factors increased, but this did not affect
neuropsychiatric behavioral symptoms [29]. However, the
authors of this study argue that there could be various inac-
curacies in the course of the experiment; therefore, absolute
results cannot be claimed. Due to the fact that most studies
in this area have positive dynamics, we can talk about con-
firmation of the effectiveness of this strategy, but it is also
worth considering all the nuances associated with the
design and conduct of these experiments. It is worth men-
tioning the fact that most studies are randomized; as a
result of this, there may be certain gaps. It is impossible
to identify the criteria for the effectiveness of the influence

of cognitive therapy on people with certain disabilities as
specific diseases and the degree of their development are
not taken into account in most cases.

The results obtained can be explained in terms of the fact
that cognitive therapy is a learning factor. During the ses-
sions, people work out new patterns of behavior reinforcing
them by repetition. As people with various intellectual dis-
abilities are able to learn the expression of various emotions
and their manifestation in different situations, we can talk
about an increase in acquired social skills.

The results described in this study are also randomized
and cannot claim absolute accuracy; therefore, additional
research is required in this area. During the comparison of
this work with other articles, no fully similar methodology
was found. It follows that this strategy may be a unique
development.

The application of the knowledge gained gives us the
understanding of the effectiveness of cognitive therapy in
the development of a culture of interpersonal relationships
in people with intellectual disabilities. This strategy can be
used in the context of learning and developing social skills.
This provides a prospect for new discoveries in the field of
interpersonal relationships, as well as changing and improv-
ing the cognitive techniques aimed at people with a narrower
specificity of intellectual disabilities.

However, it must be kept in mind that the degree of
mental retardation was not taken into account; all children
were treated equally in the experiment. Because of the vary-
ing degrees of mental retardation, the therapy may not affect
the participants in the same way. The illness that led to men-
tal retardation and its specifics were also not taken into
account. Children with different pathologies participated in
the experiment. This is a fully randomized study that aims
to determine the effects of cognitive behavioral therapy on
the socialization of children with intellectual disabilities
and their learning of social skills. It should also be noted that
the study was not carried out after the experiment had
ended. It is therefore not possible to say with certainty that
the result remains at a static level.

6. Conclusions

The results of this study showed that the use of cognitive
therapy for the development of a culture of interpersonal
relationships in children with intellectual disabilities has
proven to be effective. This conclusion can be made based
on the improvement of the indicators of self-control, team-
work, independent decision-making, logical thinking, and
emotional stability. The indicators moved from the low level
to the average one, which indicates an improvement in
socialization skills. It is also worth noting a slight increase
in the indicators of cheerfulness and sociability. The factor
of antisocial behavior, in turn, decreased, which indicates a
positive trend in the study. This leads to the conclusion that
it is advisable to use cognitive therapy for the socialization of
children with intellectual disabilities.

The scientific value of this experiment lies in the applica-
bility of the results for further research and the improvement
of the methods of cognitive therapy in this area. It should be

6 Occupational Therapy International

borne in mind that the study was based on a randomized
sample method; therefore, this strategy requires additional
experiments to obtain more accurate results. However, the
method of cognitive therapy can be used to develop a culture
of interpersonal relationships in people with intellectual dis-
abilities. It should be used in schools and specialized institu-
tions for children with intellectual disabilities. Also, the
method of cognitive therapy can be used for preschool chil-
dren with intellectual disabilities; however, it should be con-
sidered that this strategy may need to be adapted for this age
group. Cognitive therapy can also help adults with intellec-
tual disabilities socialize. Therefore, this strategy can be
applied in private psychological practice.

When assessing the prospects for further research, it is
worth pointing out the gaps in this research. The disadvan-
tage is a rather large focus group of respondents, which does
not give an absolute specificity of the results. It should be
noted that due to the large number of participants, all results
are considered in the mean value system. Also, intellectual
disorders and the degree of their severity were not consid-
ered and were not taken into account. Standard cognitive
therapy methods were chosen to promote socialization.
Therefore, further research should examine the impact of
such a strategy on a small group of respondents. Cognitive
therapy to specific cases of intellectual disability, such as
Down syndrome or autism, can also be applied. To obtain
more accurate results, the sample should include respon-
dents with the same severity of specific diseases. Other
methods of cognitive therapy can also be applied. The results
of such studies will make it possible to correct various cogni-
tive methods in accordance with the degree and form of
intellectual disabilities. This will contribute to the develop-
ment of an individual approach and increased efficiency.

Data Availability

The data will be available on request.

Conflicts of Interest

The authors declare that there is no conflict of interest
regarding the publication of this paper.

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8 Occupational Therapy International

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Cognitive Therapy for Children with Intellectual Disabilities: A New Look at Social Adaptation Skills and Interpersonal Relationships

1. Introduction

2. Literature Review

2.1. Setting Objectives

3. Methods

3.1. Research Design and Sample

3.2. Experiment

3.3. Statistical Processing and Data Analysis

3.4. Research Limitations

3.5. Ethical Issues

4. Results

5. Discussion

6. Conclusions

Data Availability

Conflicts of Interest

Vol:.(1234567890

)

Journal of Autism and Developmental Disorders (2024) 54:3316–3335
https://doi.org/10.1007/s10803-023-06063-x

1 3

ORIGINAL PAPER

Cognitive‑Based Interventions for Improving Psychological Health
and Well‑Being for Parents of Children

ith Developmental
Disabilities: A Systematic Review and Meta‑analysis

Sini Li1,2 · Yijing Yong3 · Yamin Li2 · Jianhe Li4 · Jiao Xie2,5

Accepted: 6 July 2023 / Published online: 5 September 2023
© The Author(s) 2023

Abstract
This review aims to systematically summarize existing evidence to determine the effectiveness of cognitive-based interven-
tions (CBIs) on psychological health and well-being among parents of children with developmental disabilities (DD). Six
databases were searched to identify eligible randomized controlled trials (RCTs) from their inception to April 2023. The
revised Cochrane Risk of Bias tool for RCTs was applied to assess the risk of bias and the certainty of evidence was evalu-
ated using the Grading of Recommendation, Assessment, Development and Evaluation. Meta-analyses were conducted
using a random-effects model. Twenty-five RCTs involving 1915 participants were identified. The results indicated that
CBIs reduced parental stress levels (Hedges’ g = − 0.69), depressive symptoms (g = − 0.95), anxiety levels (g = − 0.78),
and parental distress (g = − 0.29), and improved parental well-being (g = 0.6

and parent‒child relationships (g = 0.43)
postintervention compared with the active/inactive control groups. Subgroup analysis of the effectiveness of interventions
using mindfulness-based interventions and cognitive behavioural therapy showed positive effects. The favourable interven-
tion duration and participant targets were also identified in this review. Furthermore, the effects of CBIs were impacted by
the different types of DD among the children. This review highlighted the positive effects of CBIs on parental stress levels,
depressive symptoms, anxiety levels, parental distress levels, parental well-being levels, and parent‒child relationships.
Future well-designed RCTs are needed to further investigate the effects of MBIs and CBT interventions on children with DD
and their parents, as well as the factors and mechanisms of action affecting the efficacy of these interventions.

Keywords Developmental disabilities · Parents · Cognitive behavioural therapy · Mindfulness · Meta-analysis

Introduction

Developmental disorders (DD) are a set of lifelong disor-
ders (e.g., attention-deficit/hyperactivity disorder [ADHD],
autism spectrum disorder [ASD], cerebral palsy [CP],
fragile X syndrome, developmental delay, intellectual dis-
abilities [ID], learning disorders, language disorders, and
Tourette syndrome) that originate in childhood and cause
severe impairment in daily function in different domains
(e.g., physical, learning, language, emotional or behav-
ioural function) (Holm, 1989; Prevention, 2022). Previous
nationwide surveys in the United States discovered that the
prevalence of DD has risen from 12.84 to 17.76% in the last
20 years (Boyle et al., 2011; Zablotsky et al., 2019). Given
this growth, substantial care needs, support, and accessibil-
ity of resources and interventions are typically required for
children with DD and their families, enhancing long-term

* Jianhe Li
lijianhexy@126.com

* Jiao Xie
247952080@qq.com

1 The Nethersole School of Nursing, Faculty of Medicine, The
Chinese University of Hong Kong, Hong Kong, China

2 Clinical Nursing Teaching and Research Section, The Second
Xiangya Hospital, Central South University, 139 Renmin
Middle Road, Changsha 410011, China

3 Cognition and Human Behaviour Key Laboratory of Hunan
Province, Hunan Normal University, Changsha, China

4 Department of Pharmacy, The Second Xiangya Hospital,
Central South University, 139 Renmin Middle Road,
Changsha 410011, China

5 Department of Otolaryngology-Head and Neck Surgery, The
Second Xiangya Hospital, Central South University, 139
Renmin Middle Road, Changsha 410011, Hunan, China

http://crossmark.crossref.org/dialog/?doi=10.1007/s10803-023-06063-x&domain=pdf

3317Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

outcomes for those children and families (Baio et al., 2018;
Vohra et al., 2014).

Parenting a child with DD is exhausting, and it imposes
many challenges on parents because they need to invest
considerable time, energy, and money to support and nur-
ture their child’s healthy development (Resch et al., 2010).
Due to the specialized care needs of these children, par-
ents have observed amplified levels of emotional distress
(Robinson et al., 2018), also known as stress (Osmančević
Katkić et al., 2017), anxiety (Bujnowska et al., 2019), and
depression (Scherer et al., 2019), as well as impairments in
other health outcomes, such as physical function (Cantwell
et al., 2014), social function (Ali et al., 2012), and general
well-being (Baker et al., 2005) or quality of life (Arora et al.,
2020). Concerningly, these psychological issues can have
a detrimental impact on parental well-being and parenting
practice (Neece et al., 2012), resulting in poor child, parent,
and family outcomes in families with children with DD due
to bidirectional relationships between parent emotion and
child outcomes (Woodman et al., 2015).

To support the parents of children with DD and improve
their psychological well-being, a variety of cognitive-based
interventions (CBIs), including cognitive-based therapy
(CBT), dialectical behavioural therapy (DBT), mindfulness-
based intervention (MBIs), acceptance and commitment
therapy (ACT), and compassion-focused therapy (CFT),
have been recently developed. Based on the concept that
thoughts, feelings, and behaviours are interrelated, CBT
employs cognitive methods to change maladaptive beliefs
and cognitive distortions as well as modify problematic
behavioural patterns that maintain stress/distress (Beck &
Haigh, 2014). Moreover, MBIs, which include mindfulness-
based stress reduction (MBSR) and mindfulness-based cog-
nitive therapy (MBCT), can be defined as the practice of
mindfulness that improves participants’ attention/awareness
of the present moment in a nonjudgmental manner, allow-
ing them to better cope with life stressors and enhance their
general well-being (Kabat-Zinn, 2003). The first applica-
tion of these ideas to psychotherapy was developed by Dr.
Jon Kabat-Zinn in the 1970s by first applying MBSR in the
Western world (Kabat-Zinn & Hanh, 2009). The principle of
MBSR has been further adapted in MBCT, which combines
the mindfulness practices of MBSR with the concepts of
CBT to treat the process of negative thinking and feeling
rather than the content of psychological symptoms (Chad-
wick et al., 2016), or ACT, which aims to improve affective
symptoms by promoting psychological flexibility, identify-
ing personal values, and managing commitments to make
adjustments (Hayes & Strosahl, 2005; Hayes et al., 1999). In
addition, as part of third-wave CBT, DBT combines various
strategies (e.g., mindfulness, emotion regulation, awareness,
and acceptance) that enable clients to utilize new skills/strat-
egies to build lives that they feel worthwhile. Furthermore,

as newly developed CBI, CFT incorporates mindfulness to
assist in enabling mental and emotional recovery by encour-
aging participants to be compassionate towards themselves
and others (Gilbert, 2009; Khoshvaght et al., 2021).

These CBIs have reported promising results in lessen-
ing stress, depressive symptoms, and anxiety across parents
of children with special needs (Bourke-Taylor et al., 2021;
Parmar et al., 2021), further confirming their ability to help
enhance the psychological well-being of parents of children
with DD. Previous systematic reviews and meta-analyses
reported significant improvements in the psychosocial out-
comes of caregivers of children with ASD with CBIs (Yu
et al., 2019). This finding was further confirmed by Bourke-
Taylor et al. (2021), who also revealed the positive effects
of CBT on parental stress and mental health for parents of
children with DD. Several systematic reviews demonstrated
that MBIs and/or ACT were superior to the control group
regarding postintervention mental health and subjective
well-being results for parents of children with different types
of DD (Chua & Shorey, 2022; Hartley et al., 2019; Juvin
et al., 2022; Lee et al., 2022; Yu et al., 2019).

While the reviews mentioned above offer preliminary evi-
dence on the effectiveness of CBIs for parents of children
with DD, these studies contain significant methodologi-
cal limitations. First, the included studies in these reviews
used a wide range of study designs, including single-group,
pre- and post-test studies, randomized controlled trials, and
nonrandomized controlled trials (Hartley et al., 2019; Juvin
et al., 2022; Lee et al., 2022; Yu et al., 2019). Therefore,
those syntheses might provide low-quality evidence with a
significant risk of bias and unreliable outcomes. In addi-
tion, the majority of previous reviews included a limited
number of studies and small sample sizes (lower than 1,000
participants), making it difficult to draw solid conclusions
(Cachia et al., 2016; Hartley et al., 2019; Juvin et al., 2022;
Lee et al., 2022; Osborn et al., 2021). Furthermore, the study
samples were very heterogeneous, including children and
adults with DD (Hartley et al., 2019; Juvin et al., 2022), and
did not analyse outcomes separately for parents of children
with different types of DD (Bourke-Taylor et al., 2021; Chua
& Shorey, 2022; Osborn et al., 2021).

Considering the heavy caregiver burden of those parents,
the limitations of the systematic and meta-analysis demon-
strated above, and the potential benefits of CBIs for parents
of children with DD to improve their mental health, it is
paramount to synthesize the existing evidence on the use of
CBIs to enhance parents’ psychological well-being in while
caring for children with DD to drive future evidence-based
research and practice. Moreover, it is still inconclusive about
the best effective approach and optimal characteristics of
CBIs for improving those parents’ health outcomes. There-
fore, this review aimed to comprehensively summarize the
effects of CBI with respect to psychological problems and

3318 Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

well-being among parents of children with DD, when com-
pared with active/inactive controls, and investigate the opti-
mal features of the effective interventions found.

Methods

This review was registered with PROSERO registration
number CRD42022382502 and conducted based on the Pre-
ferred Reporting Items for Systematic Reviews and Meta-
Analysis statement (PRISMA) (Moher et al., 2009). Two
reviewers (SNL and YJY) independently conducted certain
phases of systematic review, including study selection, data
extraction, and quality appraisals. When confronted with a
conflict, two reviewers either discussed or consulted with the
third reviewer (YML) to achieve an agreement.

Research Strategy

Six English databases, including PubMed, Embase (Ovid),
PsycINFO, CINAHL, Cochrane Central Register, and
ProQuest, were systematically searched from inception to
December 2022. The PICOS (population, intervention, com-
parisons, outcomes, study) framework listed in Appendix
S1 was used to select MeSH terms and keywords, includ-
ing types of participants (e.g., caregiver*, parent*, mother*,
father*, maternal*, famil*), types of diagnoses (e.g., devel-
opmental disabilities, autism spectrum disorder, attention
deficit disorder with hyperactivity, fragile x syndrome,
Down syndrome), types of interventions (e.g., cognitive
behavio?ral therap*, acceptance and commitment therapy,
mindful, mindfulness-based, dialectical behavioural ther-
apy, metacognitive), and types of psychosocial outcomes
(e.g., stress, anxiety, depressi*, parenting distress). The
search strategy was designed for PubMed and then adapted
for other databases. The research strategies and results for
all the databases are listed in Supplementary Tables 2–7.
Moreover, the reference lists of pertinent publications and
internet search engines, such as Google Scholar, were manu-
ally searched for additional relevant articles.

Inclusion and Exclusion Criteria

Studies were included when they met the following criteria:

(1) Populations: The participants were parents (aged > 18)
of children (aged ≤ 18) diagnosed with DD (accord-
ing to the World Health Organization (Almeida et al.,
2020), the diagnoses for DD include a diverse group
of conditions characterized by impairments in physi-
cal ability, learning, language and/or behaviour, such
as autism spectrum disorder [ASD], attention-deficit/

hyperactivity disorder [ADHD], fragile X syndrome,
Down syndrome, intellectual disabilities).

(2) Interventions: The studies explicitly and independently
referred to CBIs, including CBT, MBIs, ACT, DBT,
or self-compassion therapy, in their description of the
primary part of the intervention.

(3) Comparison: The CBIs were compared to both active
(e.g., attention care) and inactive (e.g., treat as usual
[TAU], standard care, waitlist, no treatment, placebo)
control groups.

(4) Outcomes: The parental psychological outcomes
(including emotional distress, stress, depression, and
anxiety) were measured by valid instruments at least
at the time of postintervention.

(5) Study design: Only randomized controlled trials (RCTs)
published in peer-reviewed journals and (6) only stud-
ies in English were eligible.

Studies were excluded when (1) the primary outcomes
of interventions were focused on children with DD (e.g.,
child-focused or parent-mediated interventions) rather than
their parents; (2) multicomponent interventions (such as
combined CBIs with behavioural training) were considered
the major component in the intervention group; (3) the group
sample size for those receiving treatment was lower than
five; and (4) full-text or final results were unavailable (e.g.,
conference abstracts and protocols).

Study Selection

To check for duplicate publications, all retrieved records
were loaded into Covidence software. The abstracts and
titles were separately reviewed by two reviewers (SNL and
YJY) in accordance with the eligibility criteria. Eligible arti-
cles were eventually identified after examining the full texts
of possibly relevant research.

Data Extraction

A self-developed data extraction form was applied based on
the Cochrane data collection form for RCT review (Sam-
bunjak D et al., 2017). The form was piloted on five ran-
domly selected eligible articles and revised accordingly. Two
reviewers extracted all necessary data independently, and the
following information was collected: (1) the basic informa-
tion of the studies (including the last names of the authors,
the year of publication, and the locations, study designs, and
sample sizes); (2) participant characteristics (including the
age range and the sex proportion for the children with DD
and their parents); (3) characteristics of the interventions
(including the types of cognitive-based interventions and the
comparators, intervention contexts, research formats, dos-
ages, durations, and lengths of follow-ups); and (4) outcome

3319Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

measures (including measurement tools, assessment time-
point(s), and outcomes [effect sizes]). Two reviewers (SNL
and YJY) extracted data individually, and any differences
of opinion were resolved by discussion or contact with the
third reviewer (JHL).

The first author contacted the corresponding authors to
provide additional information if the information provided
was not sufficiently detailed (such as using figures to report
the outcomes and not revealing the specific data in the arti-
cle). When authors did not reply after being contacted twice
through email a month apart, the articles were removed from
consideration.

Quality Appraisal

The revised Cochrane Risk of Bias tool (RoB2) for RCTs
(Sterne et al., 2019) was applied to assess the quality of each
included trial. Any disagreements between critical apprais-
ers were resolved by discussion and consultation with the
third reviewer. Five categories of bias are evaluated by the
RoB: selection (random sequence generation and allocation
concealment), performance (blinding of participants and
personnel), attrition (incomplete outcome data), detection
(blinding of outcome assessment), and reporting bias (selec-
tive reporting). Bias was rated as “low,” “unclear,” or “high”
for each domain for each study. The proportion of research
that met each quality rating was then calculated.

Certainty of Evidenc

A narrative assessment of the degree of certainty of the evi-
dence was presented using the Grading of Recommenda-
tion, Assessment, Development, and Evaluation (GRADE)
system (Balshem et al., 2011). Based on the five GRADE
domains—methodological limitations of the studies or bias
risk, indirectness, imprecision, consistency, and publica-
tion bias—two independent appraisers assessed the degree
of certainty of the evidence and categorized it into four cat-
egories: high, moderate, low, and very low.

Data Synthesis

R software was applied to assess the statistical meta-
analysis by computing the Hedges’ g standard mean dif-
ferences (SMDs) with 95% confidence intervals (CIs) for
each study. Given the expected variability between studies
and outcomes, the random-effects model was chosen to
pool the SMDs across the studies. The effect sizes (ESs)
were primarily assessed postintervention; specifically, the
time-point was less than four weeks after the interven-
tion. Based on Cohen’s categories, ESs were classified as
small (g = 0.2), medium (g = 0.5), or large (g ≥ 0.8) (Lip-
sey & Wilson, 2001). Moreover, only outcomes from at

least two or more studies were pooled in the model for
the meta-analysis as well as for the subgroup analyses.
The meta-analysis included three major subgroup analyses
to investigate whether efficacy varied among intervention
approaches, durations (1–8 weeks and over eight weeks),
targeted participants (only parent-involved versus parent‒
child dyads), and the types of DD among the children. A
minimum of two trials per subgroup were required for the
subgroup analyses (Deeks & Altman, 2022). Furthermore,
several change scores, such as those associated with the
parent‒child relationship, parental well-being, mindful
parenting, mindful awareness, and psychological flexibil-
ity, were reversed for clarity, so that positive ESs were
always associated with positive clinical results.

Heterogeneity was assessed using I2 and Cochrane’s Q.
I2 values of 25, 50, and 75% were considered low, moder-
ate, and high heterogeneity, respectively. Cochran’s Q is
the standard test statistic that reveals systematic between-
study differences. Sensitivity analyses were undertaken
to explore whether the results were drastically affected
by excluding trials with highly disparate ESs. If meta-
analyses contained more than 10 studies, the assessments
of publication bias were performed by visually evaluating
Egger’s statistical test and funnel plots. An asymmetry
map highlights likely missing research as a result of pub-
lication bias. In the case of Egger’s test, a P value of < 0.05
was used to establish statistical evidence of asymmetry
(Egger et al., 1997). Outliers in which the 95% CI was
outside the 95% CI of the overall mean ESs on both sides
were identified through visual inspection of the forest
plots. Furthermore, outliers were kept if deleting them did
not significantly impact the results. A narrative synthesis
was also conducted for those trials and outcomes that were
excluded from the meta-analyses to give a comprehensive
picture of the data and to make comparisons between dif-
ferent CBIs.

Results

Study Selection

A total of 2511 records were identified. After excluding
786 duplicates, the titles and abstracts of 1725 articles
remained for the initial screening, and 76 eligible articles
were retained for further full-text screening. No extra articles
were identified from the search engines or reference lists.
Finally, a total of 25 RCTs were selected for inclusion in
this review. Figure 1 depicts the PRISMA flow chart of the
procedure and the results of the article search and selection.
Supplementary Table 8 lists all excluded articles following
full-text screening.

3320 Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

Study Characteristics

Supplementary Table 10 summarizes the main character-
istics of the 25 included RCTs. Studies were published
between 2006 and 2023, and the majority of studies were
developed in the United States (38.10%, n = 8) (Chronis
et al., 2006; Dykens et al., 2014; Feinberg et al., 2014; Fer-
raioli & Harris, 2013; Hahs et al., 2019; Kuhlthau et al.,
2020; Neece, 2014; Schwartzman et al., 2022). Other

research locations included China (n = 4; (Ho et al., 2021;
Liu et al., 2021; Lo et al., 2017a, 2017b; Lo et al., 2017a,
2017b)), Australia (n = 2; Whittingham et al., 2022; Wong
et al., 2010)), Iran (n = 4; Behbahani et al., 2018; Khosh-
vaght et al., 2021; Shareh & Yazdanian, 2023; Sharif et al.,
2015)), Spain (n = 2; Lobato et al., 2023; Valero et al., 2022),
Italy (Marino et al., 2021), the Netherlands (Siebelink et al.,
2018), Nigeria (Onyishi et al., 2023), Turkey (Çiçek Gümüş
& Öncel, 2022), and India (Pandya, 2021). All of the studies

Fig. 1 PRISMA Flow Diagram of Study Selection

3321Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

3322 Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

were two-arm RCTs with a parallel control design, and the
most of studies were pilot RCTs (36%, n = 9) (Ferraioli &
Harris, 2013; Hahs et al., 2019; Ho et al., 2021; Kuhlthau
et al., 2020; Lobato et al., 2023; Marino et al., 2021; Neece,
2014; Schwartzman et al., 2022; Valero et al., 2022).

Characteristics of Participants The 25 RCTs included
1,915 participants (ntreatment = 970, ncontrol = 945) with sample
sizes ranging from 14 (Lobato et al., 2023) to 243 (Dykens
et al., 2014). The mean age of the parents ranged from 33.5
(standard deviation [SD]: 7.00) (Feinberg et al., 2014) to
47 (range: 37–60) (Wong et al., 2010). The majority of
the participants (85.15%) were female, and eight studies
included mothers only. The mean age of children with DD
varied from 2.83 (SD: 11.00) (Feinberg et al., 2014) to 13.00
(range: 10–16) (Ho et al., 2021), with boys accounting for
the majority (70.72%). Four types of DD were identified
among the children in the included studies: ASD (n = 10,
40%), ADHD (n = 8, 32%), CP (n = 2, 8%), ID (n = 1, 4%),
and blended DD (n = 4, 16%).

Characteristics of Interventions The following five main
approaches were classified: (1) CBT (n = 6 Chronis et al.,
2006; Feinberg et al., 2014; Onyishi et al., 2023; Schwartz-
man et al., 2022; Sharif et al., 2015; Wong et al., 2010));
(2) MBIs (n = 12; (Behbahani et al., 2018; Dykens et al.,
2014; Ferraioli & Harris, 2013; Ho et al., 2021; Kuhlthau
et al., 2020; Liu et al., 2021; Lo et al., 2017a, 2017b; Lo
et al., 2017a, 2017b; C. L. Neece, 2014; Pandya, 2021; Sie-
belink et al., 2018; Valero et al., 2022)); (3) ACT (n = 5;
Çiçek Gümüş & Öncel, 2022; Hahs et al., 2019; Lobato
et al., 2023; Marino et al., 2021; Whittingham et al., 2022));
(4) DBT (n = 1; (Shareh & Yazdanian, 2023); and (5) CFT
(n = 1; (Khoshvaght et al., 2021)).

Across the included studies, the duration of CBIs ranged
from 2 days (Hahs et al., 2019) to 50 weeks (Pandya, 2021)
(mean = 70.08 days, SD = 64.98, median = 56). The aver-
age number of CBI sessions ranged from 2 to (Hahs et al.,
2019) to 24 sessions (mean = 8.4, SD = 4.05, median = 8),
except for a study with posted messages (Pandya, 2021).
Seven studies adopted the format of a parent‒child dyad
(Behbahani et al., 2018; Çiçek Gümüş & Öncel, 2022; Ho
et al., 2021; Lo et al., 2017a, 2017b; Neece, 2014; Siebe-
link et al., 2018; Valero et al., 2022), and the remaining
studies all only involved parents as active participants. Two
modes of intervention delivery were identified: face-to-face
(n = 21) and online (n = 3), and one study did not report the
delivery mode. Moreover, four studies delivered the inter-
vention to individuals, while others delivered the interven-
tions to groups of participants (n = 21; 84%). The majority

of the investigations disclosed their settings (n = 18), which
included in the community (n = 3), hospitals/clinics (n = 6),
service/rehabilitation centres (n = 4), schools (n = 2), and
internet platforms (n = 3) (Fig. 2).

Characteristics of Control Groups The majority of stud-
ies (n = 21) used inactive controls, such as waitlists (n = 13),
no treatments (n = 4), and treatments as usual (TAU; n = 4),
while the others used active controls, such as child-targeted
parenting skills training (n = 2) (Ferraioli & Harris, 2013;
Marino et al., 2021), a 1-day mindfulness workshop (Lo
et al., 2017a, 2017b), and positive psychotherapy (Dykens
et al., 2014).

Outcome Measures Table 1 presents a list of all meas-
urement instruments, all of which were valid and reliable
questionnaires. Studies used various time-points to obtain
their results. One study additionally performed an evaluation
at the midpoint of the intervention (Dykens et al., 2014).
Over half of the studies (n = 15) used multiple time-points
to assess longer-term effects, including short- (less than
3 months) (Behbahani et al., 2018; Khoshvaght et al., 2021;
Schwartzman et al., 2022; Sharif et al., 2015), medium- (3
to 5 months) (Chronis et al., 2006; Çiçek Gümüş & Öncel,
2022; Lobato et al., 2023; Onyishi et al., 2023) and long-
term effects (6 months or more) (Dykens et al., 2014; Fer-
raioli & Harris, 2013; Neece, 2014; Siebelink et al., 2018;
Valero et al., 2022; Whittingham et al., 2022; Wong et al.,
2010).

Meta‑analyses of CBI Outcom

The meta-analyses comprised 21 studies in total. Two MBI
studies developed by Dykens et al. (2014) and Neece (2014)
were excluded from the meta-analyses because the mean
and/or SD values could not be obtained from the report.
Another MBI study, Pandya (2021), which revealed extraor-
dinarily large ESs (Hedges’ g range: 4.93–11.2) for all the
long-term results (50 weeks), was considered an outlier for
several outcomes (e.g., parental stress, distress, and parent‒
child relationship). Similar to Pandya (2021), the outcomes
reported by Çiçek Gümüş and Öncel (2022) were also iden-
tified as an outlier, with large ESs ranging from 2.706 to
6.084. The results of the meta-analyses are listed in Table 2.

Parental Stress Sixteen trials with 1015 participants
were included to assess the effectiveness of CBIs on paren-
tal stress (Behbahani et al., 2018; Chronis et al., 2006;
Feinberg et al., 2014; Ferraioli & Harris, 2013; Ho et al.,
2021; Liu et al., 2021; Lo et al., 2017a, 2017b; Lo et al.,
2017a, 2017b; Marino et al., 2021; Onyishi et al., 2023;
Schwartzman et al., 2022; Sharif et al., 2015; Valero et al.,
2022; Whittingham et al., 2022; Wong et al., 2010). The
pooled results showed that CBIs had a significant effect
on lessening parental stress when compared with the con-
trol group (g = − 0.69, 95% CI [− 1.05, -0.33], P < 0.01,

Fig. 2 a Quality assessment graph about each risk of bias item pre-
sented as percentages across all included studies; b Summary of risk
of bias assessment of the included randomized controlled trails by
Cochrane Collaboration risk of bias tool

◂

3323Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

Ta
bl

e
1

M
ea

su
re

m
en

t i

tru
m

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ut

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m

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ea
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m

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ts

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fe

re
nc

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re

ss
(n

nu
m

be
r o

f R
C

Ts
=

20
)

Pa
re

nt
in

g
St

re
ss

In
de

x
(P

SI
; A

bi
di

n,
(1

98
3)

) (
n =

3)
D

yk
en

e
t a

l.,
(2

;

H
o

et
a

l.,
(2

; W
on

a
l.,

(2
01

)
Pa

re
nt

in
g

St
re

ss
In

de
x:

S
ho

rt
Fo

rm
(P

SI
-S

F;
A

bi
di

n,
(1

) (
n =

10
)

B
eh

ba
ha

ni
e

t a
l.,

(2
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; F

ei
nb

er
g

et
a

l.,
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01
4)

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er

ra
io

li
an

d
H

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ris

, (
20

13
);

Li
u

et
a

l.,
(2

02
1)

; L
o

et
a

l.,
(2

01
7a

, 2
01

7b
);

M
ar

in
o

et
a

l.,
(2

02
1)

;

N
ee

ce
,

(2
01

4)
; P

an
dy

a,
(2

02
1)

; V
al

er
o

et
a

l.,
(2

02
2)

Pe
rc

ei
ve

d
St

re
ss

S
ca

le
(P

SS
; C

oh
en

e
t a

l.,
(1

98
3)

) (
n =

)
C

hr
on

is
e

t a
l.,

(2
00

6)
; L

ob
at

o
et

a
l.,

(2
02

3)
D

ep
re

ss
io

nx
ie

ty
S

tre
ss

S
ca

le
—

21
-S

tre
ss

S
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sc
al

e
(D

A
SS

-2
1;

L
ov

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d
&

L
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d,
(1

99
5)

) (
n =

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&

Ö
nc

el
, (

20
22

);
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ny
is

hi
e

t a
l.,

(2
02

3)
; S

ar
tz

m
an

e
t a

l.,

(2
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; S

ha
rif

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t a

l.,
(2

01
5)

;

W
hi

tti
ng

ha
m

e
t a

l.,
(2

02
2)

A
nx

ie
ty

(n
=

10
)

B
ec

k
A

nx
ie

ty
In

ve
nt

or
y

(B
A

I;
A

ar
on

T
B

ec
k

&
S

te
er

, (
19

90
))

(n
=

3)
C

hr
on

is
e

t a
l.,

(2
00

6)
; D

yk
en

s e
t a

l.,
(2

01
4)

; K
ho

sh
va

gh
t e

t a
l.,

(2
02

1)
D

ep
re

ss
io

n
A

nx
ie

ty
S

tre
ss

S
ca

le
—

21
-A

nx
ie

ty
S

ub
sc

al
e

Lo
vi

bo
nd

&
L

ov
i-

bo
nd

, (
19

95
) (

=
5)

Ç
iç

ek
G

üm
üş

&
Ö

nc
el

, (
20

22
);

O
ny

is
hi

e
t a

l.,
(2

02
3)

; S
ch

w
ar

tz
m

an
e

t a
l.,

02
2)

;

S
ha

rif
e

t a
l.,

(2
01

5)
; W

hi
tti

ng
ha

m
e

t a
l.,

(2
02

2)
H

am
ilt

on
A

nx
ie

ty
S

ca
le

(H
A

M
A

;

H
am

ilt
on

, (
19

59
))

(n
=

1)
Li

u
et

a
l.,

(2
02

1)
Th

e
Pa

tie
nt

H
ea

lth
Q

ue
sti

on
na

ire
-4

(P
H

Q
-4

;

K
ro

en
ke

e
t a

l.,
(2

00
9)

) (
n =

1)
K

uh
lth

au
e

t a
l.,

(2
02

0)
D

ep
re

ss
io

n
(n

=
15

)
C

en
te

r f
or

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pi

de
m

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lo

gi
ca

l S
tu

di
es

D
ep

re
ss

io
n

Sc
al

e
(C

ES
-D

; R
ad

lo
ff,

97
7)

) (
n =

)
Lo

e
t a

l.,
(2

01
7a

, b
);

N
ee

ce
, (

20
14

)

B
ec

k
D

ep
re

ss
io

n
In

ve
nt

or
y

(B
D

I;
B

ec
k

et
a

l.,
(1

96
1)

) (
n =

2)
(C

hr
on

is
e

t a
l.,

2
00

6;
K

ho
sh

va
gh

t e
t a

l.,
2

02
1)

B
ec

k
D

ep
re

ss
io

n
In

ve
nt

or
y-

II
(B

D
I-

II
; B

ec
k

et
a

l.,
(1

99
6)

) (
n =

3)
(D

yk
en

s e
t a

l.,
2

01
4;

H
ah

s e
t a

l.,
2

01
9;

S
ha

re
h

&
Y

az
da

ni
an

, 2
02

3)
D

ep
re

ss
io

n
A

nx
ie

ty
S

tre
ss

S
ca

le
—

21
-D

ep
re

ss
io

n
Su

bs
ca

le
(L

ov
ib

on
d

Lo
vi

bo
nd

, 1
99

5)
(n

=
5)

Ç
iç

ek
G

üm
üş

&
Ö

nc
el

, (
20

22
);

O
ny

is
hi

e
t a

l.,
(2

02
3)

; S
ch

w
ar

tz
m

an
e

t a
l.,

02
2)

; S
ha

rif
e

t a
l.,

(2
01

5)
; W

hi
tti

ng
ha

m
e

t a
l.,

(2
02

2)
Q

ui
ck

In
ve

nt
or

y
of

D
ep

re
ss

iv
e

Sy
m

pt
om

at
ol

og
y

(Q
ID

S;
R

us
h

et
a

l.,
(2

00
3)

)
(n

=
1)

Fe
in

be
rg

e
t a

l.,
(2

01
4)

H
am

ilt
on

D
ep

re
ss

io
n

Sc
al

e
(H

A
M

A
; H

am
ilt

on
, (

19
60

) (
n =

1)
Li

u
et

a
l.,

(2
02

1)
Th

e
Pa

tie
nt

H
ea

lth
Q

ue
sti

on
na

ire
-4

K
ro

en
ke

e
t a

l.,
(2

00
9)

(n
=

1)
K

uh
lth

au
e

t a
l.,

(2
02

0)
D

ist
re

ss
(n

=
14

)
V

is
ua

l A
na

lo
gu

e
Sc

al
e

(V
A

S)
–D

ist
re

ss
L

es
ag

e
et

a
l.,

(2
01

2)
(n

=
1)

K
uh

lth
au

e
t a

l.,
(2

02
0)

Pa
re

nt
in

g
St

re
ss

In
de

—
Pa

re
nt

al
D

ist
re

ss
S

ub
sc

al
e

A
bi

di
n,

(1
99

0)
(n

=
1)

H
o

et
a

l.,
(2

02
1)

Pa
re

nt
in

g
St

re
ss

In
de

x:
S

ho
rt

Fo
rm

—
Pa

re
nt

al
D

ist
re

ss
S

ub
sc

al
e

A
bi

di
n,

99
0)

(n
=

9)
B

eh
ba

ha
ni

e
t a

l.,
(2

01
8)

;

D
yk

en
s e

t a
l.,

(2
01

4)
; L

iu
e

t a
l.,

(2
02

1)
; L

o
et

a
l.,

01
7a

, b
);

M
ar

in
o

et
a

l.,
(2

02
1)

; P
an

dy
a,

(2
02

1)
; S

ch
w

ar
tz

m
an

e
t a

l.,
(2

02
2)

;
Va

le
ro

e
t a

l.,
(2

02
2)

D
ep

re
ss

io
n

A
nx

ie
ty

S
tre

ss
S

ca
le

-2
1

Lo
vi

bo
nd

&
L

ov
ib

on
d,

(1
99

5)
(n

=
3)

Ç
iç

ek
G

üm
üş

&
Ö

nc
el

, (
20

22
);

Sh
ar

eh
&

Y
az

da
ni

an
, (

20
23

);
Si

eb
el

in
k

et
a

l.,

(2
01

8)
Pa

re
nt

al
w

el
l-b

ei
ng

(n
=

9)
Ry

ff
Sc

al
es

o
f P

sy
ch

ol
og

ic
al

W
el

l-B
ei

ng
—

Sh
or

t F
or

m
(R

yff
&

K
ey

es
,

(1
99

5)
) (

n =
1)

D
yk

en
s e

t a
l.,

(2
01

G
en

er
al

H
ea

lth
Q

ue
sti

on
na

ire
(G

H
Q

;

G
ol

db
er

g
&

W
ill

ia
m

s,
(1

98
8)

) (
n =

1)
Sh

ar
if

et
a

l.,
(2

01
5)

G
en

er
al

H
ea

lth
Q

ue
sti

on
na

ire
—

12
(G

H
Q

-1
2;

G
ol

db
er

g
&

W
ill

ia
m

s,
(1

98
8)

);
(n

=
2)

Lo
ba

to
e

t a
l.,

(2
02

3;
W

on
g

et
a

l.,
(2

01
0)

G
en

er
al

H
ea

lth
Q

ue
sti

on
na

ire
—

28
(G

H
Q

-2
8;

G
ol

db
er

g,
(1

97
8)

) (
n =

1)
Fe

rr
ai

ol
i &

H
ar

ris
, (

20
13

)
W

or
ld

H
ea

lth
O

rg
an

iz
at

io
n-

5
W

el
l-b

ei
ng

In
de

x
(W

H
O

-5
; B

ec
h

et
a

l.,
(2

00
3)

)
(n

=
3)

H
o

et
a

l.,
(2

02
1)

; L
o

et
a

l.,
(2

01
7a

, b
);

Si
eb

el
in

k
et

a
l.,

(2
01

Pe
rs

on
al

W
el

lb
ei

ng
In

de
x

(P
W

I;
La

u
et

a
l.,

(2
00

5)
) (

n =
1)

W
hi

tti
ng

ha
m

e
t a

l.,
(2

02
2)

3324 Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

I2 = 83%; Fig. 3a). Additionally, the robustness of the find-
ing was demonstrated by the fact that the pooled results
remained unchanged after performing a sensitivity analysis
(Supplementary Fig. 1). No publication bias (P = 0.1255)
was identified by using Egger’s test and trim-and-fill fun-
nel plot (Supplementary Fig. 2).

Depressive Symptoms A total of 12 RCTs including
925 subjects were included to analyse the effects of CBIs
on depressive symptoms (Chronis et al., 2006; Feinberg
et al., 2014; Hahs et al., 2019; Khoshvaght et al., 2021;
Kuhlthau et al., 2020; Liu et al., 2021; Lo et al., 2017a,
2017b; Onyishi et al., 2023; Schwartzman et al., 2022;
Shareh & Yazdanian, 2023; Sharif et al., 2015; Whitting-
ham et al., 2022). The results indicated a large effect of
CBIs on alleviating depressive symptoms compared to
the control group (g = − 0.95, 95% CI [− 1.47, − 0.43],
P < 0.01, I2 = 90%; Fig. 3b). The robustness of finding was
confirmed by sensitivity analysis and trim-and-fill funnel
plot, despite Egger’s test revealed potential publication
bias (p = 0.0467) (Supplementary Figs. 3, 4).

Anxiety Anxiety was assessed by eight trials with 484
participants (Chronis et al., 2006; Khoshvaght et al., 2021;
Kuhlthau et al., 2020; Liu et al., 2021; Onyishi et al., 2023;
Schwartzman et al., 2022; Sharif et al., 2015; Whittingham
et al., 2022). Compared with the control group, the CBIs
identified a significant reduction in anxiety (g = − 0.78,
95% CI [− 1.39, − 0.18], P < 0.01, I2 = 90%; Fig. 3c). The
sensitivity analysis confirmed the robustness of the results
(Supplementary Fig. 5).

Parental Distress The effectiveness of CBIs on parental
distress was evaluated in 11 trials with 838 participants
(Behbahani et al., 2018; Ho et al., 2021; Kuhlthau et al.,
2020; Liu et al., 2021; Lo et al., 2017a, 2017b; Lo et al.,
2017a, 2017b; Marino et al., 2021; Schwartzman et al.,
2022; Shareh & Yazdanian, 2023; Siebelink et al., 2018;
Valero et al., 2022). The results revealed that, in com-
parison with the control group, parental distress was sig-
nificantly reduced (g = − 0.29, 95% CI [− 0.42, − 0.15],
P = 0.44, I2 = 1%; Fig. 3e). Furthermore, following a sen-
sitivity analysis in which studies were removed one by
one, the pooled results remained constant, confirming the
robustness of the finding (Supplementary Fig. 6). The Egg-
er’s test (P = 0.1042) and funnel plot also revealed no evi-
dence of potential publication bias (Supplementary Fig. 7).

Parental Well-being Eight RCTs involving 426 subjects
were used to examine the effects of CBIs on parental well-
being (Ferraioli & Harris, 2013; Ho et al., 2021; Lo et al.,
2017a, 2017b; Lobato et al., 2023; Sharif et al., 2015; Sie-
belink et al., 2018; Whittingham et al., 2022; Wong et al.,
2010). The pooled results showed that CBIs had a medium
effect on enhancing parental well-being (g = 0.62, 95% CI
[0.20, 1.03], P < 0.01, I2 = 69%; Fig. 4a). The sensitivity

Ta
bl

e
1

(c
on

tin
ue

O
ut

co
m

es
M

ea
su

re
m

en
ts

Re
fe

re
nc

Q
ua

lit
y

of
re

la
tio

ns
hi

p
(p

ar
en

t–
ch

ild
) (

n =
10

)
Pa

re
nt

in
g

St
re

ss
In

de
x—

Pa
re

nt
–c

hi
ld

D
ys

fu
nc

tio
na

l I
nt

er
ac

tio
n

Su
bs

ca
le

bi
di

n,
(1

99
0)

(n
=

1)
H

o
et

a
l.,

(2
02

Pa
re

nt
in

g
St

re
ss

In
de

x:
S

ho
rt

Fo
rm

—
Pa

re
nt

–c
hi

ld
D

ys
fu

nc
tio

na
l I

nt
er

ac
tio

n
Su

bs
ca

le
A

bi
di

n,
(1

99
0)

(n
=

9)
B

eh
ba

ha
ni

e
t a

l.,
(2

01
8)

;

C
hr

on
is

e
t a

l.,
(2

00
6)

; L
iu

e
t a

l.,
(2

02
1)

; L
o

et
a

l.,

(2
01

7a
, (

b)
; M

ar
in

o
et

a
l.,

(2
02

1)
; P

an
dy

a,
(2

02
1)

; S
ch

w
ar

tz
m

an
e

t a
l.,

02
2)

; V
al

er
o

et
a

l.,
(2

02
2)

Ps
yc

ho
lo

gi
ca

l fl
ex

ib
ili

ty
(n

=
6)

A
cc

ep
ta

nc
e

an
d

A
ct

io
n

Q
ue

sti
on

na
ire

—
Se

co
nd

v
er

si
on

(A
A

Q
-I

I;
B

on
d

B
un

ce
, (

20
03

))
(n

=
5)

Ç
iç

ek
G

üm
üş

&
Ö

nc
el

, (
20

22
);

H
ah

s e
t a

l.,
(2

01
9)

; M
ar

in
o

et
a

l.,
(2

02
1)

;
Sc

hw
ar

tz
m

an
e

t a
l.,

(2
02

2)
; W

hi
tti

ng
ha

m
e

t a
l.,

(2
02

2)
Pa

re
nt

al
A

cc
ep

ta
nc

e
Q

ue
sti

on
na

ire
(6

-P
A

Q
; G

re
en

e
et

a
l.,

(2
01

5)
) (

n =
1)

Lo
ba

to
e

t a
l.,

(2
02

)
M

in
df

ul
p

ar
en

tin
g

(n
=

4)
Th

e
In

te
rp

er
so

na
l M

in
df

ul
ne

ss
in

P
ar

en
tin

g
(I

M
P;

D
un

ca
n

et
a

l.,
(2

00
9)

)
Lo

e
t a

l.,
(2

01
7a

, b
);

Si
eb

el
in

k
et

a
l.,

(2
01

8)
; W

hi
tti

ng
ha

m
e

t a
l.,

(2
02

2)
M

in
df

ul
aw

ar
en

es
s (

n =
4)

M
in

df
ul

A
tte

nt
io

n
A

w
ar

en
es

s
Sc

al
e

(M
A

A
S;

B
ro

w
n

et
a

l.,
(2

00
3)

) (
n =

4)
H

ah
s e

t a
l.,

(2
01

9)
; L

iu
e

t a
l.,

(2
02

1)
; M

ar
in

o
et

a
l.,

(2
02

1)
; S

ch
w

ar
tz

m
an

e
t a

l.,

(2
02

3325Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

Ta
bl

e
2

S
um

m
ar

y
of

fi
nd

in
gs

*p
<

0.
05

;

<
0.

00
1

O
ut

co
m

es
M

et
a-

an
al

ys
es

N
ar

ra
tiv

e
sy

nt
he

se
s

C
er

ta
in

ty
o

f
th

e
ev

id
en

ce
N

o.
o

f
pa

rti
ci

–
pa

nt
s

SM
D

(9
5%

C
I)

Re
fe

re
nc

es
N

o.
o

f
pa

rti
ci

–
pa

nt
s

H
ed

ge
s’

g
Re

fe
re

nc
es

Pa
re

nt
al

st
re

ss
10

5
−

0
.6

9
(−

1
.0

5,
−

0
.3

3)
B

eh
ba

ha
ni

e
t a

l.,
(2

01
8)

; C
hr

on
is

e
t a

l.,
(2

00
6)

; F
ei

nb
er

g
et

a
l.,

(2
01

4)
; F

er
ra

io
li

an
d

H
ar

ris
, (

20
13

);
H

o
et

a
l.,

02
1)

; L
iu

e
t a

l.,
(2

02
1)

; L
o

et
a

l.,
(2

01
7a

, 2
01

7b
);

M
ar

in
o

et
a

l.,
(2

02
1)

; O
ny

is
hi

e
t a

l.,
(2

02
3)

; S
ch

w
ar

tz
–

m
an

e
t a

l.,
(2

02
2)

; S
ha

rif
e

t a
l.,

(2
01

5)
; V

al
er

o
et

a
l.,

02
2)

; W
hi

tti
ng

ha
m

e
t a

l.,
(2

02
2)

; W
on

g
et

a
l.,

(2
01

13
7

60 46

−
8

.6
4*

*
−

5
.8

1*
*

−
0

.7
0*

Pa
nd

ya
, (

20
21

)
Ç

iç
ek

G
üm

üş
a

nd
Ö

nc
el

, (
20

22
)

N
ee

ce
, (

20
14

)

M
od

er
at

D
ep

re
ss

iv
e

sy
m

pt
om

s
92

5
−

0
.9

5
(−

1
.4

7,
−

0
.4

3)
C

hr
on

is
e

t a
l.,

(2
00

6)
; F

ei
nb

er
g

et
a

l.,
(2

01
4)

; H
ah

s e
t a

l.,

(2
01

9)
; K

ho
sh

va
gh

t e
t a

l.,
(2

02
1)

; K
uh

lth
au

e
t a

l.,

(2
02

0)
; L

iu
e

t a
l.,

(2
02

1)
; L

o
et

a
l.,

(2
01

7a
, 2

01
7b

);
O

ny
is

hi
e

t a
l.,

(2
02

3)
; S

ch
w

ar
tz

m
an

e
t a

l.,
(2

02
2)

;
Sh

ar
eh

a
nd

Y
az

da
ni

an
, (

20
23

);
Sh

ar
if

et
a

l.,
(2

01
5)

;
W

hi
tti

ng
ha

m
e

t a
l.,

(2
02

24
3

46 60

−
1

.0
5*

*
−

0
.8

7*
−

5
.0

4*
*

D
yk

en
s e

t a
l.,

(2
01

)
N

ee
ce

, (
20

14
)

Ç
iç

ek
G

üm
üş

a
nd

Ö
nc

el
, (

20
22

)

H
ig

A
nx

ie
ty

48
4

−
0

.7
8

(−
1

.3
9,

−
0

.1
8)

C
hr

on
is

e
t a

l.,
(2

00
6)

; K
ho

sh
va

gh
t e

t a
l.,

(2
02

1)
;

K
uh

lth
au

e
t a

l.,
(2

02
0)

; L
iu

e
t a

l.,
(2

02
1)

; O
ny

is
hi

a
l.,

(2
02

3)
; S

ch
w

ar
tz

m
an

e
t a

l.,
(2

02
2)

; S
ha

rif
e

t a
l.,

01
5)

; W
hi

tti
ng

ha
m

e
t a

l.,
(2

02
2)

24
3

60
−

0
.9

0*
*

−
2

.7
1*

*
D

yk
en

s e
t a

l.,
(2

01
4)

Ç
iç

ek
G

üm
üş

a
nd

Ö
nc

el
, (

20
22

)
M

od
er

at
e

Pa
re

nt
al

d
ist

re
ss

83
8

−
0

.2
9

(−
0

.4
2,

−
0

.1
5)

B
eh

ba
ha

ni
e

t a
l.,

(2
01

8)
; H

o
et

a
l.,

(2
02

1)
; K

uh
lth

et
a

l.,
(2

02
0)

; L
iu

e
t a

l.,
(2

02
1)

; L
o

et
a

l.,
(2

01
7a

,
20

17
b)

; M
ar

in
o

et
a

l.,
(2

02
1)

; S
ch

w
ar

tz
m

an
e

t a
l.,

02
2)

; S
ha

re
h

an
d

Ya
zd

an
ia

n,
(2

02
3)

; S
ie

be
lin

k
et

a
l.,

01
8)

; V
al

er
o

et
a

l.,
(2

02
2)

13
7

46 60

−
6

.7
**

−
0

.7
0*

−
5

.5
0*

Pa
nd

ya
, (

20
21

)
N

ee
ce

, (
20

14
)

Ç
iç

ek
G

üm
üş

a
nd

Ö
nc

el
, (

20
22

)

H
ig

Pa
re

nt
al

w
el

l-b
ei

ng
42

6
0.

62
(0

.2
0,

1
.0

3)
(F

er
ra

io
li

an
d

H
ar

ris
, (

20
13

);
H

o
et

a
l.,

(2
02

1)
; L

o
et

a
l.,

01
7a

, 2
01

7b
);

Lo
ba

to
e

t a
l.,

(2
02

3)
; S

ha
rif

e
t a

l.,

(2
01

5)
; S

ie
be

lin
k

et
a

l.,
(2

01
8)

; W
hi

tti
ng

ha
m

e
t a

l.,

(2
02

2)
; W

on
g

et
a

l.,
(2

01
0)

–
–

–
M

od
er

at
e

Pa
re

nt
–c

hi
ld

re
la

tio
ns

hi
p

61
5

0.
43

(0
.2

2,
0

.6
4)

B
eh

ba
ha

ni
e

t a
l.,

(2
01

8)
; C

hr
on

is
e

t a
l.,

(2
00

6)
; H

o
et

a
l.,

02
1)

; L
iu

e
t a

l.,
(2

02
1)

; L
o

et
a

l.,
(2

01
7a

, 2
01

7b
);

et
a

l.,
(2

01
7a

, 2
01

7b
);

M
ar

in
o

et
a

l.,
(2

02
1)

; S
ch

w
ar

tz
–

m
an

e
t a

l.,
(2

02
2)

; V
al

er
o

et
a

l.,
(2

02
2)

13
7

5.
49

**
Pa

nd
ya

, (
20

21
)

H
ig

M
in

df
ul

p
ar

en
tin

g
43

4
0.

15
(−

0
.0

5,
0

.3
5)

Lo
e

t a
l.,

(2
01

7a
, 2

01
7b

);
Si

eb
el

in
k

et
a

l.,
(2

01
8)

; W
hi

t-
tin

gh
am

e
t a

l.,
(2

02
2)

–
–

–
M

od
er

at
e

M
in

df
ul

aw
ar

en
es

s
18

5
1.

99
(−

0
.6

4,
4

.6
2)

H
ah

s e
t a

l.,
(2

01
9)

; L
iu

e
t a

l.,
(2

02
1)

; M
ar

in
o

et
a

l.,

(2
02

1)
; S

ch
w

ar
tz

m
an

e
t a

l.,
(2

02
2)

–
–

–
Ve

ry
lo

Ps
yc

ho
lo

gi
ca

l fl
ex

ib
ili

ty
13

8
1.

47
(−

0
.4

2,
3

.3
6)

H
ah

s e
t a

l.,
(2

01
9)

; L
ob

at
o

et
a

l.,
(2

02
3)

; M
ar

in
o

et
a

l.,

(2
02

1)
; S

ch
w

ar
tz

m
an

e
t a

l.,
(2

02
2)

; W
hi

tti
ng

ha
m

e
t a

l.,

(2
02

60
6.

08
**

Ç
iç

ek
G

üm
üş

a
nd

Ö
nc

el
, (

20
22

)
Ve

ry
lo

3326 Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

Fi
g.

Fo
re

st
pl

ot
s e

ffe
ct

o
f C

B
Is

o
n
a

pa
re

nt
al

st
re

ss
; b

d
ep

re
ss

iv
e

sy
m

pt
om

o
f p

ar
en

ts
; c

a
nx

ie
ty

o
f p

ar
en

ts
; d

p
ar

en
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3328 Journal of Autism and Developmental Disorders (2024) 54:3316–3335

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analysis confirmed the robustness of the result (Supple-
mentary Fig. 8).

Parent‒Child Relationship The parent‒child relationship
was examined by nine studies with 615 participants (Behba-
hani et al., 2018; Chronis et al., 2006; Ho et al., 2021; Liu
et al., 2021; Lo et al., 2017a, 2017b; Lo et al., 2017a, 2017b;
Marino et al., 2021; Schwartzman et al., 2022; Valero et al.,
2022). CBIs had a small effect on the parent‒child rela-
tionship (g = 0.43, 95% CI [0.22, 0.64], P = 0.15, I2 = 33%;
Fig. 4b). Furthermore, the result was not altered after per-
forming a sensitivity analysis (Supplementary Fig. 9).

Mindful Parenting Four trials involving 434 participants
reported the effects of CBIs on mindful parenting (Lo et al.,
2017a, 2017b; Lo et al., 2017a, 2017b; Siebelink et al.,
2018; Whittingham et al., 2022). The findings demonstrated
that CBIs did not substantially promote mindful parenting
(g = 0.15, 95% CI [− 0.05, 0.35], P = 0.40, I2 = 0%; Fig. 4c).
The sensitivity analysis confirmed that these findings were
reliable (Supplementary Fig. 10).

Mindful Awareness Four trials with 185 subjects were
used to investigate the influence of CBIs on mindful aware-
ness (Hahs et al., 2019; Liu et al., 2021; Marino et al.,
2021; Schwartzman et al., 2022). No significant improve-
ments were revealed in the pooled results (g = 1.99, 95%
CI [− 0.64, 4.62], P < 0.01, I2 = 88%; Fig. 4d); however,
the results of the sensitivity analysis revealed the potential
benefit of CBIs after removing an outlier (g = 0.61, 95%
CI [0.27, 0.96], P < 0.01, I2 = 0%; Supplementary Fig. 11)
(Marino et al., 2021).

Psychological Flexibility A total of five studies includ-
ing 138 participants were used to examine the effect of
CBIs on psychological flexibility (Hahs et al., 2019; Lobato
et al., 2023; Marino et al., 2021; Schwartzman et al., 2022;
Whittingham et al., 2022). The results of the meta-analysis
revealed that the CBIs that were implemented in those stud-
ies did not significantly enhance psychological flexibility
(g = 1.47, 95% CI [− 0.42, 3.36], P < 0.01, I2 = 85%; Fig. 4e).
However, the favourable effect of CBIs was discovered
after excluding one outlier (g = 0.43, 95% CI [0.03, 0.83],
P = 0.14, I2 = 0%; Supplementary Fig. 12) (Marino et al.,
2021).

Comparison of Treatment Effects Between Different
Intervention Approaches

This subgroup analysis did not include mindful aware-
ness, or psychological flexibility due to the paucity of
relevant research. The subgroup analysis indicated that
MBIs had a significant effect on parental stress levels
(knumber of outcomes = 8, g = − 0.50, 95% CI [− 0.78, − 0.22],
P = 0.03, I2 = 55%), depressive symptoms (k = 3, g = − 0.38,
95% CI [− 0.60, − 0.17], P = 0.72, I2 = 0%), parental distress
levels (k = 8, g = − 0.24, 95% CI [− 0.39, − 0.08], P = 0.59,

I2 = 0%), parental well-being levels (k = 4, g = 0.42, 95%
CI [0.17, 0.68], P = 0.15, I2 = 44%), and parent‒child rela-
tionships (k = 6, g = 0.37, 95% CI [0.16, 0.58], P = 0.18,
I2 = 34%). And CBT could also effectively decrease these
parents’ parental stress levels (k = 5, g = − 1.02, 95% CI
[− 1.89, − 0.15], P < 0.01, I2 = 93%) and depressive symp-
toms (k = 5, g = − 1.31, 95% CI [− 2.28, − 0.34], P < 0.01,
I2 = 94%), while improving parental well-being (k = 2,
g = 1.20, 95% CI [0.31, 2.09], P = 0.03, I2 = 79%). The
results of subgroup analysis for different interventions are
displayed in Figs.3 and 4.

Comparison of Treatment Effects Between
Parent‑Only and Parent‒Child Dyad CBIs

A subgroup analysis revealed that parent‒child dyad CBIs
were more favourable than parent-only CBIs in improving
parent‒child relationships (g = 0.66, 95% CI [0.15, 1.16] vs.
0.33, 95% CI [0.15, 0.51]; Supplementary Fig. 15), while
parent-only CBIs were more beneficial than parent‒child
dyad CBIs in decreasing parental stress levels (g = − 0.73,
95% CI [− 1.16, − 0.30] vs. − 0.57 [− 1.18, 0.04]; Supple-
mentary Fig. 13), distress levels (g = − 0.29, 95% CI [− 0.51,
− 0.10] vs. − 0.28, 95% CI [− 0.55, − 0.00]; Supplementary
Fig. 14), and enhancing parental well-being (g = 0.76, 95%
CI [0.24, 1.29] vs. 0.30, 95% CI [− 0.19, 1.03]; Supplemen-
tary Fig. 16).

Comparison of Treatment Effects Between
Intervention Durations

According to the subgroup analyses, the ideal intervention
duration was 1 to 8 weeks for decreases in parental stress
levels (k = 7, g = − 0.60, 95% CI [− 0.95, − 0.25], P = 0.03,
I2 = 58%; Supplementary Fig. 17), depressive symptoms
(k = 5, g = − 0.91, 95% CI [− 1.63, − 0.18], P < 0.01,
I2 = 82%; Supplementary Fig. 18), anxiety levels (k = 3,
g = − 0.97, 95% CI [− 1.43, − 0.51], P = 0.25, I2 = 27%;
Supplementary Fig. 19), and parental distress levels (k = 7,
g = − 0.30, 95% CI [− 0.49, − 0.11], P = 0.25, I2 = 23%; Sup-
plementary Fig. 20), as well as for improvements in paren-
tal well-being levels (k = 4, g = 0.49, 95% CI [0.22, 0.75],
P = 0.33, I2 = 13%; Supplementary Fig. 21), parent‒child
relationships (k = 5, g = 0.59, 95% CI [0.21, 0.97], P = 0.03,
I2 = 62%; Supplementary Fig. 22), mindful awareness (k = 2,
g = 0.88, 95% CI [0.31, 1.45], P = 0.52, I2 = 0%; Supplemen-
tary Fig. 23), and parental psychological flexibility (k = 3,
g = 0.69, 95% CI [0.18, 1.19], P = 0.98, I2 = 0%; Supplemen-
tary Fig. 24). However, significant effects on parental stress
levels (k = 8, g = − 0.43, 95% CI [− 0.72, − 0.15], P = 0.03,
I2 = 54%; Supplementary Fig. 17) and parent‒child relation-
ships (k = 4, g = 0.28, 95% CI [0.01, 0.55], P = 0.93, I2 = 0%;

3329Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

Supplementary Fig. 22) were also observed when the inter-
vention duration was over eight weeks.

Comparison of Treatment Effects Between Two
Types of DD in Children

No subgroup analyses were conducted for children with
CP, ID, or blended types of DD due to the limited num-
ber of relevant studies. The subgroup analysis found that
CBIs had significantly positive effects on parental stress
levels (k = 7, g = − 0.60, 95% CI [− 0.84, − 0.36], P = 0.18,
I2 = 32%; Supplementary Fig. 25), parental distress lev-
els (k = 5, g = − 0.33, 95% CI [− 0.52, − 0.13], P = 0.66,
I2 = 0%; Supplementary Fig. 28), parental well-being levels
(k = 4, g = 0.79, 95% CI [0.25, 1.33], P < 0.01, I2 = 77%; Sup-
plementary Fig. 29), and parent‒child relationships (k = 5,
g = 0.43, 95% CI [0.14, 0.73], P = 0.14, I2 = 43%; Supple-
mentary Fig. 30) for parents of children with ADHD. In
addition, CBIs were shown to effectively reduce parental
stress levels (k = 7, g = − 0.99, 95% CI [− 1.79, − 0.20],
P < 0.01, I2 = 91%; Supplementary Fig. 25), depressive
symptoms (k = 5, g = − 0.99, 95% CI [− 1.83, − 0.15],
P < 0.01, I2 = 91%; Supplementary Fig. 26), and anxiety
levels (k = 3, g = − 1.40, 95% CI [− 2.62, − 0.17], P < 0.01,
I2 = 92%; Supplementary Fig. 27) for parents of children
with ASD.

Narrative Syntheses

Four studies (Dykens et al., 2014; Pandya, 2021) (Çiçek
Gümüş & Öncel, 2022; Neece, 2014) conducted narrative
analyses. When compared to the positive psychotherapy
group, Dykens et al. (2014) observed substantial postint-
ervention reductions in depression (g = 1.05) and anxiety
(g = 0.90) symptoms for parents of children with DD using
an in-person MBI. Moreover, Pandya (2021) reported that
utilizing online MBI versus a waitlist control group resulted
in a considerable reduction in parental stress (g = − 8.64)
distress (g = − 6.70) levels, and a postintervention improve-
ment in parent‒child relationships (g = 5.63). Furthermore,
Neece (2014) identified that mindfulness-based stress reduc-
tion could significantly alleviate parental distress (Cohens’
d = 0.70) and depression (d = 0.87) for parents of children
with DD postintervention compared to the wait-list con-
trol group. In addition, Çiçek Gümüş and Öncel (2022)
found significant reductions in parental stress (g = − 5.81),
depressive symptoms (g = − 5.04), anxiety (g = − 2.71),
parental distress (g = − 5.50), and psychological flexibility
(g = − 6.08) for parents of children with ASD and mental
disorder(s) postintervention when comparing ACT to the
TAU control group.

Risk of Bias

In general, one study was determined to have a high risk of
bias (Behbahani et al., 2018), while the other studies were
judged to have some concerning aspects regarding the risk
of bias (Figure 2). Due to a lack of information on allo-
cation concealment, 13 studies (52%) were found to have
some concerning aspects regarding a risk of bias resulting
from the randomization technique, whereas the other studies
showed low risk. A total of 18 studies (72%) were revealed
to have some concerning aspects regarding deviations from
the intended intervention, while the remaining seven stud-
ies were deemed to be low risk. Except for one study, which
was deemed high risk due to no information concerning
insufficient/missing data, other studies were deemed low
risk (96%). All studies were noted to have some concern-
ing aspects regarding outcome measurements because they
all used self-reported instruments. In the selection of the
published results, 13 studies (52%) were rated as low risk,
while the remaining studies were evaluated as having some
concerning aspects due to inadequate information regarding
prespecified analytical plans/protocols.

Quality of the Evidence

The aggregate GRADE evaluation of the outcomes revealed
that the certainty of evidence results ranged from “high”
to “very low” (Table 1). The effects of CBIs on parental
distress, depression levels, and parent‒child relationships
were determined to have a high certainty of evidence. The
evidence regarding effects on parental stress and anxiety lev-
els, parental well-being, and mindful parenting was judged
as having moderate certainty of evidence because of signifi-
cant heterogeneity or inconsistency. The evidence regarding
effects on mindful awareness and psychological flexibility
had a low level of certainty, mainly because of the risk of
bias, inconsistency (high heterogeneity), and/or imprecision
(sample size lower than 400) of the relevant studies.

Discussion

This review and meta-analysis summarized and synthesized
25 RCTs to examine the effectiveness of CBIs in reducing
distress levels and improving mental health and wellbe-
ing among parents of children with DD. The results of the
meta-analysis highlight that CBIs may significantly allevi-
ate the levels of parental stress, depressive symptoms, anxi-
ety, and parental distress and improve parental well-being
and parent‒child relationships for parents of children with
DD. Moreover, MBIs and CBT interventions showed posi-
tive effects and were recommended as potential optimal
approaches in the subgroup analyses. The findings of our

3330 Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

review echo those of previous systematic reviews and meta-
analyses that CBIs had positive effects for reducing parental
stress and psychological symptoms postintervention in par-
ents of children with DD. Osborn et al., (2021) explored the
impact of mindfulness therapies on psychological distress in
parents of children with DD and reported small to large ESs
(g range: 0.39 to 1.94). Lee et al. (2022) examined the effect
of mindfulness parent training on parenting stress levels and
found small to large ESs (g range: 0.06 to 0.84) for parents
of children with ADHD. Hartley et al. (2019) conducted a
meta-analysis on MBIs for parents of children with ASD and
revealed postintervention improvement in subjective well-
being. Bourke-Taylor et al. (2021) performed a meta-analysis
on group interventions for mothers of children with disabili-
ties and found that CBT demonstrated significantly large
postintervention ESs for parenting stress levels (g = 0.86)
and mental health (g = 1.14). As MBIs and CBT interven-
tions have been identified as optimal approaches, future
well-designed RCTs are needed to confirm their effects on
parents of children with DD and, equally importantly, the
factors and mechanisms of action impacting their efficacy.

However, this review did not identify significant improve-
ment in the outcomes of mindfulness parenting, mindfulness
awareness, and psychological flexibility postintervention for
parents of children with DD, which is in line with Chua and
Shorey’s (2022) meta-analysis, which examined the effec-
tiveness of MBIs and ACT interventions among parents of
children with DD. The findings of the current study sug-
gest that cautious interpretation is needed due to the limited
number of studies and the small sample sizes included in the
meta-analysis, as well as the heterogeneity of the interven-
tion content. Another reason for the resulting ineffective-
ness is that those studies did not set mindfulness parenting,
mindfulness awareness, and/or psychological flexibility as
primary outcomes. The intervention may only indirectly
impact those outcomes, implying that some outcomes need
to be sufficiently addressed with current CBIs. In contrast,
Rayan and Ahmad (2018) found that five out of six trials
reported postintervention improvements in mindful parent-
ing among parents of children with disabilities, although
only a narrative synthesis was performed in that study and
only one RCT was included, implying that direct compari-
sons could not be conducted. Similarly, studies included in
our study indicated that CBIs could facilitate mindful aware-
ness and psychological flexibility outcomes, but the opposite
pooled result was obtained after performing meta-analyses.
This may be because we applied the random-effects model
to account for the significant heterogeneity since one study
(Marino et al., 2021) displayed an extremely large ES for
these two outcomes. The positive effect appeared for mindful
awareness (g = 0.70, 95% CI [0.39, 1.01], P < 0.01, I2 = 88%)
and psychological flexibility (g = 0.56, 95% CI [0.19, 0.92],
P < 0.01, I2 = 85%) after we switched to the fixed-effects

model. Therefore, additional studies are required to further
explore the potential benefits of CBIs on these inconsistent
outcomes.

Moreover, Chua and Shorey’s (2022) meta-analysis also
demonstrated that MBIs and ACTs were effective in reduc-
ing parental stress, anxiety, and depression, which supported
the findings of our study discussed above; however, our
pooled results showed that no significant reductions were
observed for parental stress or depressive symptoms when
using ACT for parents of children with DD. This may be
due to the paucity of research investigating the effectiveness
of ACT for parents of children with DD, which allowed for
only 4 eligible studies to be included in our meta-analysis.
All included studies concluded that ACT could be applied
to lessen depressive symptoms, anxiety, and parental dis-
tress and to promote parental well-being, parent‒child rela-
tionships, mindful parenting, and mindful awareness, even
though the conclusions for parental stress and psychological
flexibility were inconsistent. The reason that these two out-
comes did not change in the RCT conducted by Whittingham
et al. (2022) may be because some of the parents of children
with CP had to cope with not only their children’s motor
problems but also other problems caused by comorbidi-
ties, such as epilepsy (14.93%), ASD (8.96%), and ADHD
(4.48%), resulting in a higher level of stress and making
it more difficult to actively develop personal growth (e.g.,
psychological flexibility) (Li et al., 2016). Furthermore, as
Chua and Shorey (2022) did not further conduct a subgroup
analysis to explore the effectiveness of MBIs and ACT sepa-
rately, a direct comparison could not be drawn. In addition,
we did not perform a subgroup analysis for DBT and CFT
because only one relevant study was included in our review,
respectively. However, Shareh et al. (2023) revealed that
DBT significantly reduced distress and depression in moth-
ers of children with ID postintervention compared with the
wait-list control. And Khoshvaght et al. (2021) demonstrated
that CFT effectively alleviated anxiety and depression in
mothers of children with CP postintervention compared with
no treatment. As a result, future well-designed RCTs are
recommended to examine and confirm the effectiveness of
ACT, DBT, and CFT on the outcomes mentioned above for
parents of children with DD as well as to investigate the
broad potential to confer meaningful benefits to these par-
ents beyond those outcomes.

Apart from the impact of the intervention approach men-
tioned above, other moderators, including intervention dura-
tion, targeted participants, and the types of DD among the
children, also revealed a significant impact on the outcomes.
Consistent with previous studies showing that eight weeks
of MBIs (Gotink et al., 2016) and no more than five ACT
sessions (Li et al., 2021) can significantly change various
health indicators postintervention, our review found that 1
to 8 weeks was regarded as the optimal duration of CBIs

3331Journal of Autism and Developmental Disorders (2024) 54:3316–3335

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for parents of children with DD to reduce parental anxiety
and improve parental well-being, parent‒child relationships,
mindful awareness, psychology flexibility. Furthermore, for
participant targets, including parent‒child dyads and par-
ent-only participants, parent-only participants showed more
positive effects for the CBI outcomes (e.g., parental stress,
distress, and well-being) than parent‒child dyads. However,
parent–child dyads showed greater ES than parent-only par-
ticipants in parent–child relationships. This may be because
parent‒child dyads could improve parent‒child interactions,
thus further alleviating relational frustration, parental stress,
and other mental health problems (Dennis et al., 2018).
Moreover, subgroup analyses also demonstrated that CBIs
were associated with significant improvements for parents
of children with two different types of DD (ADHD and/or
ASD) in parental stress and other outcomes, which is in line
with previous studies (Hartley et al., 2019; Lee et al., 2022;
Yu et al., 2019). However, considering the unique needs and
experiences among parents of children with different disease
types, future studies and research should be syndrome- and
disease-specific. Furthermore, these subgroup analyses were
complicated by the fact that format was confounded with
different intervention approaches. Therefore, explore other
variable that potentially affect the outcomes is another rec-
ommendation for future research to consider.

There are several limitations to consider. First, the gender
imbalance among the participants, which may limit findings
to mother-specific experiences, should be taken into account.
The proportion of women in the sample largely reflects that
mothers have historically been the primary caregivers of
children with DD. However, given that there is evidence
to suggest that parenting experiences, mental health, and
stress outcomes may differ for fathers of children with DD
(Seymour et al., 2018), future studies should consider these
gender differences.

Second, because many potential moderators were not dis-
closed and/or reported inconsistently across studies, such
as sociodemographic factors (e.g., child and parent ages,
gender, race/ethnicity, family income, child symptom sever-
ity and functioning), intervention characteristics (e.g., inter-
vention context, dosage, number of sessions, and delivery
location), and measurement tools, this review was unable to
evaluate them all. These moderators/variations may bring
further significant heterogeneity into the meta-analyses.
Therefore, more consistent reporting of these variables is
required for future studies to meaningfully examine system-
atic moderators.

Third, a total of eight studies (38.10%) were pilot
studies with a small sample size (of which the number
of participants in six studies was ≤ 20 per group), which
may not provide enough statistical power to identify
intervention effects and thus may hinder the internal and

external validity of study outcomes. Moreover, no study
was assessed as having a low risk of bias, and the majority
of included studies had some methodological limitations,
such as a lack of information about allocation conceal-
ment, intention-to-treat analyses, and prespecified proto-
cols, as well as unblinding the intervention to participants
and intervenors and the use of self-report questionnaires.
In addition, the effects of CBIs on some of the apparently
unaffected outcomes, such as mindful parenting, mindful
awareness, and psychological flexibility, still need to be
determined due to the paucity of relevant studies. There-
fore, future research with rigorously designed RCTs is
recommended with different intervention approaches and
with the objective of extending the list of outcomes to
include currently unclear outcomes to support parents of
children with DD.

Finally, this study did not conduct subgroup analysis
for comparison between parents of children with medical
comorbidity (such as ASD-ID, ADHD-ID, ASD-ADHD,
ASD-epilepsy) versus ASD as a single medical condition,
or between parents of children with or without ID. This
restriction was due to lack of such information reported
in the included studies. This restriction is likely to limit
the generalizability of the findings reported here across all
those diagnosed with ASD. One factor relevant to this has
been the changes in this population resulting from changes
to diagnostic criteria. More specifically, researchers using
data from parents whose children were diagnosed prior to
2017 and who were funded by the National Institute of
Mental Health (NIMH) in the United States were required
to ensure that their sample met DSM-IV or IV-Tr criteria.
These criteria explicitly excluded children from diagno-
sis with ASD-ADHD comorbidity; this restriction was
removed in 2017 with the release of DSM-5, which per-
mitted comorbidity and this subgroup now constitutes a
significant part of the ASD population. In addition, Asper-
ger syndrome which was previously coded separately,
became part of the general ASD category. Asperger syn-
drome constituted a significant group of children without
significant developmental delay or intellectual difficulties,
and a reduced level of medical comorbidity. These broad-
ening of criteria mean that post- 2017 parents were likely
to experience more diverse levels of distress and caregiver
burden. For families with DD children, more healthcare,
education, and social support services, are often required
and it is essential to identify them, to allocate additional
resource. We also need to design and evaluate syndrome-
and disease-specific interventions. It is recommended,
therefore that a proportion of future studies are focussed
on these specific populations, clearly describe the eligibil-
ity criteria of their participants, and use this framework to
develop interventions that best meet the specific needs of
their parents’ in caring for themselves and their children.

3332 Journal of Autism and Developmental Disorders (2024) 54:3316–3335

1 3

Conclusion

The positive effects of CBIs on parental stress levels, depres-
sive symptoms, anxiety levels, parental distress, parental
well-being, and parent–child relationships were highlighted
in this review. Factors that influenced intervention effects
included intervention approaches and durations, participant
targets, and the types of DD among the children. The current
evidence should be strengthened by additional well-designed
RCTs that explore and examine the process, predictive fac-
tors, and mechanism of action of the best interventions for
parents of children with DD.

Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s10803- 023- 06063-x.

Acknowledgments None.

Author Contributions Sini Li contributed to records identification,
data extraction and curation, formal analysis, and writing and revising
manuscripts. Yijing Yong contributed to records identification, data
extraction and curation. Yamin Li contributed to records identifica-
tion, data extraction and curation, and obtaining funding. Jianhe Li and
Jiao Xie contributed to Conceptualisation, methodology, supervision,
visualization, final review and editing.

Funding The research was funded by the National Natural Science
Foundation of China (No: 81873806).

Data Availability All data generated or analysed during this study are
included in this published article as Supplementary information files.

Declarations

Conflict of interest There is no conflict of interest between all authors.

Ethical Approval and Consent to Participate This is a systematic review
and meta-analyses for which the patient data were all obtained from
previous published studies. It does not contain any studies with animal
or human participants.

Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.

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Cognitive-Based Interventions for Improving Psychological Health and Well-Being for Parents of Children with Developmental Disabilities: A Systematic Review and Meta-analysis

Abstract

Introduction

Methods

Research Strategy

Inclusion and Exclusion Criteria

Study Selection

Data Extraction

Quality Appraisal

Certainty of Evidence

Data Synthesis

Results

Study Selection

Study Characteristics

Meta-analyses of CBI Outcomes

Comparison of Treatment Effects Between Different Intervention Approaches

Comparison of Treatment Effects Between Parent-Only and Parent‒Child Dyad CBIs

Comparison of Treatment Effects Between Intervention Durations

Comparison of Treatment Effects Between Two Types of DD in Children

Narrative Syntheses

Risk of Bias

Quality of the Evidence

Discussion

Conclusion

Acknowledgments

References

Brief Report

Potential for children with intellectual disability to engage
in cognitive behaviour therapy: the parent perspective

A. Hronis,1 R. Roberts,2 L. Roberts1 & I. Kneebone1

1 Graduate School of Health, University of Technology Sydney, Ultimo, Australia
2 The University of Adelaide, Adelaide, Australia

Abstract

Background This study aimed to obtain the opinions
of parents and carers of children with intellectual
disability (ID) as to whether cognitive behaviour
therapy (CBT) could be useful for their children.
Methods A mixed qualitative and quantitative
method was employed. Twenty-one carers of children
aged 10 to 17 having borderline to moderate
intellectual functioning responded to an online
questionnaire. Participants were provided with
information about CBT and asked to respond to
open-ended questions. Quantitative data pertained to
questions about their child’s ability to identify and
describe thoughts, feelings and behaviours. Thematic
analysis of responses was conducted using an
inductive method of identifying themes from the
qualitative data collected.
Results Five themes emerged from the qualitative
analysis: Emotional Attunement (i.e. parent’s
understanding and recognition of their child’s
emotions), Role of the Therapist (i.e. ways therapists
could facilitate the intervention), Role of the Parent
(i.e. ways parents could engage in the therapy
process), Anticipated Obstacles (i.e. what may get in the
way of the therapy) and Suggested Adaptations for

Therapy (i.e. how CBT can be adapted to suit the
needs of children with ID). Seventy-six per cent
agreed that their child would be able to engage in
CBT with assistance.
Conclusions The majority of parents believed that
CBT is an intervention that children with ID could
engage in, provided the therapy is adapted, and the
therapist accommodates their needs.

Keywords children, cognitive behaviour therapy,
intellectual disability, learning disability

Background

Up to 50% of children with intellectual disability (ID)
have a comorbid mental illness (Einfeld et al. 2011;
Tonge & Einfeld 2000). Because of deficits in
intellectual functioning, treatments have largely
involved behavioural interventions and use of
medications (Vereenooghe & Langdon 2013).
Recently, cognitive behaviour therapy (CBT) has
been identified as an effective treatment for adults
with mild to moderate ID and comorbid depression,
anxiety and anger (e.g. Hassiotis et al. 2013; Osugo &
Cooper 2016; Roberts & Kwan 2018; Vereenooghe &
Langdon 2013). While similar trials have not been
conducted among children with ID, CBT could be a
treatment option for children with ID, provided
adaptations are made (Hronis et al. 2017).

Correspondence: Ms Anastasia Hronis, Discipline of Clinical

Psychology, Graduate School of Health, University of Technology

Sydney, PO BOX 123, Broadway NSW 2007, AUSTRALIA. (e-mail:

anastasia.hronis@uts.edu.au)

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https://orcid.org/0000-0001-6489-0231

Neuropsychological deficits for children with ID have
been identified in learning, memory, attention,
executive functions and language. The impact on
therapy and adaptations for therapy has been
proposed specific to CBT (see Hronis et al. 2017).
Cognitive behaviour therapy is the gold standard

intervention for many psychopathologies for children
without ID (e.g. Cartwright-Hatton et al. 2004;
Compton et al. 2004). At the foundation of CBT is
the identification and linking of thoughts, emotions
and behaviours, which adults with ID can do (Dagnan
et al. 2000; Joyce et al. 2006; Oathamshaw &
Haddock 2006; Sams et al. 2006). To our knowledge,
this has not been evaluated among children with mild
to moderate ID. Parents play a crucial role in the
therapy process for children with and without
developmental disabilities (Manassis et al. 2014;
White et al. 2010). Involving parents is in line with
family-centred practices for interventions for children,
recognising that parent-therapist collaboration in
planning and evaluating interventions is key, and
based on the principle that parents know their child
best (Hanna & Rodgers, 2002; Rosenbaum et al.
1998).
The aim of this study was to gather the opinions of

parents who have children with ID about CBT. The
researchers set out to understand if parents who have
children with ID believe their child could engage in
the process of CBT and factors associated with this.
As to our knowledge, no research has previously
investigated this, the study was exploratory.

Method

Procedure

This research was approved by the University Ethics
Committee (approval number: 2015000482–54).
Participants were recruited via online advertising
through mental health organisations and social media.
The study was advertised as seeking parents/carers of
children with a mild to moderate ID, aged 10 to 17, to
respond to questions online about how their child
thinks and feels.

Measures

Parent report of child’s ability to engage in CBT

Participants read information about CBT and rated
their child’s ability to express feelings, articulate

thoughts, describe actions and link thoughts, feelings
and behaviours. Parents rated on a 5-point Likert
scale how often they know if their child is feeling
happy, sad, angry and anxious/worried.

Emotions development questionnaire – parent form (Wong
et al. 2009)

The Emotions Development Questionnaire – Parent
Form (EDQ-P) assesses emotional understanding,
emotional and behavioural regulation, theory of mind
and problem solving in children with autism spectrum
disorder, with or without ID (Ratcliffe et al. 2014).
Quantitative data were used to supplement qualitative
data to describe the emotional development of the
sample. It has 29 items rated on a 5-point Likert scale,
added to produce a total score. The EDQ-P has
excellent internal consistency (α = .91; Ratcliffe et al.
2014), and was high in the current sample (α = 0.92).
Higher scores indicate greater emotional
understanding.

Open-ended questions

Participants were provided with information about the
components of CBT, illustrated by a case example
(Data S1), and responded to open-ended questions
about their child’s potential to engage in CBT (Data
S2).

Data analysis

Descriptive statistics for quantitative data were
calculated. Thematic analysis was used to analyze the
qualitative data. This involved initial prolonged
engagement with the data via repeated readings,
coding of responses by two independent researchers
and codes then collated into themes (Braun & Clarke,
2006).

Results

Participants

Participants were 21 parents/carers of children in
Australia between the ages of 10 and 17 with a mild or
moderate ID or borderline intellectual functioning.
The average age was 13.33 (SD = 2.58). Based upon
parent reports, 23% had mild ID, 33% had moderate
ID, 10% were on the border of mild to moderate ID,
5% had borderline intellectual functioning and 29%

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were unspecified. Comorbid diagnoses are reported in
Table 1.

Quantitative data

Most participants reported they could often or almost
always tell when their child was sad (76%), angry
(76%) and happy (72%). 48% could often or almost
always tell when their child was anxious or worried.
One third agreed that their child can describe their

emotional state, while one third disagreed/strongly
disagreed, and 24% were undecided (Figure 1).
Fourteen per cent agreed their child can articulate
their thoughts, while 43% disagreed/strongly
disagreed, and one third were undecided. Twenty-
four per cent agreed their child can describe their
actions, however 33% disagreed/strongly disagreed,
and one third were undecided. Finally, only 10%
agreed that their child could link thoughts, feelings
and behaviours, while 19% were undecided and over
half (62%) disagreed/strongly disagreed. Overall, 76%
agreed that their child would be able to participate in
CBT with assistance.
Seventeen parents completed the EDQ-P, with

scores ranging from 80 to 168 out of 200 (M = 108.1;
SD = 19.9), indicating a range of emotional
development within the sample.

Qualitative data

Length of responses ranged from a few words, to
multiple sentences and were organised into five
themes: (1) emotional attunement, (2) role of the

parent/carer, (3) role of the therapist, (4) anticipated
obstacles and (5) suggested adaptations to therapy.

Emotional attunement

Responses reflected parents’ ability to recognise
emotional states in their child. Indicators of a child’s
emotions reported were body language, facial
expressions, behaviours, verbal expressions of the
emotion and increased or decreased social
interactions.

Role of the parent/carer

Participants referenced taking on the role of the
therapist outside of sessions, to help practice and
generalise using strategies, as participants stated “I
would become the teacher for the therapy and reaffirm
therapy at home” and “help with homework”. Parents
acknowledged they could provide practical support by
“sit[ting] in on sessions” and “taking notes”.
Emotional support they could provide involved
encouragement to participate.

Role of the therapist

Therapist’s knowledge and experience working with
children with ID were identified as important. One
participant wrote, it would help “if the therapist was
understanding of the disabilities my son has and had
experience working with them”. Parents wanted
therapists to understand the strengths and weaknesses
of their child and adapt therapy, as one parent stated
“the approach taken to engage a child needs to be
carefully thought out prior to engagement to reduce
the likelihood of shutdown during therapy”.

Anticipated obstacles

The difficulty of identifying and expressing thoughts
and emotions was identified. Parents questioned
whether CBT may be too complex with “too many
steps in the process”. Rigid thinking was a potential
obstacle, as one participant stated their child is “a
literal person so won’t generalise”. Practical obstacles
included time constraints, cost of therapy,
geographical restrictions and the difficulty of “finding
a clinician willing to work with intellectual disability”.

Table 1 Rate of comorbid diagnoses in the sample

Diagnosis n %

Autism spectrum disorder 14 67
Attention deficit hyperactivity disorder 12 57
Specific learning disorder 7 33
Anxiety 6 29
Oppositional defiant disorder 3 14
Depression 2 10
Auditory processing disorder 1 5
Cerebral palsy 1 5
Epilepsy 1 5
Robertsonian translocation 1 5
Sensory processing disorder 1 5

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Suggested adaptations to therapy

Parents suggested how CBT could be adapted for
their child’s needs (Table 2).

Discussion

The involvement of stakeholders is in line with
patient-centred care best practices (Epstein & Street,

Figure 1. Parents rating of child’s

ability for CBT skills. CBT,

cognitive behavioural therapy

[Colour figure can be viewed at

wileyonlinelibrary.com]

Table 2 Proposed adaptations to CBT by parents of children with ID

Adaptations Specific suggestions from parents

Providing instructions •Provide explicit instructions
•Break instructions into small steps
•Use stories to explain concepts and to provide examples
•Use videos to explain and teach

“Teaching in baby steps”
“Make it as simple as possible”

Prompts and cues •Use of visual cues
•Colour coded charts as prompts and reminders

“Make a chart of feelings and thoughts so they can visualise them”
“Behavioural cues to “lock in” lessons”

Check understanding •Confirm the child has understood before progressing to the next step
“Making sure he understands how to do it before moving onto the next thing”

Practicing skills •Repeat each step multiple times
•Repeat practices of skills
•Practice with multiple examples
“Getting him to show you”
“Practice in therapy sessions and then practice outside of sessions”

Emotion training •Additional time to be spent on establishing an awareness and understanding of different emotional states
“Teaching children to recognise feelings in the body that occur when getting close to a meltdown”

Support network •Have teachers involved in the treatment process
•Have parents involved throughout treatment

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2011). To our knowledge, this is the first study
exploring the carer perspective about how children
with ID can engage in CBT. The results indicate
that parents believe their child may benefit from
CBT with assistance, provided therapy is adapted for
their needs and barriers to treatment are managed.
Although more than half of participants did not
think their child could link thoughts, feelings and
behaviours, three quarters agreed their child could
participate in CBT with assistance. This is
promising, because while parents acknowledge their
child may not currently have those skills, they are
hopeful their child could learn them. Parents
provided suggestions on adapting CBT, which were
consistent with those suggested by Hronis, Roberts
and Kneebone (2017). Furthermore, parents were
willing to take an active role in treatment, which is
beneficial for CBT outcomes (Mendlowitz et al.,
1999; Wood et al., 2009).
A limitation was that parents who responded may

be more open to therapy, providing a possible biassed
sample. Furthermore, the sample size was small, and
some participants provided brief responses. Because
of the nature of the online questionnaire, there was no
opportunity to question further. Additionally, formal
measures of intellectual and adaptive functioning
were not used to confirm diagnoses. Nonetheless, the
findings show promise for the use of CBT for children
and adolescents with ID and mental health disorders.
The results hold important practice implications and
can contribute to the development and piloting of
adapted CBT programmes for children with ID.
Future research should focus on experimental studies
exploring whether children with ID can make links
between thoughts, feelings and behaviours and
research trials evaluating the efficacy of adapted CBT
for children with ID.

Conflict of Interest

The authors have declared that no conflict of interests
exists.

Source of Funding

No external funding was received for the research
reported in the paper.

Ethical Approval

This research was approved by the University Ethics
Committee and undertaken with the understanding
and written consent of each participant.

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British Journal of Clinical Psychology 56, 189–207.

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Accepted 15 September 2019

Supporting Information

Additional Supporting Information may be found
online in the supporting information tab for this
article.

Data S1 Supporting information

Data S2 Supporting information

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https://doi.org/10.1177/15407969221119848

Research and Practice for Persons
with Severe Disabilities

2022, Vol. 47(3) 158 –175
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Special Section Diversity, Equity, and Inclusion

Reconceptualizing Education
Grounded in the Multimodal
Discourses of Girls of Color Labeled
with Significant Cognitive Disabilities

Amanda L. Miller1

Abstract
The experiences of girls of color labeled with significant cognitive disabilities in middle school and high
school have historically been excluded from educational research. This study sought to better understand
how girls of color labeled with significant cognitive disabilities navigated multimodal discourses and
classroom practices as well as how they were impacted by them. Using Disability Critical Race Theory
and critical discourse theory, six students were focal participants and eight educators were secondary
participants. Multiple case studies were used with primary (i.e., observations, audio/video recordings) and
secondary (i.e., interviews, focus groups) data sources. Findings revealed how focal participants showed
their discursive resourcefulness, despite absent communication supports and prioritization of oral/aural
communication. Students also repositioned themselves in response to marginalization through talk and
actions. Implications for research and practice are discussed. This study underscores the necessity of
centering the experiences of girls of color labeled with significant cognitive disabilities in educational
research to improve their school experiences.

Keywords
girls of color labeled with significant cognitive disabilities, multimodal discourses, disability critical race
theory (DisCrit), critical discourse theory, reimagining education

Multimodal discourses, including talk and actions, are inextricably connected to learning in schools.
Youth engage in multimodal discourses throughout the day as they learn with and from peers and educa-
tors (e.g., teachers, paraprofessionals). Talk may be verbalizations (e.g., “What do you think?”), vocal-
izations (e.g., “Huh?,” “Oh,” “Eh”), or speech generated by a voice output device (Gee, 2014; Teachman
et al., 2018). Actions or action-oriented expressions include eye gazes, facial expressions, gestures, and
selections made on a communication board (Light & Drager, 2007; Scollon & Scollon, 2017). As such,
students use talk and actions to explore concepts and content and to question and process (Rogoff, 2003).

Learning is a social process wherein students become active participants in knowledge communities
(Lim & Renshaw, 2001). Youth labeled with significant cognitive disabilities have long been excluded
from the social processes of learning. However, a mutually constitutive relationship exists between
multimodal discourses and social practices for youth labeled with significant cognitive disabilities

1Wayne State University, Detroit MI, USA

Corresponding Author:
Amanda L. Miller, Wayne State University, 285 College of Education, Detroit, MI 48202, USA.
Email: almiller@wayne.edu

1119848 RPSXXX10.1177/15407969221119848MillerResearch and Practice for Persons with Severe Disabilities
research-article2022

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mailto:almiller@wayne.edu

Miller 159

(Wodak & Meyer, 2016). For example, when a student hears an educator continually praise a peer in class
and condone another, then the student may attribute certain traits (e.g., smartness, goodness; Broderick &
Leonardo, 2016) to one peer and not the other, based on how the educator responds. Moreover, these
observations and interactions dictate how the student feels about their own responses and their willingness
to take learning risks.

In addition, multimodal discourses mediate power relationships (Foucault, 1982). When students labeled
with significant cognitive disabilities are not afforded opportunities to interact with peers, share knowledge,
or construct meaning, then learning becomes a tool of inequity based on ideology. In response, youth may
reposition or refuse to accept individual, group, and/or societal marginalization (Davies & Harre, 1990).
They may speak out or act in another way when they notice educators and/or peers marginalizing one
another (Annamma et al., 2020). Therefore, it is not only the educators and students who generate dis-
courses, but the discourses also create who they are. In sum, a focus on multimodal discourses and social
practices can illuminate how power and ideology are (re)produced in schools.

Context is crucial because of the constituted and constituting nature of thought, talk, and action. For
example, the opportunities teachers create hold power over what exists and comes next in the classroom.
When educators design opportunities for students to work with peers, then the knowledge the students
explore and/or create together is influenced by each learner’s histories, perspectives, and experiences. That
said, multimodal discourses can play a role in transforming society as students and educators use them in
creative and agentic ways, thus exposing the dialectic nature of discourse and ideology (Gee, 2014). This
can be true for the school experiences of girls of color labeled with significant cognitive disabilities; how-
ever, these girls are often ignored in educational research (Sinclair et al., 2018) and their multimodal dis-
courses are underrecognized and understudied. The term “girls of color” is used instead of “young women
of color” to honor the experiences, expertise, and youthfulness of the girls in this project who identify as
Afghan, Black, Hispanic, and Latina. While youth labeled with significant cognitive disabilities often expe-
rience perpetual infantilization, the focal participants attended K–12 schools. Furthermore, childhood is
often withheld from girls of color (Onyeka-Crawford et al., 2017).

While most of the multimodal discourse literature in education attends to educators (e.g., Berry, 2006a;
Kurth et al., 2016; Orsati, 2014, 2015; Orsati & Causton-Theoharis, 2013), it is important to consider how
students contribute to classroom discourses. For example, researchers have found student responding was
unidirectional (i.e., students followed teacher directions, students answered teacher questions) rather than
bidirectional (i.e., students asked questions, student–teacher, and student–student reciprocal conversations)
in special education classrooms and segregated schools (Pennington & Courtade, 2015). Moreover, stu-
dents with disabilities in special education classrooms have also experienced and engaged in disrespectful
talk with their peers (Causton-Theoharis et al., 2011). Thus, students may unknowingly (re)produce harmful
ideas about peer belonging, membership, and worth through their classroom discourses.

Scholars have also reported on how students with disabilities have repositioned or subtly claimed brief
authority. For example, Black boys with disabilities repositioned by asking educators questions (e.g., “What
did I do?”; Collins, 2011a) and sharing personal narratives (e.g., “I like to draw and paint.”; Collins, 2011b).
Students with disabilities have also modified discussion topics or attempted to change an assumed turn-
taking sequence with peers in the general education classroom (e.g., “Why are you taking over the paper?”;
Berry, 2006b). In another study, one girl with autism persisted with personal narratives in a small group
setting in response to her peers’ disinterest (e.g., “She talks to some Spanish people,”; Dean et al., 2013).
Students with disabilities have also remained silent when urged to participate or have opted out (Collins,
2011b). Yet, more information is needed to understand how girls of color labeled with significant cognitive
disabilities reposition multimodally in response to marginalization.

While little is known about the multimodal discourses of students labeled with significant cognitive dis-
abilities, and girls of color specifically, the studies reviewed here provide a foundation. Few scholars have
examined students’ multimodal discourses and many did not provide fine-grained details of their actions.
Furthermore, student repositioning is a relatively newer point of inquiry, particularly for students labeled with
significant cognitive disabilities. Therefore, additional research is needed to understand how intersecting
oppressions at macrosociopolitical (e.g., ableism, racism; Erevelles & Minear, 2010) and microinteractional

160 Research and Practice for Persons with Severe Disabilities 47(3)

levels (e.g., lack of access to classroom spaces, microaggressions in classroom interactions; Dávila, 2015)
impact student experiences with a particular focus on multimodal discourses. Thus, the purpose of this study
was to better understand how girls of color labeled with significant cognitive disabilities in middle school and
high school navigated multimodal discourses and classroom practices as well as how they were impacted by
them. Two questions guided the inquiry: (a) How do girls of color labeled with significant cognitive disabili-
ties multimodally navigate classroom discourses? (b) How do classroom multimodal discourses impact girls
of color labeled with significant cognitive disabilities?

Method

This project focuses on a subset of data from a study examining educational opportunities for girls of color
labeled with significant cognitive disabilities in one middle school and one high school in a large Midwestern
city school district (see Miller, 2019). Like the larger study, this project used a critical, qualitative multiple
case study design (Merriam & Tisdell, 2015).

Strategy of Inquiry

A multiple case study design was chosen for three reasons. First, the research questions required an in-depth
understanding of how the focal participants navigated multimodal discourses and classroom practices as well as
how they were impacted by them (Bhattacharya, 2017). Second, the research questions were explanatory, pro-
cess-oriented, and framed as “how” questions. This allowed me to examine systems and processes while focus-
ing on talk and action within learning contexts. Third, multiple case study methodology can offer new
understandings inductively as bounded by a case and revealed across multiple cases (Merriam & Tisdell, 2015).

Conceptual Framework

This empirical project was grounded in Disability Critical Race Theory (DisCrit; Annamma et al., 2013)
and critical discourse theory (Foucault, 1972; Gee, 2014; Rogers, 2011). First, DisCrit, as the broader theo-
retical framework, is discussed. Then, critical discourse theory is described. Finally, a consideration of how
the two theories strengthen one another is presented.

Disability critical race theory. A sibling of critical race theory and disability studies in education, DisCrit
seeks to uncover how interlocking oppressions (e.g., ableism, racism) operate as institutional and societal
mechanisms to oppress, segregate, and surveil multiply marginalized youth (e.g., youth of color with dis-
abilities; Annamma et al., 2013). Each of DisCrit’s seven tenets affords an examination of how power is
(re)produced in education (see Table 1). As an intersectional theory, DisCrit is particularly interested in
human responses to difference and the activism and resistance individuals and groups engage in (Annamma
et al., 2018). The question is not whether differences are perceived but what meaning is wielded based on
those perceptions and the ensuing mutually constituted ideologies and consequences (Gallagher, 2001).

By affirming how racism and ableism are active and naturalized, DisCrit exposes how girls of color
labeled with significant cognitive disabilities are outside perceptions of what is normal and thus are posi-
tioned as problematic (Erevelles et al., 2006). Moreover, DisCrit questions the ways in which other, less
prominent identity markers (e.g., communication preference, immigration status) may also be used to posi-
tion students as different. For example, linguicism (Phillipson & Skutnabb-Kangas, 1996) may be used with
students of color labeled with significant cognitive disabilities who use varied modes of action-oriented
expression, low- and/or high-tech communication supports, or whose home language is not solely English.
To do so, DisCrit centers the lived experiences and perspectives of multiply marginalized individuals and
communities who are often unrecognized in research (Collins, 2003; Matsuda, 1987). It also considers the
historical and legal aspects of disability and race and how both have been used independently and collec-
tively to deny rights to some individuals (Gotanda, 1991). Such implications include how whiteness and
ability are used as property wherein economic, political, and social benefits are afforded to those who are
constructed as “white” while benefits are withheld from those who cannot claim whiteness (Harris, 1993).

Miller 161

Critical discourse theory. Foucault’s (1972) theory of discourse acknowledges how individuals make mean-
ing of the social world through communicative acts. Multimodal discourses symbolize active and contex-
tual processes that hold power and shape realities (Foucault, 1982). Since schools reproduce social
realities, teachers and students play a role in how multimodal discourses and environments are produced
(Rogers, 2011). Drawing on Foucault, I examined how particular ideologies (e.g., students are knowledge-
able, disability is less than, talk is more important than action) were embedded in classroom multimodal
discourses. Therefore, critical discourse theory strengthened DisCrit by affording an explicit examination
of how linguicism operated in learning contexts, including how classroom meaning depended on how the
focal participants were positioned, the opportunities provided to them, and the discursive moves and
choices they made because of those affordances and constraints.

By grounding this work in DisCrit and critical discourse theory, I used multimodal discourses as analyti-
cal tools to expose how intersecting oppressions at macrosociopolitical and microinteractional levels
impacted the school experiences of girls of color labeled with significant cognitive disabilities. Talk and
actions were examined to make more distinct the structures that are positioning these girls as invisible (Gee,
2014). That way, scholars and educators can address the negative impact certain systems and processes have
on girls of color labeled with significant cognitive disabilities while showing students’ discursive strengths
and educators’ acts of resistance.

Participants

Girls of color labeled with significant cognitive disabilities were purposively sampled aligning with the
aims of the study (Lincoln & Guba, 1985). The phrase “labeled with significant cognitive disabilities” is
used throughout this manuscript to (a) foreground the sociopolitical significance of disability and the
preoccupation of medicine, psychology, and education with categorizing students as deficient (Connor &
Gabel, 2010), particularly youth of color (Kulkarni, 2020), and (b) honor the journal’s person-first lan-
guage requirement. Students were included in this analysis if they self-identified or their family identi-
fied them as having autism, intellectual disability, and/or multiple disabilities. Six students were the focal
participants. The school district designated intellectual disability and speech/language impairment labels
on five of the students’ Individualized Education Programs (IEPs). Educators were also purposively
sampled as secondary participants. At least one teacher was invited as a secondary participant per case.
Seven teachers and one paraprofessional were included in the analysis. All participant names used in this
article are pseudonyms. Student demographic information was taken from student and family demo-
graphic questionnaires (see Table 2).

Data Collection and Sources

Three phases of data collection were conducted. This process allowed for the data to be collected and ana-
lyzed iteratively as each preceding phase informed subsequent phase(s). For example, I collected observa-
tion data, analyzed it for emerging themes, turned hunches into questions, and returned for another

Table 1. Tenets of Disability Critical Race Theory (DisCrit).

DisCrit tenets

Tenet One uncovers how racism and ableism circulate interdependently.
Tenet Two values multidimensional identities.
Tenet Three emphasizes the social constructions of ability and race.
Tenet Four privileges the voices of multiply marginalized individuals and groups.
Tenet Five considers ideological, historical, and aspects of disability and race.
Tenet Six examines how ability and whiteness operate as property.
Tenet Seven necessitates activism and upholds all forms of resistance.

162 Research and Practice for Persons with Severe Disabilities 47(3)

observation with new questions (Bhattacharya, 2017). Similarly, each focus group was a chance to continue
ongoing member checks with focal participants (Rodwell, 1998), as the information gathered from the first
and second interviews iteratively informed follow-up questions for the focus groups.

Primary data sources. Classroom observations were primary data sources. I conducted 3-5 observations of
teaching and learning in general and special education classrooms, including audio/video recordings and
detailed field notes. This yielded 28 audio/video recordings and 27 detailed field notes as primary data
sources. Field notes from one observation were missing during the analysis. Four focal participants were
afforded access to only general education special or elective classes (e.g., Choir, Theater). Two students
(Amy and Luna) were only assigned to one segregated special education classroom across the school day,
so observations during community-based instruction were also conducted.

Secondary data sources. Interviews and focus groups were secondary data sources. Each focal participant had
2 to 3 interviews and 1 to 2 focus groups, yielding 17 student interviews, 2 high school focus groups, and 1
middle school focus group. The girls and their families also completed demographic forms. In three cases,
parents shared additional information via phone and in-person about their daughter’s educational trajectory
with me. Seven teachers and one paraprofessional consented to the observation component of the study. Four
teachers participated in two interviews and two teachers participated in one interview. Mr. Armstrong, one of
the general education teachers, and Ms. Cari, the paraprofessional, did not participate in the interview com-
ponent due to scheduling and time constraints. This yielded 10 teacher interviews. Teacher interviews existed
across more than one case because most focal participants were in the same segregated classrooms (e.g.,
Meena, Emma-Mae, and Isabella, Amy and Luna). Secondary sources contextualized observations and trian-
gulated data (Brantlinger et al., 2005).

Primary Data Source Preparation

First, the audio/video recordings of teaching and learning were turned into verbatim transcriptions of talk-
by-speaker utterances as an entry point to data analysis (Gee, 2014). Utterances were defined as completed
words, partial words, and on-record vocalizations within each observation. Transcribing three types of
utterances helped answer both research questions because they revealed how students and teachers com-
municated with one another. In addition, they showed the importance of vocalizations to students without

Table 2. Participants and Classroom Content Areas by Case.

Student
participant Age Grade Race/ethnicity Disability label

Educator
participant

Content area
observations

Amy 16 11th Hispanic Down syndrome;
SLI

Mr. Clifford
Ms. Cari (Para)

Language Arts (SE)
CBI (SE)

Emma-Mae 11 6th Black ADHD; ASD Ms. Taub
Ms. Snow
Ms. Summitt

Language Arts (SE)
Physical Education (GE)

Isabella 14 8th Latina ASD Ms. Snow
Mr. Fenn

Social Studies
(SE)
Theater (GE)

Jimena 19 1st year
post-secondary

Hispanic OHI; OI; SLI;
VI/B

Ms. Parker
Mr. Armstrong

Language Arts (SE)
Choir (GE)

Luna 14 9th Latina Epilepsy; ID;
SLD; TBI

Mr. Clifford
Ms. Cari (Para)

Language Arts (SE)
CBI (SE)

Meena 14 8th Afghan OI; SLI Ms. Taub
Mr. Fenn

Language Arts (SE)
Theater (GE)

Note. SLI = speech or language impairment; SE = special education; CBI = community-based instruction; ADHD = attention deficit hyperactivity
disorder; ASD = Autism spectrum disorder; GE = general education; OHI = other health impairment; OI = orthopedic impairment; VI/B = vision
impairment/ blindness; ID = intellectual disability; SLD = specific learning disability; TBI = traumatic brain injury; Para = paraprofessional.

Miller 163

communication supports, how often interruptions without repairs occurred, and how prevalent educators
responded to talk but not actions. Then, details were iteratively added (e.g., tonal marks, truncated or inter-
rupted speech, and pauses were noted; Ochs, 1979).

Talk was then organized by lines based on speaker intonation, action, and interruption. Some lines had
only one utterance while others had multiple utterances. Interruptions were shown with a code rather than
dictated by the placement of the utterance on a line (Du Bois, 2006). Next, lines were organized by stan-
zas—a group of lines about a theme, happening, or topic (Gee, 2014). Lines were organized by stanzas
based on turn sequences and topics. A new stanza began when the teacher started talking to the whole class
or when topics shifted. It was important to organize lines in this way to understand classroom participation
structures and teacher and student initiations and responses (Cazden, 2001).

Next, detailed descriptions of salient actions were added to the transcripts (Norris, 2004). Because I was
most interested in the focal participants’ classroom experiences, I focused on actions they used most often,
including eye gazes, facial expressions, body movements, and gestures. Like talk, actions were indicated
line-by-line as speakers took turns. When there was simultaneous talk and action, interruptions are shown
with a code rather than dictated by placement on a line (see Table 3 for transcription conventions).

Researcher Positionality

As a White, cisgender woman who identifies with several nonvisible disabilities, the focal participants
and I did not share age, disability label, race, or ethnicity. However, the participants and I did share gen-
der and language. Thus, gender and language were the starting points of commonality that we built trust
from. I volunteered in their special education and general education classrooms for several weeks before
the project started. Before, during, and after data collection, I spent time with the girls across the school
day, including during class, at lunch, and on class trips. Also, I took extra steps to ensure the project was
enjoyable and generative for them. Ensuring a generative project meant thinking with and alongside the
focal participants about the problems they were facing in school and focusing on their solutions to ineq-
uitable school systems and processes (Kinloch & San Pedro, 2014). In addition, and as part of solution-
generating, I examined multimodal discourses with the educators who participated in second interviews
to reflect on their teaching and make important pedagogical changes focused on girls of color labeled
with significant cognitive disabilities.

Ableism, linguicism, and racism held real consequences for the focal participants that I did not experi-
ence. For example, I moved around both schools with relative ease. At the high school, I learned and used the
code to get in and out of “the annex” freely (the separate building at the high school for the segregated special
education classes), whereas the high school girls could not come and go unless they were with me or a school
staff member. At both schools, I used the dominant mode of expression which granted me positioning and
privileges not afforded to the focal participants. Through reflexive journaling and peer debriefing, I continu-
ously considered how my analysis of classroom discourses and my presence could impact the students.

Table 3. Transcription Conventions.

Code Meaning Example

. Final tone, a period in speech Emma-Mae: Ms. Taub. Ms. Taub.
, A non-final tone, like a comma in speech Isabella: Oh wait, wait. No, no.
? A rise in pitch, like a question in speech Mr. Clifford: Amy, do you want to bowl?
! A rise in pitch, like an exclamation in speech Luna: I did it myself!
– Truncated, cut-off word/interrupted speech Isabella: Um, the ma:: mash::-
– Truncated, cut-off action/interrupted action Jimena: [Pointing and looking ahead, in that same direction-]
[ ] Student and teacher actions Meena: [Looking at Ms. Taub. Raises her hand again.]
:: Lengthening of syllable Mr. Fenn: There are winners in Wah::
() Time passed in seconds (12)

164 Research and Practice for Persons with Severe Disabilities 47(3)

Data Analysis

The data analytic plan was informed by the study purpose, conceptual framework, and strategy of inquiry.
Critical multimodal discourse analysis (Kress, 2010) was used to develop codes of multimodal discourses
within cases and then across cases following data analysis for multiple case study design (Merriam, 2001).
Once all data had been collected, iterative data analysis continued as I searched for patterns across the data
(Erickson, 1986). I moved back and forth reading the data, turning hunches into questions or writing down
new questions, and returning to the data to look for patterns (Bhattacharya, 2017). As such, I engaged in
multiple rounds of meaning-making and coding.

First cycle: Within-case analysis. During within-case analysis, I used inductive analysis, open to ideas that
emerged from the data not yet represented in the literature (Erickson, 1986). I moved through three rounds
of initial coding, including unitizing, categorizing, and labeling (Rodwell, 1998) attentive specifically to the
focal participants’ multimodal discourses (e.g., Answers Teacher’s Question and Initiates About Finished
Work both emerged as inductive categories). Then, the deductive analysis focused on how the talk was
structured and the roles of actions. Using this process, patterns in the data were identified based on the lit-
erature (e.g., student repositioning) and the conceptual framework (Annamma, 2018; Collins, 2011a e.g.,
Repositions was a deductive code category).

Second cycle: Across-case analysis. During across-case analysis, I used axial coding (Rodwell, 1998), placing
code categories across the six cases in relation to one another and used data displays to compare and cluster
data across cases. Clustering and comparing were helpful when considering similarities and differences across
cases. The checklist matrix data display helped me expand and collapse code categories (Miles & Huberman,
1994). For example, I expanded the code category Responds to Teacher (Not Answering a Question) as it
became important to draw out when the focal participants were responding to teachers. Expanding this code
category highlighted the ways in which discourse was controlled in the classroom, including in student
responses. Then, I asked new questions about how that discursive control was impacting the positioning or
importance of talk over action in the classroom. I engaged in three cycles of inductive analysis across cases.

Finally, I engaged in one cycle of deductive analysis wherein the conceptual framework was used to look
for intersecting oppressions the students experienced while remaining open to those that arose from the
data. For example, layers of linguicism were exposed as schools failed to recognize and embrace the focal
participants’ multilingual strengths (Mindel & John, 2018; Young, 2009). These practices were revealed
within the code categories of Expresses a Need or Want and Asks a Question.

Trustworthiness

Several strategies to support the trustworthiness of the findings (Lincoln & Guba, 1985) and advance rigor
(Bhattacharya, 2017) were used including iterative data collection and analysis, disconfirming evidence, and
analytic memos (Miller, 2020; Miller & Kurth, 2021). For brevity, triangulation and reflexive journaling are
discussed next.

Triangulation improved the probability that the findings and interpretations were credible and trustwor-
thy. In this study, data and methodological triangulation were used. First, data were collected from more
than one participant source (e.g., students and teachers). Second, several data collection methods were used,
including field notes and transcriptions of classroom discourse as primary data sources and interviews and
focus groups as secondary data sources. Using data and methodological triangulation allowed me to look
for patterns and outliers across sources and contexts.

Reflexive journaling supported trustworthiness as it revealed my orientation toward inquiry, social
action, and analysis (Saldaña, 2013; e.g., I wrote in a research journal to interrogate reactions, check work-
ing hypotheses, and generate novel ideas). During the analysis, I journaled to remain close to the data and
existing literature months after data collection. Also, journaling was used to examine how my participation
in the study contributed to the production or disruption of power. In summary, journaling was a way to
honor axiological commitments and understand project roles.

Miller 165

Results

Next, I share two themes that emerged from the analysis focused on how girls of color labeled with signifi-
cant cognitive disabilities engaged in multimodal discourses with educators.

Students’ Resourceful Multimodal Discourses

Across cases, girls of color labeled with significant cognitive disabilities used resourceful multimodal dis-
courses in the classroom. Their discourses were resourceful because of how the focal participants conver-
sationally navigated their classrooms so they would be honored and strengthened, not discounted or
remediated. Students’ Multimodal Discourses was defined as “Focal participants communicate with their
teachers about their learning through talk and actions.”

At the middle school. It was Friday and the middle school students were graphing their scores for the whole
group Daily Language Review activities (e.g., sentence structure, grammar). Emma-Mae used talk and
action to inquire about her missing scores. She initiated with Ms. Taub for help (line I) and the teacher
responded with eye contact (line I.1) and a question (line I.3). However, when Emma-Mae encouraged Ms.
Taub to look at her paper as a discursive move to support her in conveying her thoughts (line I.6), Ms. Taub
did not walk over to Emma-Mae and engage with her. Instead, she told Emma-Mae that she would look at
her packet later (line I.7, line I.9):

I. Emma-Mae: Ms. Taub. Ms. Taub. [Looking at Ms. Taub.]
1. Ms. Taub: [Turns her eyes away from another student and looks at Emma-Mae.]
2. Emma-Mae: I don’t have any numbers. [Looking down at her paper then at Ms. Taub from the side.]
3. Ms. Taub: Oh, for Wednesday and Thursday, you guys didn’t grade them?
4. Emma-Mae: Yeah.
5. Ms. Taub: That’s fine.
6. Emma-Mae: See look. [Picks the paper up from the table, turns sideways in her chair. Looks at and

points to her paper with her pencil. Looks at Ms. Taub.] This one doesn’t have any numbers.
7. Ms. Taub: [Looks away from another student and back at Emma-Mae.] I’ll just look at it.
8. Emma-Mae: [Turns in her chair and faces the front again. Continues pointing at her paper with her

pencil while looking at Ms. Taub.] So, I don’t have anything for Wednesday because we don’t have
any numbers.

9. Ms. Taub: [Looking at Emma-Mae.] I’ll look at ’em, ok? [Looks at the whole class.]
10. Emma-Mae: [Looks at her paper.]

Emma-Mae held subtle discursive power as she tried to get help from Ms. Taub. However, her academic
earnestness was diminished when the teacher would not look at her paper. Their interaction ended when Ms.
Taub started giving directions to the whole class.

During an audio-recorded Social Studies lesson missing some video footage, Isabella responded to Ms.
Snow’s anticipatory query. Initially, Ms. Snow used closed or known-answer questioning (a technique
wherein the teacher already has an answer in mind) with the class to prepare for a short video on New
Hampshire (line II). Importantly, students hold limited power when known-answer questions are present.
Still, Isabella attempted a response (line II.1) but because she expected a certain response, Ms. Snow inter-
rupted Isabella with an additional prompt (line II.2). In response, Isabella processed aloud and repaired (line
II. 4). Then, she answered Ms. Snow’s known-answer question two turns later (line II.6). Afterwards, Ms.
Snow praised her (line II.7):

II. Ms. Snow: The largest city, thank you. Isabella, what else are we going to be looking for?
1. Isabella: Um, the ma:: mash::-
2. Ms. Snow: No, on your, your book.

166 Research and Practice for Persons with Severe Disabilities 47(3)

3. Student: Qué libro?
4. Isabella: Where am I at? Oh wait, wait. No, no.
5. Ms. Snow: Turn the other way. No, what are we going to be looking for on the next page here?

[Points to the page in her book.] On this page, babe. [Taps the page in the book.] Someone’s already
said nickname. Someone’s already said largest city. What else? Pick one, Isabella.

6. Isabella: Um. Um. Um. Um. Um. Um, landmark of the state.
7. Ms. Snow: Landmark, good. What else? (Student), what else are we going to listen for?

Teachers used known-answer questions often. As such, Isabella received praise from Ms. Snow when she
responded correctly. If Ms. Snow had tried to repair with Isabella after she interrupted her (e.g., asking more
about what Isabella was thinking or had meant to say), then her discursive move would have honored
Isabella as a thinker and a learner beyond having the “right” answer.

At the middle school, the class was working independently decorating their journal pages with drawings
of holiday-themed objects and characters after a writing lesson about Halloween jokes. Meena used actions
to connect with Ms. Taub about her finished work. In her third interview, Meena shared that writing for
extensive periods of time made her hand feel sore. She also indicated this through her actions (line III). Here,
Meena tried more than once (line III, III.1, III.2, line III.4) to get her teacher’s attention. After four tries, Ms.
Taub noticed Meena (line III.5) and permitted her to come to the front of the room through her actions:

III. Meena: [Looks up from her journal at Ms. Taub sitting at the front of the room. Raises her hand and
arm briefly, then puts it down. Shakes her left hand in the air. Looks down at her journal and then up at
the big cup of coloring pencils. Picks up the big cup and returns it to the art shelf.]
(10)
1. Meena: [Sits back down in her seat. Looks at Ms. Taub while she picks up her notebook, holds it

with two hands close to her. Turns her body to face Ms. Taub. Looks at and watches Ms. Taub talk
to Emma-Mae.]

(5)
2. Meena: [Looking at Ms. Taub. Raises her hand and then puts it down.]
3. Ms. Taub: [Looks up from the table to the right side of the room.]
4. Meena: [Looking at Ms. Taub. Raises her hand again.]
5. Ms. Taub: [Scans the room toward the left and looks at Meena raising her hand. Smiles. Looks down

at Emma Mae’s notebook. Motions with her left hand for Meena to come to the front of the room.]
6. Meena: [Stands up. Pushes in her chair. Walks to the front. Sets her notebook down in front of Ms.

Taub who is talking to Emma-Mae. Looks at Ms. Taub.]

Meena showed discursive ingenuity by using multiple actions (e.g., gestures, eye contact, body movements)
to initiate with Ms. Taub about her finished work. Moreover, she did so over time while also waiting until
the teacher looked up from the conversation that she was engaged in.

At the high school. In Luna’s case, she used talk to initiate about her Language Arts work. While there is
some video footage missing in this example, Luna shared how she had finished her Esperanza Rising col-
lage (line IV). When no one responded, she pronounced completion again (line IV.1) with an emphasis that
she had worked independently, a common school goal, particularly for students receiving special education
supports and services. When there was still no response, Luna directed her comment to a paraprofessional
(line IV.2) who took up her initiation and praised her with talk and actions (line IV.3):

IV. Luna: I did it myself! I did it. I did it!
(8)
1. Luna: All by myself!
(12)
2. Luna: Cari, I did it myself.

Miller 167

3. Ms. Cari: Alright! [Gives Luna a high five.] Good job! Put your name up at the top so we make sure
it’s your paper. Oh, let me find you a pencil.

4. Luna: [Turns to talk to a classmate.]

In a crowded segregated classroom, this was inherently a resourceful discursive move by Luna to gain adult
recognition of her completed work. However, no one discussed her college with her, and the opportunity to
engage with Luna about her learning on a deeper level was missed.

In her second interview, Jimena shared that she liked reading the Twilight series and preferred the second
book. Before each chapter, Ms. Parker asked the students to make a prediction about the outcome. This
time, she asked, “What causes chaos at Bella’s birthday celebration at the Cullen’s? Is it an ex-girlfriend?
Or blood?” Jimena used actions to communicate her literary prediction. When Ms. Parker approached
Jimena, she repeated the two choices (line V). Jimena communicated her prediction with gestures (line V.1).
When Ms. Parker confirmed (line V.2), Jimena used additional multimodal discourses, including eye con-
tact, head movements, and facial expressions (line V.3) to ensure she was understood. Ms. Parker responded
with talk and actions affirming Jimena’s choice (line V.4):

V. Ms. Parker: Jimena, what do you think? Blood or an ex-girlfriend? [Holds out two visual choices on
little pieces of paper, one in each hand. Ex-girlfriend and blood are depicted with pictures from
Boardmaker.]
1. Jimena: [Looks at the visuals. Reaches out and selects blood with her right hand.]
2. Ms. Parker: You’re going blood too?
3. Jimena: [Looks at Ms. Parker. Nods head yes. Smiles.]
4. Ms. Parker: Ok. [Nods her head. Sets the two choices down on the table.]

Ms. Parker always presented the students with two predetermined choices for their predictions. Here, she
did not engage deeply with Jimena about why she made that prediction or what it meant for the broader
storyline. Then, after gathering everyone’s predictions, Ms. Parker read the chapter aloud without pauses,
guided questions, or conversation. Afterward, Ms. Parker asked each student individually to confirm if their
prediction was correct.

Across cases, there were instances when teachers did not respond to or missed the girls’ initiations.
For example, Amy used talk five distinct times over the course of more than 6 min to initiate a turn with
Mr. Clifford about her completed project in Language Arts. Despite Amy’s enthusiasm and persistence,
neither Mr. Clifford nor the paraprofessionals in the room responded to her. It was possible that Mr.
Clifford did not see or hear Amy as she did not approach him but remained seated at her desk. However,
Amy’s discursive opportunity lost all potential when the adults (the intended audience) did not respond.
Girls of color labeled with significant cognitive disabilities held subtle discursive power when teachers
did respond to their initiations. Consequently, they held no discursive power when teachers did not
respond.

Students’ Strategic Repositioning

Across cases, focal participants repositioned or refused to accept marginalization. I expand on prior defini-
tions (Annamma et al., 2020; Miller et al., 2022) to define Student Repositioning as, “Girls of color labeled
with significant cognitive disabilities engage in strategic maneuvering in response to individual, school, or
societal marginalization.”

At the middle school. Girls of color labeled with significant cognitive disabilities repositioned by mentioning
their strengths and skills. For example, Isabella repositioned in response to Mr. Fenn, the Theater teacher,
in the general education classroom. As the students transitioned to a new game, Mr. Fenn commented on the
room’s temperature and how that should not impact participation (line VI). In that same turn, he also
prompted Isabella and a classmate to partake in the activity. Isabella repositioned by stating that she was
good at the game (line VI.2). However, Mr. Fenn ignored Isabella’s comment (line VI.3):

168 Research and Practice for Persons with Severe Disabilities 47(3)

VI. Mr. Fenn: Even though it’s too cold, stand up. So, our hands are here. First step. Show me your
hands, (Student). We need hands for the game even though you’re cold, put your hands up. Isabella, let’s
make these hands. Let’s go.
1. Student: I’m good at this.
2. Isabella: Me too.
3. Mr. Fenn: Hey (Student), can you find that space where you’re facing us not out the way? Here we

go. This is the least engaging part of this activity. Let’s get the instructions and then we can go. It’s
an elimination-based game. There are winners in Wah:: Pay attention so you can be a winner.

The power that focal participants could hold when their teachers ignored their repositioning was context
dependent. In this instance, Isabella gained no discursive power when Mr. Fenn did not respond to her.
Instead, Mr. Fenn could have affirmed Isabella’s comment about her skills.

Emma-Mae used physical maneuvering to reposition at the literacy station. After losing the opportunity
to sit in a seat of her choice (line VII) and being told how to sit (line VII.2), Emma-Mae repositioned and
responded with a personal choice—using her pencil to point to the first word instead of her finger (line
VII.5). Instead of allowing her this subtle personal choice, Ms. Snow directed Emma-Mae to use her finger
(line VII.6) and Emma-Mae followed the direction (line VII.7):

VII. Ms. Snow: I’ll still help you bud. [Looking down at the table, pulls out the chair next to her.] I need
her to sit here. [Pats the table.]
1. Emma-Mae: [Sits down next to Ms. Snow with her spelling journal and pencil. Looks at Ms. Snow’s

journal.]
2. Ms. Snow: Ok. Feet on the floor? [Looks down at Emma-Mae’s feet.]
3. Emma-Mae: [Looks past the peer across the table. Puts her foot that was crossed under her down on

the floor.]
4. Ms. Snow: Great. Here we go. [Looking down at her own spelling journal.] Put your finger on the

first word. [Looks over and down at Emma-Mae’s journal.]
5. Emma-Mae: [Looking down at her journal, points to the first word with her pencil in her left hand.]
6. Ms. Snow: Finger.
7. Emma-Mae: [Puts the pencil down. Still looking down at her journal, points to the first word with

her right pointer finger.]

In this instance, Ms. Snow used directions and redirections to respond to Emma-Mae’s repositioning.
Student repositioning held no power when the teacher would not affirm or allow it.

At the high school. Luna used talk to reposition regarding her academic participation in Language Arts. As
Mr. Clifford transitioned to the next activity (line VIII), Luna used talk to interrupt and speak out in response
to the notion that not everyone was going to be involved (line VIII.1). Similar to other activities, this one
focused on the story’s plot and was not age sensitive or differentiated. Yet, during the first focus group, Luna
expressed how much she enjoyed Esperanza Rising. Mr. Clifford responded with a general reminder (line
VIII.2) without engaging with Luna:

VIII. Mr. Clifford: So, if we have everybody’s collage, we’re moving on here. Kinda look at what,
what’s, to look at what’s next. We’re going to, a lot of us are going to work on this project. I’m just going
to kinda, that is also related to our book. Not everybody’s going-
1. Luna: Me too.
2. Mr. Clifford: I want everybody listening even though I’ll get it to you. If it’s, basically what you

have here is a flip book. We kind of show the beginning of a book with your drawings. Sort of the
beginning. . .

Speaking out was one strategy focal participants used to reposition in the classroom. Teachers’ responses
(e.g., ignoring, redirecting, taking up) dictated how much (if any) discursive power was afforded to focal
participants when they multimodally spoke out.

Miller 169

Focal participants also repositioned by honoring their needs and wants. After cleaning the arcade during
community-based instruction, sometimes the students got to go bowling. It was the only part of the arcade
that was open for play. When Amy arrived, her peers had already started. She sat down on one of the nearby
cushioned benches without any materials. When Mr. Clifford asked her if she wanted to bowl (line IX),
Amy repositioned and responded to Mr. Clifford by pairing actions (i.e., moving her head and pointing)
with eye contact (line IX.1). Her message was clear as seen in Mr. Clifford’s response (line IX.2):

IX. Mr. Clifford: Amy, do you want to bowl? Do you want to bowl? There’s a lane over there.
1. Amy: [Looks at Mr. Clifford. Shakes her head no and then points to the seat cushion she is sitting

on.]
2. Mr. Clifford: Nope, no. Ok.

Although he did not inquire further, Mr. Clifford afforded Amy subtle discursive power by acknowledging
and responding to her. Opting out was one way Amy could hold some power at the moment.

Focal participants also repaired or attempted to repair when misunderstood (Macbeth, 2004). During the
transition from Language Arts to the next activity, Jimena initiated a request with Ms. Parker through talk
and action (line X). In response, Ms. Parker asked similar questions while using context clues (line X.1, line
X.3, line X.5). Yet, she did not vary her questions. When Ms. Parker misunderstood, Jimena physically
repositioned by using gestures and eye gaze to repair (line X.2, line X.4, line X.6). After these three addi-
tional turns, Jimena was understood, and her request was approved (line X.7):

X. Jimena: Eh. [Pointing ahead of herself to the other side of the room and looking in that direction.]
1. Ms. Parker: [Walking away and looking toward the class.] Huh? [Stops and looks at Jimena.] What

did I forget? Your foot things?
2. Jimena: [Pointing and looking ahead.]
3. Ms. Parker: What? [Looks in the direction Jimena points.]
4. Jimena: [Turns to look at her. Taps Ms. Parker. Turns and points ahead of her again.]
5. Ms. Parker: What? [Looks in the direction Jimena points.]
6. Jimena: [Pointing and looking ahead, in the same direction-]
7. Ms. Parker: Oh. [Points in the same direction as Jimena.] You can go see Judy if you want to.
8. Jimena: [Smiles. Looks ahead. Reverses her wheelchair and then starts moving toward Judy.]

During her second interview, Ms. Parker described how she had not tried low- or high-tech communication
supports this school year because “most of the time, it really boils down to knowing (Jimena).” It was more
important to know Jimena because the district provided “the same, like, solution for every kid” rather than
person-centered supports. As such, Jimena’s repositioning through repair was also a response to the lack of
supports.

Discussion

Girls of color labeled with significant cognitive disabilities initiated with and responded to their teachers
about their ongoing and completed work through multimodal discourses. They asked questions about their
learning (e.g., for help) and made requests (e.g., permission). As DisCrit tenet one foregrounds, racism and
ableism position girls of color labeled with significant cognitive disabilities as less than and not capable
(Annamma et al., 2013). Therefore, it may be assumed that they cannot share information, ask questions,
and make requests. However, the findings here are consistent with prior research in that youth claimed
nuanced discursive power by asking questions (Ingram & Elliott, 2014) and sharing information (Brooks,
2015). The findings extend prior research showing how girls of color labeled with significant cognitive dis-
abilities also claim discursive power through questioning and sharing information.

Another contribution of this study, supported by DisCrit tenet seven (Annamma et al., 2013), centers the
focal participants’ repositioning through various discursive strategies as creative acts of resistance. The

170 Research and Practice for Persons with Severe Disabilities 47(3)

findings described here support existing research examining how students reposition by speaking out
(Annamma et al., 2020) and sharing personal information (Collins, 2011b). This study expands that litera-
ture with a particular focus on the strategies the focal participants employed including physical maneuver-
ing, repairing, and opting out. Little is known about how girls of color labeled with significant cognitive
disabilities reposition or refuse individual, classroom, and societal marginalization and how their teachers
respond to them. This study presents novel information for future scholarship to build upon.

This study demonstrates how girls of color labeled with significant cognitive disabilities had few visible
supports for communicating with their teachers. Here, DisCrit tenets one and six blended with critical dis-
course theory illuminated how racism and ableism intersected with linguicism and multimodal communica-
tion supports, technologies, and tools were withheld from the focal participants. As a result, they had to
work hard to communicate and express themselves across the school day, holding the burden of presenting
themselves as knowledge generators (Delgado Bernal, 2002). While most of the girls often successfully
dialogued without supports, exemplifying their agency and resourcefulness in the classroom (Tichavakunda,
2021), their discursive strengths and gifts were not responded to.

Educators responded to the focal participants with directions and redirections, questions, and praise. At
times, they interrupted or made assumptions about students’ discourses. This finding supports existing
research wherein educators’ interruptions disrupted the fluency of the initiation and subtracted from the
subtle discursive power youth could claim (Bliss et al., 1998). At times, teachers made repairs to ensure
understanding and other times they did not. Also, some teachers did not help the students when they asked
for help (Annamma et al., 2020). These findings add to the literature by considering the kinds of unproduc-
tive interactions girls of color labeled with significant cognitive disabilities had with educators.

Teachers did not vary their questioning techniques as most questions were closed or known-answer ques-
tions rather than open questions (Piccolo et al., 2008). In this study, praise and affirmation replaced open-
questioning techniques, resulting in brief turn sequences and little to no opportunity to engage deeply with
the content. Black (2004) found that teachers varied their questioning based on how they perceive students’
abilities, resulting in more controlling forms of talk when teachers’ perceptions of students’ abilities were
deficit-based. In this study, teachers’ responses demonstrated how students were positioned. This position-
ing resulted in teachers withholding (a) goodness and smartness and (b) meaningful learning from girls of
color labeled with significant cognitive disabilities, as identified through DisCrit tenet six (Leonardo &
Broderick, 2011).

Importantly, there were instances wherein teachers did not respond to the focal participants (Clarke,
2007), resulting in no shifts in discursive control. At times, this may have been because the teacher did not
see or hear a student as the girls did not always physically approach teachers or say a teacher’s name before
initiating. In crowded special education classrooms, educators were often in proximity when communicat-
ing with a focal participant. Moreover, this omission highlights how classrooms prioritize oral/aural com-
munication over actions. The findings presented here add to the literature as teachers most often controlled
classroom discourses and upheld talk as the dominant mode of expression, thus limiting opportunities for
the girls to play more active learning roles multimodally.

Limitations and Future Research Directions

While the focus on students as primary participants is a strength of the study, the lack of stakeholders
beyond students and educators is a limitation. Therefore, one research implication revolves around partici-
pation and supports the focus of DisCrit tenet two on participants’ multidimensional identities. For exam-
ple, speech-language pathologists would provide insight into IEP team collaboration continuities and
fissures when considering communication supports and tools (Soto & Yu, 2014). Inviting participation from
additional school personnel, including school administrators, would be an important next step while still
centering girls of color labeled with significant cognitive disabilities.

Although student-generated data and student-involved analysis are also strengths of the study, more
youth participatory action research (Cammarota & Fine, 2008) led by girls of color labeled with significant
cognitive disabilities is needed. Such scholarship would (a) be grounded in the girls’ lived experiences and

Miller 171

concerns, (b) incorporate training and practice of research skills, (c) iteratively combine research and action,
and (d) involve power-sharing between adults and youth. Youth participatory action research is a promising
tool for engaging girls of color labeled with significant cognitive disabilities in youth-driven transformative
educational change.

Reimagining Schooling

The first implication for reimagining schooling focuses on how girls of color labeled with significant cogni-
tive disabilities are positioned and supported in schools. In this study, some teachers supported the girls’
multimodal discourses by getting to know them and what they needed. This was often done from the per-
spective of student learning need (Naraian, 2016) rather than from the perspective that these students have
strengths and gifts (Annamma & Morrison, 2018). While educators resisted the school’s marginalizing
practices in these microinteractional ways, their efforts were often spent initiating communication instead
of findings ways for classroom discourses to be multidirectional and multimodal. In this way, interactions
felt one-sided with the adult holding the power. Instead, girls of color labeled with significant cognitive
disabilities must be positioned as epistemic agents (Taylor & McDonough, 2021) and vulnerable assets
(Proffitt, 2020) rather than solely as knowledge consumers, and supported as such.

A second implication focuses on the necessity to expand what is considered discourse. In schools, educa-
tors often prioritize oral/aural communication over actions. Yet, communication is richer and more complex
than that. People often use multimodal discourses across contexts and communication partners (Jewitt,
2017). Expanding what is considered discourse by positioning actions as important as talk is essential for
all students, particularly students labeled with significant cognitive disabilities and students with complex
communication needs.

A third implication centers on multimodal communication supports, technologies, and tools as an inte-
gral part of schooling (Hamraie, 2013). This includes providing access to and use of low-tech (e.g., com-
munication book, eye-gaze board) and more complex systems, sign language, and multiple languages.
Here, girls of color labeled with significant cognitive disabilities and their families are positioned as experts
leading/co-leading multimodal discourse access considerations so that the design, development, and imple-
mentation are “both accessible and responsive” (Foley & Ferri, 2012, p. 199), rather than tailored to district
conveniences and/or school personnel comfort. Furthermore, optimal multimodal communication supports,
technologies, and tools are person- and family-centered and change over time as necessary (Yu et al., 2021).
In summary, girls of color labeled with significant cognitive disabilities ought to be afforded ample oppor-
tunities to experiment with and use varied multimodal communication supports, technologies, and tools
consistently, ones that incorporate their multilingualism authentically.

Conclusion

The purpose of this study was to expand current understandings of how multimodal discourses and class-
room practices impacted youth with disabilities broadly by considering the unique intersectional experi-
ences of six girls of color labeled with significant cognitive disabilities. Critical multimodal discourse
revealed how the focal participants showed their discursive resourcefulness. Meaning, they used discursive
strategies that should be honored and strengthened to navigate their classrooms despite absent communica-
tion supports and prioritization of oral/aural communication. In addition, the focal participants repositioned
in response to marginalization through talk and actions, including physical maneuvering, repairing, and
opting out. Ultimately, this study underscores the necessity to center the experiences of girls of color labeled
with significant cognitive disabilities in educational research to reimagine schooling.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of
this article.

172 Research and Practice for Persons with Severe Disabilities 47(3)

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this
article: This work was supported by the U.S. Department of Education (DED0072555).

ORCID iD

Amanda L. Miller https://orcid.org/0000-0002-5342-0717

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Amanda L. Miller is an associate professor of education at Wayne State University. Her research focuses on youth
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Received: January 31, 2022
Final Acceptance: June 20, 2022
Editor in Charge: Sharon M. Darling

https://doi.org/10.1177/1077800417727763

https://doi.org/10.1080/13613324.2021.2019004

https://www.jstor.org/stable/20866886

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Systematic Review

The effectiveness of cognitive behavioural therapy for
individuals with an intellectual disability and anxiety: a
systematic review

G. Fynn,1 M. Porter,1 T. Borchard,1 C. Kazzi,1 Q. Zhong1 & L. Campbell2

1 School of Psychology, Macquarie University, Sydney, New South Wales, Austral

2 School of Psychology, University of Newcastle, Newcastle, New South Wales, Australia

Abstract

Introduction

Individuals with intellectual disability
(ID) are at higher risk of experiencing difficulties with
anxiety than the general population. However, there
are major barriers for individuals to receive
appropriate services. There is a growing
understanding of the importance of developing
appropriate psychological interventions for thi

group. The objective of the current review was to
systematically evaluate the findings of studies
investigating the effectiveness of cognitive behavioural
therapy (CBT) for individuals with ID and anxiety

Another aim was to explore which adaptions to CB

and treatment components were currently being
utilised within the field.
Method The electronic databases of CINAHL,
EMBASE, Medline, PsycINFO, Psychology and
Behavioural Sciences Collection and Scopus were
searched to identify relevant studies. The
methodological quality of these studies was assessed
using established quality assessment tools by the

National Institutes of Health for pre and post studies
and case serie

Results

Nine studies were included in this systematic
review, all of which reported improvements in anxiety
severity for some participants (25%–100%; N = 60)
following CBT. Only three studies reported moderate
effect sizes for CBT interventions on anxiety for
individuals with ID.

Discussion

and Conclusions There is emerging
literature supporting the effectiveness of CBT for
individuals with mild ID. Findings highlight that
CBT for individuals with anxiety and mild ID,
including cognitive components, may be feasible and
tolerable. While the field is gradually receiving more
attention, there are significant methodological flaws
present, which limit the conclusions that can be
drawn regarding the effectiveness of CBT for
individuals with ID. However, there is emerging
evidence for techniques such as cognitive
restructuring and thought replacement and
modifications such as visual aids, modelling and
smaller groups based on this review. Future research
is warranted to investigate whether individuals with
more severe ID can benefit from CBT, as well as
further exploring what are the necessary components
and modifications.

816

Correspondence:

A/Prof Melanie Porter, Room 3.519, AHH, School of Psychology,

Macquarie University, Herring Road, Sydney, New South Wales

Australia 2109.

(e-mail: melanie.porter@mq.edu.au)

Journal of Intellectual Disability Research doi: 10.1111/jir.13046

VOLUME 67 PART 9 pp 816–841 SEPTEMBER 2023

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits

use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial

purposes.

bs_bs_banner

https://orcid.org/0000-0003-3281-1732

https://orcid.org/0000-0002-8872-9626

mailto:melanie.porter@mq.edu.au

http://creativecommons.org/licenses/by-nc/4.0/

Introduction

Individuals with an intellectual disability (ID) are at
greater risk of experiencing mental illness at all ages,
compared with the general population (21.7% vs.
4.3%; Hughes-McCormack et al. 2017). Nonetheless,
anxiety is underdiagnosed in the ID population due to
diagnostic challenges (Hsieh et al. 2020). First, people
with ID are less able to self-report anxiety symptoms
due to expressive communication difficulties (Scott &
Havercamp 2014); second, anxiety disorders may
wrongly be attributed to pre-existing ID (i.e.
diagnostic overshadowing; Reiss et al. 1982). This
lack of diagnostic sensitivity impedes appropriate
treatment.

Individuals with an ID are at greater risk of
developing anxiety due to various factors, such as an
increased number of stressful life events or chronic
health conditions (Hsieh et al. 2020), and they may
have limited psychological resources to cope with
adverse experiences (Taylor et al. 2008). Moreover,
several neurodevelopmental conditions with
comorbid ID are associated with elevated anxiety,
such as autism spectrum disorder (ASD; van Steensel
& Heeman 2017), Fragile X syndrome (Cordeiro
et al. 2011) andWilliams syndrome (Kozel et al. 2021).
Despite this, there is a lack of evidence-based
approaches in clinical practice and limited expertise
and confidence of professionals working with people
with ID and concurrent mental health difficulties,
which may contribute to the difficulties accessing
appropriate services (Unwin et al. 2016).

Historically, there has been an overreliance on
medication and behaviour modification when treating
mental health difficulties of individuals with an ID
(Whitehouse et al. 2006). It was commonly asserted
that psychological therapy involving talk therapy or
cognitive components was not appropriate for
individuals with an ID due to their cognitive deficits.
However, this notion has been challenged, and there
is growing recognition that individuals with a
cognitive impairment, including an ID may benefit
from psychological treatments, such as cognitive
behavioural therapy (CBT; Taylor et al. 2008).
Indeed, the clinical guidelines published in the UK
recommend CBT for individuals with milder ID, to

treat depression or subclinical depressive symptoms
(National Institute for Health and Care
Excellence 2016).

There is a wealth of research on the effectiveness of
CBT for anxiety disorders in the general population
which include social anxiety disorder, specific phobia,
generalised anxiety disorder (GAD),
obsessive–compulsive disorder (OCD) and
post-traumatic stress disorder (PTSD). CBT may be
conceptualised as a class of interventions that are
collaborative, structured and skills-orientated, which
focus on the interaction between thoughts, feelings
and behaviours. It involves attempting to modify
unhelpful thoughts, behaviours or both to improve
emotional responses (Kaczkurkin & Foa 2015). The
treatment components of CBT for anxiety may vary
between interventions but can include
psychoeducation, relaxation, cognitive strategies,
exposure, social skills training and problem solving
(Hofmann et al. 2012).

There is a growing body of evidence that has
evaluated the effectiveness of CBT in managing
problemswith anxiety, anger, and depression in the ID
population (Vereenooghe & Langdon 2013; Osugo &
Cooper 2016). A meta-analysis of psychological
therapies for children and adults with ID found CBT
to be at least moderately effective in treating anger and
depression with emerging evidence for anxiety
(Vereenooghe & Langdon 2013). A scoping review
found equivocal evidence for the effectiveness of CBT
in improving anxiety for individuals with ID (Unwin
et al. 2016). However, amongst these studies, few
utilised standardised criteria related to a diagnosis or
specific level of anxiety symptomatology and no
studies were controlled studies. Nonetheless,
qualitative data have shown that CBT is generally
perceived as feasible and was well-tolerated amongst
clients and carers (Unwin et al. 2016). A subsequent
systematic review reported positive outcomes of CBT
interventions on anxiety for people with ID (Dagnan
et al. 2018); however, the majority of the reviewed
literature consisted of single case studies. In addition,
some studies included in the systematic review
included participants with mixed presentations in a
transdiagnostic group, whereby the effects of CBT
may have been diluted due to the combination of
anxious and depressed participants in treatment
outcomes. Furthermore, none of the reviews have
included children with an ID up until this point.

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anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

Therefore, the existing literature investigating the
effectiveness of CBT on anxiety in people with ID is
ambiguous, but positive results are emerging.

There are some challenges associated with
delivering CBT to the ID population. Individuals
with ID may present with significant deficits in
attention, learning, memory, executive function and
language, all cognitive abilities required for effective
CBT (Hronis et al. 2017). Hronis et al. (2017)
contend that while it may be challenging to adapt
CBT interventions to an individual’s unique cognitive
profile, it should not preclude their participation in
CBT. Moreover, there may be greater difficulties
adapting CBT for certain presentations of anxiety for
those with ID. For example, cognitive interventions
may be more central to interventions targeting
conditions such as PTSD and GAD, in comparison
with specific phobia (Arch & Craske 2009) and
therefore may be more difficult to adapt. Some
pertinent recommendations include simplification of
techniques, adjusting language, utilising activities,
using directive methods, using flexible methods and
involving caregivers (e.g. assign homework or
rehearsals at home with the help of support persons).
For children with ID, modifications include shorter
sessions, engaging in implicit learning processes (e.g.
role play), using visual aids and presenting
information numerous times (Hronis et al. 2017).

With increased interest in anxiety interventions for
the ID population over recent years and with growing
insights into its potential utility and effectiveness for
the ID population, a critical review of the literature on
CBT treatment for anxiety in the ID group is
warranted. This is pertinent considering the growing
literature in the field since the previous systematic
review was conducted by Dagnan et al. (2018);
therefore, this study seeks to update the field of
knowledge. Furthermore, this study will attempt to
provide a more focused exploration of the evidence
base compared with previous reviews, by applying
more stringent exclusion criteria whereby only studies
with interventions targeting anxiety disorders (rather
than transdiagnostic groups) will be included; it is also
the first systematic review to examine the effectiveness
of CBT for children with anxiety and ID.

This systematic review aims to encourage
awareness of the current literature around whether
CBT is appropriate and effective for individuals with
ID and an anxiety disorder. Moreover, it aims to

identify which adaptations to CBT and which
components of CBT are currently being utilised for
individuals with ID, as well as a critical analysis of the
strengths and limitations and the clinical challenges
within this field of research.

Materials and methods

The reporting of this systematic review was guided by
the standards of the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA;
Moher et al. 2009; Page et al. 2021) statement.
Methods of the analysis and inclusion criteria were
specified in advance and documented in a protocol
(registration number: CRD42020208353).

Eligibility criteria

Inclusion and exclusion criteria

Table 1 demonstrates the inclusion and exclusion
criteria of this systematic review. Published studies
were required to meet the following criteria: (1) to
evaluate the effectiveness of CBT interventions for
individuals with ID and anxiety; (2) to include
participants who (a) were formally diagnosed with ID
using current or older editions of any internationally
recognised diagnostic criteria (e.g. Diagnostic and
Statistical Manual or the International Classification
of Diseases), (b) were found to demonstrate an IQ
below 70 through formal cognitive testing, (c)
provided previous reports from appropriate health
practitioners confirming the diagnosis of ID or (d)
had confirmed involvement with a community ID
service provider; (3) participants were required to
demonstrate anxiety through (a) a formal diagnosis
using current or older editions of any recognised
diagnostic criteria for anxiety, (b) report elevated
levels of anxiety symptoms using a validated measure
anxiety (including non-specified anxiety) or (c)
demonstrate elevated anxiety that was observed
through a clinical assessment or interview with a
qualified health practitioner; (4) to report at least two
assessment time points (e.g. baseline and post-
intervention); and (5) to have been published in a peer
review journal in the English language.

The current systematic review excluded studies
that included a non-anxious disorder as the primary
target of intervention (e.g. a mood disorder). If there
was evidence that the participants experienced anxiety

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G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

as their primary concern, comorbidities such as ASD
and mood disorder such as major depressive disorder
were included. Studies were excluded if the
intervention did not include a specific cognitive
component or if there was another non-CBT-based
psychological therapy present in parallel to the
intervention, whereby it would be impossible to tease
apart the specific efficacy of CBT treatment on
anxiety symptomology. Dissertations, book chapters,
expert reviews and conference abstracts without the
full text, and protocols without data were excluded.
Restrictions were not placed on the age of participants
in the studies included.

ID has replaced older terms, such as ‘mental
retardation’, and is recognised alongside other terms
such as ‘learning disability’ in the UK, and therefore,
participants meeting these diagnoses were
considered. Anxiety disorders that would be
considered included the following: GAD; specific
phobia; panic disorder; agoraphobia; social anxiety
disorder; selective mutism; separation anxiety

disorder; and anxiety disorder that was induced by a
substance or medication or that was due to another
medical condition. OCD, acute stress disorder and
PTSD were also included, as these disorders were
previously considered to be anxiety disorders in
previous editions of recognised diagnostic criteria.

The systematic review was limited to studies
investigating CBT interventions and included
studies evaluating CBT cognitive and behavioural
techniques, such as cognitive restructuring;
psychoeducation; behavioural activation; social
skills training; relaxation; or coping skills (Cuijpe

et al. 2008). In line with Dagnan et al. (2018),
interventions that were considered to be a part of
the wider family of CBT, such as behavioural
activation or third-wave variants of CBT (e.g.
mindfulness and acceptance commitment therapy),
were only included if there was a specific cognitive
component.

819

Table 1 The inclusion and exclusion criteria for the current systematic review

Inclusion criteria Exclusion criteria

Study topic Evaluated the effectiveness of CBT
for individuals with ID and anxiety

The primary target of the intervention
was a non-anxious disorder (e.g. mood disorder)

Participant Evidence of an ID through:

• Formal diagnostic assessment
• Cognitive testing (IQ < 70)
• Previous reports from health practitioners or,
• Involvement with a community ID provider
• Includes evidence for ‘mental retardation’

or a ‘learning disability’ in UK
Evidence of anxiety through:

• Formal diagnostic assessment of anxiety
• Elevated anxiety on a validated measure
• Interview/assessment with a qualified

health practitioner
Comorbidities (e.g. ASD and mood disorders)
were included if anxiety was identified as the
primary concern
All ages

Study type/design At least two assessment time points
(e.g. baseline and post-treatment)

Dissertations, book chapters, expert reviews
and conference abstracts without the
full text and protocolsPublished in a peer review journal in English

Intervention CBT intervention with at least a cognitive component A non-CBT based psychological therapy was also present

ASD, autism spectrum disorder; CBT, cognitive behavioural therapy; ID, intellectual disability.

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

Information sources

The following databases were accessed: CINAHL
(1937 to August 2021), EMBASE (1974 to August
2021), Medline (1946 to August 2021), PsycINFO
(1806 to August 2021), Psychology and Behavioural
Sciences Collection (1965 to August 2021) and
Scopus (1875 to August 2021). For each database, no
date limit was applied. The last search was run on 10

August 2021 by two independent researchers. Subject
headings and keywords were used where available.

Search strategy

The search strategy was adapted for each specific data
base. The search terms were as follows: ((learn* or
intellect*) adj2 (disorder* or impair* or disab* or
dysfunction*) OR mental retardation OR mental*
handicap*) AND (anxi* OR phobi* OR obsessive
compulsive disorder OR panic disorder OR
agoraphobia OR mutism OR GAD OR OCD OR
PTSDOR ((post traumatic stress or post traumatic or
overanxi* or avoidan* or internali* or panic*) adj2
disorder*)) AND (cognitive behavi* therapy OR cbt
OR mindfulness OR acceptance and commitment
therapy OR dialectical behavi* therapy OR ACT OR
MBCT OR DBT).

Study selection

In accordance with the PRISMA guidance to
reporting (Moher et al. 2009; Page et al. 2021), the
process for selecting studies commenced by removing
duplicate articles. This was achieved using the online
EndNote programme, which can automatically
remove duplicates. Further duplicates were removed
manually. The remaining results were screened on the
basis of the title, the abstract, the participant section
and other selection and exclusion criteria. The
reference lists were then screened. Two independent
researchers reviewed these papers in an unblinded,
standardised manner. Disagreements between
reviewers were resolved by a third independent
reviewer.

Data collection process and synthesis of results

One researcher extracted information from each
included study, utilising a pre-designed data
extraction form. Information extracted from the
selected studies included: aims of the study, country

of origin, participant characteristics, recruitment,
intervention characteristics, medication use, study
characteristics and measures, results, and quality
appraisal. The results were presented and synthesised
in the tables. Table 2 presents the results of pre–post
intervention studies whereas Table 3 presents the
results of the case studies and series. The degree of
the effect sizes was interpreted utilising Ferguson’s
recommendations for social science data (2009),
whereby the effect sizes for r ranged from minimal
(.20), moderate (.50) and strong (.80) and the effect
sizes for ωp

2 ranged from minimal (.04), moderate
(.25) and strong (.64). Where necessary and possible
the mean and standard deviations of the outcome
measures for anxiety severity were calculated.

In addition, information was collected by one
researcher in relation to the treatment components of
the included studies. The treatment descriptions
and/or treatment manuals were examined, and the
following characteristics were recorded:
psychoeducation (providing didactic instruction on
the nature of anxiety, information on the connection
between thoughts, feelings and behaviours);
relaxation strategies (diaphragmatic breathing,
progressive muscle relaxation); cognitive strategies
(identifying and categorising distorted automatic
thoughts, cognitive restructuring, Socratic
questioning, downward arrow technique, behavioural
experiments); and exposure techniques (in vivo or
imaginal). In addition, strategies were further
specified to examine the presence of cognitive
restructuring (cognitive challenging) and thought
replacement, also known as self-instructional training
(Willner 2005), which involves reminding oneself of
coping statements. When coding the specific
treatment components of each intervention, the
author’s description of the purpose of the treatment
component was carefully considered.

Methodological quality

The methodological quality of each study was
appraised using established quality assessment tools
by the National Institutes of Health (NIH). The NIH
has developed a set of quality assessment tools that are
tailored to various study designs, such as before-and-
after (pre–post) studies with no control group
(National Institutes of Health 2014a) and case series
designs (National Institutes of Health 2014b). The

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G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

821

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co
m
pu

ls
iv
e

fe
ar
s.

•
Fa
m
ily
-fo

cu
se
d

C
BT

in
te
rv
en
tio

w
hi
ch

w
as

ad
ap
te
d

fr
om

an
ex
is
tin

g
ev
id
en
ce
-b

as
ed

m
an
ua
l,

Fa
ci
ng

Y
ou

r
Fe
ar
s

(R
ea
ve
n
et

al
.2

0
1
1
)

•
G
ro
up

in
te
rv
en
tio

n
w
ith

2
–
4
ad
ol
es
ce

nt
s

an
d
th
ei
r
pa
re
nt
s

•
1
4
×
4
5
–
6
0
m
in

se
ss
io
ns

ov
er

1
4
w
ee
ks

•

D
id

no
t
re
po

rt
th
e
tr
ai

ni
ng

of
th
e
fa
ci
lit
at
or
s

•
A
D
A
M
S,
a
sc
re
en
er

fo
r

ps
yc
hi
at
ri
c
di
so
rd
er
s

•
SC

A
R
ED

-P
ar

en
t

V
er
si
on

m
ea
su
re
s

an
xi
et
y

•
FS
SC

-R
w
hi
ch

m
ea
su
re
s

av
oi
da
nc
e
to
w
ar
ds

fe
ar
ed

si
tu
at
io
ns

•

A
BC

-C
w
hi
ch

m
ea
su
re
s
th
e

se
ve

ri
ty

of
pr
ob

le
m

be
ha
vi
ou

R
ef
er
en

ce
an

d
co

un
tr
y

M
ai
n
fi
nd

in
gs

†

L
im

it
at
io
ns

M
et
ho

do
lo
gi
ca

lq
ua

lit
y

‡

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

822

T
ab

le
2.

(C
on
tin

ue
d)

R
ef
er
en

ce
an

d
co

un
tr
y

M
ai
n
fi
nd

in
gs

†
L
im

it
at
io
ns

M
et
ho

do
lo
gi
ca

lq
ua

lit
y‡

Ph
ill
ip
s
&
K
le
in
-T
as
m
an

(2
00
9)

U
SA

•
R
es
ul
t

s
fr
om

th
e
A
D
IS
re
ve
al
ed

th
at

th
e

pa
rt
ic
ip
an
t
no

lo
ng
er

m
et

cr
ite

ri
a

fo
r

G
A
D
,O

C
D
,h

ow
ev
er

sh
e

st
ill

m
et

th
e

cr
ite

ri
a
fo
r
Sp
ec
ifi
c
Ph
ob

ia
.

•
W

ee
kl
y
ra
tin

g
an
d
qu
es
tio

nn
ai
re

m
ea
su
re
s
di
d
no

t
de
m
on

st
ra
te

pr
ov
em

en
t

in
an
xi
et
y.

•
M
ix
ed

re
su
lts

fo
r
pa
rt
ic
ip
an
t
tw

o-
so
m
e

im
pr
ov
em

en
ts

m
ea
su
re
s.

•
PT

as
se
ss
m
en

t
co

nd
uc
te
d

6
m
on

th
s
an
d
2
m
on

th
s

af
te
r
th
e
co
nc
lu
si
on

th
e
in
te
rv
en
tio

fo
r
ea
ch

pa
rt
ic
ip
an
t.

le
ar

st
ud
y
qu
es
tio

n
2.

C
le
ar

ca
se

de
fi
ni
tio

n
3.

C
on

se
cu
tiv
e
ca
se
s

4.
C
om

pa
ra
bl
e
su
bj
ec
ts

.
C
le
ar

in
te
rv
en
tio

n
6.

O
M

de
fi
ne
d,

va
lid

&
re
lia
bl
e

A
de
qu
at
e
fo
llo
w
-u
p
le
ng
th

8.
St
at
is
tic
al

m
et
ho

w
el
l-d

es
cr
ib
ed

R
es
ul
ts

w
el
l-d

es
cr
ib
ed

Q
ua
lit
y
ra
tin

Y Y N

Y Y

N
/A

G
oo

d
(B
la
ke
le
y-
Sm

ith
et

al
.

20
21
)

U
SA

•
Si
g
re
du
ct
io

n
in

an
xi
et
y
sc
or
es

w
as

se
rv
ed

at
PT

co
m
pa
re
d
w
ith

BL
on

al
lm

ea
su
re
s
[A
D
A
M
S
(ω

2 p
=
.4
5
),

SC
A
R
ED

-P
(ω

2 p
=
.1
4
)
an
d
FS
SC

-R
(n

=
1
6
;ω

2 p
=
.2
0
)]
.

•
Si
g
re
du
ct
io
n
in

so
ci
al
av
oi
da
nc
e

(ω
2 p
=
.5
0
),
ob

se
ss
iv
e–

co
m
pu
ls
iv
e

sy
m
pt
om

s
(ω

2 p
=
.1
8
),

de
pr
es
si
on

(ω
2 p
=
.2
3
),
an
d
m
oo

d
sy
m
pt
om

s
(ω

2 p
=
.2
0
)

w
er
e

se
rv
ed

on
th
e

A
D
A
M
S
sc
al
e
fr
om

BL
to

PT
.

•

A
si
g
re
du
ct
io
n
in

le
th
ar
gy

w
as

ob
se
rv
ed

(ω
2 p
=
.1
4
),
on

th
e

A
BC

fr
om

BL
to

PT
.

•
A
nx
ie
ty

m
ea
su
re

re
lie
d
on

ly
on

pa
re
nt
-r
ep
or
t

•
A
nx
ie
ty

di
so
rd
er
s
w
er
e
no

fo
rm

al
ly

di
ag
no

se
d

•
D
id

no
t
re
po

rt
on

th
e
le

ve
lo

ft
ra
in
in
g

of
th
e
fa
ci
lit
at
or
s

•
N
o
fo
llo
w
-u
p
ou

tc
om

e
da
ta

•
O
ne

m
ea
su
re

w
as

no
t
ad
m
in
is
te
re
d
to

al
lp

ar
tic
ip
an
ts
(F
SS
C
-R
)

1.
C
le
ar

ob
je
ct
iv
es

2.
C
le
ar

el
ig
ib
ili
ty

cr
ite

ri
a

3.
R
ep
re
se
nt
at
iv
e
pa
rt
ic
ip
an
ts

A
ll
el
ig
ib
le

pe
rs
on

s
en
ro
lle
d

5.
Su
ffi
ci
en
t
sa
m

pl
e
si
ze

In
te
rv
en
tio

n
7.

O
M

de
fi
ne
d,

va
lid
,r
el
ia
bl
e

A
ss
es
so
r
bl
in
di
ng

9.
Fo

llo
w
-u
p
20
%
or

le
ss
?

10
.S
ta
tis
tic
al
an
al
ys
is

11
.M

ul
tip

le
O
M

12
.I
nd
iv
id
ua
l-l
ev
el
ou

tc
om

e
fo
r

gr
ou

p-
le
ve
li
nt
en
tio

ns
Q
ua
lit
y
ra
tin

Y Y Y N
R

Y N Y

Y N N
/A

Fa
ir

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

quality assessment tool for case series designs was also
applied to case reports, as there were limited tools
available for this study design and because the tool
captured important aspects to assess which are
relevant to case studies. These tools were selected as
they assessed the internal validity and risk of bias in a
similar manner. The quality assessments were
undertaken by two independent researchers. Any
disagreements (N = 16, and 15%) were resolved
through discussions with a third party (co-author,
M. P.) and were re-coded by the independent third
party (co-author, M. P.). These tools informed the
reviewers’ critical appraisal of the studies and their
classification of the studies as ‘good’, ‘fair’ or ‘poor’.
Results of the overall quality assessments are reported
in Tables 2 and 3.

Results

Study selection

Figure 1 presents the flowchart describing the
inclusion and exclusion of studies.

Study characteristics

Five of the nine included studies were uncontrolled
before and after (pre–post) studies, two were case
studies and two were case series. Tables 2–6 show the
characteristics of studies across various groups of
participants.

Participants

The selected studies included a total of 60
participants, aged between 12 and 73 years. The
majority of studies included individuals with a mild
ID (Marwood & Hewitt 2013; Stuart et al. 2014;
Carrigan & Allez 2017; Roberts & Kwan 2018;
Giannaki & Hewitt 2021). Four studies included
participants with borderline or moderate ID (Lindsay
et al. 1997; Douglass et al. 2007; Phillips & Klein-
Tasman 2009; Roberts & Kwan 2018). One study did
not specify the participants’ level of ID but reported a
range of intellectual functioning for participants
(IQ = 40–79; Blakeley-Smith et al. 2021). ID was
confirmed by a written report from a qualified
clinician (Roberts & Kwan 2018), by formally testing
IQ and adaptive functioning (Lindsay et al. 1997;
Phillips & Klein-Tasman 2009; Stuart et al. 2014;

823

†

T
he

ou
tc
om

e
m
ea
su
re
s
pr
ov
id
e
ba
se
lin
e
an
d
po

st
-t
re
at
m
en
t
da
ta
.

‡

T
he

m
et
ho

do
lo
gi
ca
lq

ua
lit
y
of

st
ud
ie

s
w
as

as
se
ss
ed

us
in
g
th
e
N
IH

Q
ua
lit
y
A
ss
es
sm

en
tT

lf
or

Be
fo
re
-A
fte

r
(P
re
-P
os
t)
St
ud
ie
s
W

ith
N
o
C
on

tr
ol

G
ro
up
.1

le
ar

ob
je
ct
iv
es

=
W

th
e
st
ud
y
qu
es
tio

n
or

ob
je
ct
iv
e

cl
ea
rl
y
st
at
ed
?;
2.

C
le
ar

el
ig
ib
ili
ty

cr
ite

ri
a
=
W

er
e
el
ig
ib
ili
ty
/s
el
ec
tio

n
cr
ite

ri
a
fo
r

th
e
st
ud
y
po

pu
la
tio

pr
es
pe

ci
fi
ed

an
d
cl
ea
rl
y

de
sc
ri
be
d?

.R
ep
re
se
nt
at
iv
e
pa
rt
ic
ip
an
ts

=
W

er
e
th
e
pa
rt
ic
ip
an
ts

in
th
e

st
ud
y
re
p-

re
se
nt
at
iv
e
of

th
os
e

w
ho

w
ou

ld
be

el
ig
ib
le
fo
r
th
e
te
st
/s
er
vi
ce
/in
te
rv
en
tio

n
in

th
e
ge
ne
ra
lo

r
cl
in
ic
al
po

pu
la
tio

n
of

in
te
re
st

?;
4.
A
ll
el
ig
ib
le
pe
rs
on

s
en
ro
lle
d
=
W

er
e
al
le
lig
ib
le
pa
rt
ic
ip
an
ts

th
at

m
et

th
e
pr
es
pe
ci
fi
ed

en
tr
y
cr
ite

ri
a
en
ro
lle
d?
;5

.S
uf
fi
ci
en
t
sa
m
pl
e
si
ze

=
W

as
th
e
sa
m
pl
e
si
ze

su
ffi
ci
en
tly

la
rg
e
to

pr
ov
id
e
co
nfi
de
nc
e
in

th
e
fi
nd
in
gs
?;
6.

In
te
rv
en
tio

n
=
W

as
th
e
te
st
/s
er
vi
ce
/in
te
rv
en
tio

n
cl
ea
rl
y
de
sc
ri
be
d

an
d
de

liv
er
ed

co
ns
is
te
nt
ly

ac
ro
ss

th
e
st
ud
y
po

pu
la
tio

n?
;7

=
O
M

de
fi
ne
d,

va
lid
,r
el
ia
bl
e
=
W

er
e
th
e
ou

tc
om

e
m
ea
su
re
s
pr
es
pe
ci
fi
ed
,c
le
ar
ly
de
fi
ne
d,

va
lid
,r
el
ia
bl
e,
an
d
as
se
ss
ed

co
ns
is
te
nt
ly
ac
ro
ss

al
ls
tu
dy

pa
rt
ic
ip
an
ts
?;

A
ss
es
so
r
bl
in
di
ng

=
W

er
e
th
e

pe
op

le
as
se
ss
in
g
th
e
ou

tc
om

bl
in
de
d
to

th
e
pa
rt
ic
ip
an
ts
’e
xp
os
ur
es
/in
te
rv
en
tio

ns
?;
9.
Fo

llo
w
-u
p
20
%
or

le
ss
?=

W
as

th
e
lo
ss
to

fo
llo
w
-u
p
af
te
r
ba
se
lin
e
20
%
or

le
ss
?W

er
e
th
os
e

lo
st

fo
llo
w
-u
p
ac
co
un
te
d
fo
r
in

th
e
an
al
ys
is
?;
10
.S
ta
tis
tic
al
an
al
ys
is
=
D
id
th
e
st
at
is
tic
al
m
et
ho

ds
ex
am

in
e
ch
an
ge
s
in

tc
om

e
m
ea
su
re
s
fr
om

be
fo
re

to
af
te
r
th
e
in
te
rv
en
tio

n?
W

er
e
st
at
is
tic
al
te
st
s
do

ne
th
at

pr
ov
id
ed

p
va
lu
es

fo
r
th
e
pr
e-
to
-p
os
t
ch
an
ge
s?
;1

1.
M
ul
tip

le
O
M

=
W

er
e
ou

tc
om

e
m
ea
su
re
s
of

in
te
re
st

ta
ke
n
m
ul
tip

le
tim

es
be
fo
re

th
e
in
te
rv
en
tio

n
an
d
m
ul
tip

le
tim

es
af
te
r
th
e
in
te
rv
en
tio

n
(…

)?
;1

2.
In
di
vi
du
al
-le

ve
l

ou
tc
om

e
fo
r
gr
ou

p-
le
ve
li
nt
en
tio

n
=
If
th
e
in
te
rv
en
tio

n
w
as

co
nd
uc
te
d
at

a
gr
ou

p
le
ve
l(
…

)
di
d
th
e
st
at
is
tic
al
an
al
ys
is
ta
ke

in
to

ac
co
un
t
th
e
us
e
of

in
di
vi
du
al
-le

ve
ld

at
a
to

de
te
rm

in
e

ef
fe
ct

s
at

th
e
gr
ou

p
le
ve
l?

N
ot
e:
A
BC

-C
,A

be
rr
an
t
Be

ha
vi
ou

r
C
he
ck
lis
t-
C
om

m
un
ity

(A
m
an

al
.1

99
5)
;A

D
A
M
S,
A
nx
ie
ty

D
ep
re
ss
io
n
an
d
M
oo

d
Sc
al
e
(E
sb
en
se
n
et

al
.2

00
3)
;A

D
IS
-IV

,A
nx
ie
ty

D
is
or
de
rs

In
te
rv
ie
w

Sc
he
du
le
fo
r

D
SM

-IV
,

pa
re
nt

ve
rs
io
n
(S
ilv
er
m
an

&
A
lb
an
o
19
96

);
BA

I-Y
,B

ec
k
A
nx
ie
ty

In
ve
nt
or
y
Y
ou

th
(B
ec
k
et

al
.2

00
1)
;C

BC
L,

C
hi
ld

Be
ha
vi
ou

r
C
he
ck
lis
t
(A
ch
en
ba
ch

&
R
es
co
rl
a
20
01

);
FS
SC

-R
,F
ea
r
Su
rv
ey

Sc
he
du
le
fo
r

C
hi
ld
re
n-

R
ev
is
ed

(O
lle
nd
ic
k
19
83

);
M
A
SC

,M
ul
tid

im
en
si
on

al
A
nx
ie
ty

Sc
al
e

fo
r
C
hi
ld

re
n
(M

ar
ch

19
97

);
R
C
M
A
S,
R
ev
is
ed

C
hi
ld
re
n’
s
M
an
ife
st
A
nx
ie
ty

Sc
al
e
(R
ey
no

ld
s
&
R
ic
hm

on
d
19
98

);
SC

A
R
E-
P,
Sc
re
en

fo
r
C
hi
ld

A
nx
ie
ty

R
el
at
ed

D
is
or
de
rs
,P

ar
en
t
V
er
si
on

(B
ir
m
ah
er

et
al
.1

99
9)
.

A
D
H
D
,a
tt
en
tio

n-
de
fi
ci
t/
hy
pe
ra
ct
iv
ity

di
so
rd
er
;B

L,
ba
se
lin
e;
C
BT

,c
og
ni
tiv
e
be
ha
vi
ou

ra
lt
he

ra
py

D
,c
a

n
no

t
de
te
rm

in
e;
M
,g
ro
up

m
ea
n;
N

,n
o;

N
,n
um

be
r
of

pa
rt
ic
ip
an
ts
;N

/A
,n
ot

ap
pl
ic
ab
le
;N

R
,n
ot

re
po

rt
ed

;

O
D
D
,o

pp
os
iti
on

al
de
fi
an
t
di
so
rd
er
;O

M
,o

ut
co
m
e
m
ea
su
re
;P

T
,p

os
t-

tr
ea
tm

en
t;
SD

,s
ta
nd
ar
d
de
vi
at
io
n;

si
g,
si
gn

ifi
ca

nt
;s
ig
,s
ig
ni
fi
ca
nt
;Y

,y
es
.

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

824

T
ab

le
3

S
ys
te
m
at
ic

re
vi
ew

su
m
m
ar
y
of

fi
n
d
in
gs

fo
r
C
B
T

fo
r
ad

u
lt
s
w
it
h
ge
n
er
al
is
ed

an
xi
et
y
or

m
ix
ed

an
xi
et
y
(n

=
4
)

R
ef
er
en

ce
an

d
co

un
tr
y

St
ud

y/
sa
m
pl
in
g
ch

ar
ac

te
ri
st
ic
s

A
nx

ie
ty

co
nd

it
io
ns

In
te
rv
en

ti
on

de
si
gn

an
d
de

ta
ils

M
ea

su
re
s
us
ed

D
ou

gl
as
s

al
.(
20
07
)

U
K

•
N
=
6
(4

fe
m
al
es
),
2
2
–
6
5
ye
ar
s
ol
d

•
1
pa
rt
ic
ip
an
t
dr
op

pe
d
ou

t
be
fo
re

th
e
be
gi
nn
in
g
of

th
e
gr
ou

p
•

Bo
rd
er
lin
e-
m
od

er
at
e

•

Pr
e-
po

st
st
ud
y

•

G
en

er
al
is
ed

an
xi
et
y

sy
m
pt
om

s
•

Pr
e
&
po

st
in
te
rv
en
tio

n
no

co
nt
ro
l,

m
ix
ed

m
et
ho

d
de
sig
n

•
C
BT

w
ith

th
e
as
sis
ta
nc
e

of
a
su
pp
or
t
pe
rs
on

•
1
2
×
1
2
0
m
in

se
ss
io
ns

ov
er

1
2
w
ee
ks

•
G
ro
up

th
er
ap
y,

fa
ce

-t
o-
fa
ce

in
th
e
co
m
m
un
ity

•
C
lin
ic
ia
ns
:A

ss
is
ta
nt

Ps
yc
ho

lo
gi
st

T
ra
in
ee

C
lin
ic
al

Ps
yc
ho

lo
gi
st
,L

ea
rn
in
g

is
ab
ili
ty

N
ur
se

an
d

O
cc
u

p
at

io
na
lT

he
ra
pi
st
T
ec
hn
ic
ia
n

•
G
A
S-
ID

se
lf-
re
po

rt
m
ea
su
re

of
an
xi
et
y

(G
ia
nn
ak
i&

H
ew

itt
20
21
)

U
K

•
N
=
4
(3

fe
m
al
es
),
ag
ed

2
1
–
5
5
ye
ar
s
of

ag
e

•
M
ild

ID
•

Pa
rt
ic
ip
an
ts

w
er
e

re
fe
rr
ed

th
e

ps
yc
ho

lo
gy

se
rv
ic
e
fo
r

pe
op

le
w
ith

le
ar
ni
ng

di
sa
bi
lit
y

•
Pr
e-
po

st
st
ud
y

•
Sy
m
pt
om

s
re
la
te
d

ge
ne
ra
lis
ed

an
xi
et
y
an
d

sp
ec
ifi
c
ph
ob

•
Pr
e
&
po

st
in
te
rv
en
tio

n
no

co
nt
ro
l

•
Fo

llo
w
-u
p
at

4
m
on

th
s

•
C
BT

w
ith

th
e
as
sis
ta
nc
e

of
a
su
pp
or
t
pe
rs
on

•
C
BT

co
nc
ep
ts
w
er
e

ba
se
d
on

Be
ck

(1
9
7
9
)

•
7
w
ee
kl
y
se
ss
io
ns

(d
id

no
t
re
po

rt
on

th
e

du
ra
tio

n
of

se
ss
io
ns
)

•
G
ro
up

th
er
ap
y,
fa
ce
-t
o-
fa
ce

in
th
e
co
m
m
un
ity

•
C
lin
ic
ia
ns
:t
ra
in
ee

cl
in
ic
al
ps
yc
ho

lo
gi
st
s

an
d
as
si
st
an
t
ps
yc
ho

lo
gi
st
s

•
G
A
S-
ID

se
lf-
re
po

rt
•

H
oN

O
S-
LD

,a
se
lf-
re
po

rt
m
ea
su
re

gl
ob

al
fu
nc
tio

ni
ng
.

•
PT

O
S-
ID
,s
el
f-

an
d
su
pp
or
te
r-

re
po

rt
m
ea
su
re

of
ps
yc
ho

lo
gi
ca
ld

is
tr
es
s

an
d
w
el
lb
ei
ng
.

M
ar
w
oo

d
an
d

H
ew

itt
(2
01
3)

U
K

•
N
=
8
(4

fe
m
al
es
),
ag
ed

1
7
–
7
3
ye
ar
s
of

ag
e

•
M
ild

ID
•

Pa
rt
ic
ip
an
ts
w
er
e
re
cr
ui
te
d

th
ro
ug
h
N
H
S

re
fe
rr
al
s
to

th
e
ps
yc
ho

lo
gi
ca
l

se
rv
ic
e
fo
r

pe
op

le
w
ith

a
le
ar
ni
ng

di
sa
bi
lit
y

•
In
cl
ud
ed

pa
rt
ic
ip
an
ts
w
ith

au
tis
m

an
d
de
pr
es
si
on

.
•

Pr
e-
po

st
st
ud
y

•
In
cl
ud
ed

sy
m
pt
om

s
of

sp
ec
ifi
c
ph
ob

ia
,

so
ci
al
an
xi
et
y,

ge
ne
ra
lis
ed

an
xi
et
y,

an
d
ob

se
ss
io
na
la
nx
ie
ty
.

•
Pr
e
&
po

st
in
te
rv
en
tio

n
no

co
nt
ro
l,

m
ix
ed

m
et
ho

d
de
sig
n

•
C
BT

th
er
ap
y

w
ith

th
e

as
si
st
an
ce

of
a
su
pp
or
t
pe
rs
on

•
6
×
6
0
m
in

se
ss
io
ns

ov
er

6
w
ee
ks

•
G
ro
up

th
er
ap
y,
fa
ce
-t
o-
fa
ce

in
th
e
co
m
m
un
ity

•
C
lin
ic
ia
ns
:t
ra
in
ee

ps
yc
ho

lo
gi
st
an
d

an
as
si
st
an
t
ps
yc
ho

lo
gi
st

•
G
A
S-
ID

se
lf-
re
po

rt
•

Q
oL

•
H
oN

O
S–
LD

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

825

T
ab

le
3.

(C
on
tin

ue
d)

R
ef
er
en

ce
an

d
co

un
tr
y

St
ud

y/
sa
m
pl
in
g
ch

ar
ac

te
ri
st
ic
s

A
nx

ie
ty

co
nd

it
io
ns

In
te
rv
en

ti
on

de
si
gn

an
d
de

ta
ils

M
ea

su
re
s
us
ed

R
ob

er
ts

&
K
w
an

(2
01
8)

A
U
S

•
N
=
1
3
(7

fe
m
al
es
),
ag
ed

1
8
–
5
5
ye
ar
s
of

ag
e

•
M
ild

(n
=
1
0
)
an
d
m
od

er
at
e

(n
=
3
)
ID

•
Pa
rt
ic
ip
an
ts
w
er
e
re
cr
ui
te
d

th
ro
ug
h
ad
ve
rt
is
em

en
ts

to
se
rv
ic
es

an
d
gr
ou

ps
fo
r

pe
op

le
w
ith

ID
(e
.g
.r
es
pi
te

se
rv
ic
es
,

m
en
ta
lh

ea
lth

se
rv
ic
es
)

•
Pr
e-
po

st
st
ud
y

•
D
ia
gn
os
es

of
sp
ec
ifi
c

ph
ob

ia
,s
oc
ia
l

ph
ob

ia
an
d

ge
ne
ra
lis
ed

an
xi
et
y
di
so
rd
er

•
Pr
e
&
po

st
in
te
rv
en
tio

n
no

co
nt
ro
l

•
C
BT

gr
ou

p
th
er
ap
y
w
ith

op
tio

na
l

as
si
st
an
ce

of
a
th
er
ap
y
pa
rt
ne
r

•
6
×
9
0
m
in

se
ss
io
ns

ov
er

6
w
ee
ks

•
G
ro
up

th
er
ap
y,
fa
ce
-t
o-
fa
ce

•
T
he

th
er
ap
y
m
at
er
ia
ls

w
er
e
cr
ea
te
d
by

a
re
gi
st
er
ed

cl
in
ic
al
ps
yc
ho

lo
gi
st
,

th
e
fi
rs
t
au
th
or

an
d
w
er
e
ba
se
d

on
C
BT

pr
og
ra
m
m
es

fo
r

ty
pi
ca
lly

de
ve
lo
pi
ng

in
di
vi
du
al
s
w
ith

an
xi
et
y

•
G
A
S-
ID

co
m
pl
et
ed

by
th
e

pa
rt
ic
ip
an
ts
an
d
th
ei
r
ca
re
r

or
su
pp
or
t
w
or
ke
r

•
PA

S-
A
D
D
,a

cl
in
ic
al
in
te
rv
ie
w
,

w
as

ad
m
in
ist
er
ed

a
cl
in
ic
al
ps
yc
ho

lo
gi
st
to

di
ag
no

an
xi
et
y
di
so
rd
er
s

•
M
in
iP

A
S-
A
D
D

w
as

ad
m
in
ist
er
ed

by
a
cl
in
ic
al
nu
rs
e

co
ns
ul
ta
nt

to
sc
re
en

fo
r

an
xi
et
y
di
so
rd
er
s

R
ef
er
en

ce
an

d
co

un
tr
y

M
ai
n
fi
nd

in
gs

†
L
im

it
at
io
ns

M
et
ho

do
lo
gi
ca

lq
ua

lit
y‡

D
ou

gl
as
s
et

al
.(
20
07
)

U
K

•
H
al
ft
he

pa
rt
ic
ip
an
ts
re
po

rt
ed

im
pr
ov
em

en
ts

in
an
xi
et
y

sc
or
es

at
PT

•
Si
g
lo
w
er

se
lf-
re
po

rt
ed

an
xi
et
y
(G

A
S-
ID
)

or
2
pa
rt
ic
ip
an
ts

•
Sl
ig
ht

in
cr
ea
se
s
in

se
lf-
re
po

rt
ed

an
xi
et
y

(G
A
S-
ID
)
fo
r
3
pa
rt
ic
ip
an
ts

•
A
ll
pa
rt
ic
ip
an
ts
re
po

rt
ed

le
ar
ni
ng

ne
w

w
ay
s

of
co
pi
ng

w
ith

th
ei
r
an
xi
et
y
at

PT
•

N
o
at
tr
iti
on

•
G
ro
up

m
ea
n
of

an
xi
et
y

re
du
ce
d

fr
om

BL
(M

=
2
5
.5
0
,S
D
=
3
.0
4
)
to

PT
(M

=
2
1
.8
3
,S
D
=
7
.3
8
)§

•
D
id

no
t
ad
eq
ua
te
ly
de
sc
ri
be

th
e
in
te
rv
en
tio

n
•

D
id

no
t
ve
ri
fy
th
e
ID

of
al
lp

ar
tic
ip
an
ts
,l
ev
el
s

of
ID

w
er
e
de
te
rm

in
ed

by
cl
in
ic
al
ju
dg
em

en
t

•
A
nx
ie
ty

di
so
rd
er

w
as

no
t

fo
rm

al
ly
di
ag
no

se
d

•
N
o
fo
llo
w
-u
p
da
ta

•
La
ck

of
m
ul
tip

le
-b
as
el
in
es

1.
C
le
ar

ob
je
ct
iv
es

2.
C
le
ar

el
ig
ib
ili
ty

cr
ite

ri
a

3.
R
ep
re
se
nt
at
iv
e
pa
rt
ic
ip
an
ts

4.
A
ll
el
ig
ib
le
pe
rs
on

s
en
ro
lle
d

5.
Su
ffi
ci
en
t
sa
m
pl
e
si
ze

6.
In
te
rv
en
tio

n
7.

O
M

de
fi
ne
d,

va
lid
,r
el
ia
bl
e

8.
A
ss
es
so
r
bl
in
di
ng

9.
Fo

llo
w
-u
p
20
%
or

le
ss
?

10
.S
ta
tis
tic
al
an
al
ys
is

11
.M

ul
tip

le
O
M

12
.I
nd
iv
id
ua
l-l
ev
el
ou

tc
om

e
fo
r
gr
ou

p-
le
ve
li
nt
en
tio

ns
Q
ua
lit
y
ra
tin

Y Y Y Y N N Y N Y N N N
/A

Po
or

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

826

T
ab

le
3.

(C
on
tin

ue
d)

R
ef
er
en

ce
an

d
co

un
tr
y

M
ai
n
fi
nd

in
gs

†
L
im

it
at
io
ns

M
et
ho

do
lo
gi
ca

lq
ua

lit
y‡

(G
ia
nn
ak
i&

H
ew

itt
20
21
)

U
K

•
A
ll
fo
ur

pa
rt
ic
ip
an
ts
ex
pe
ri
en
ce
d

si
g
re
du
ct
io
ns

in
an
xi
et
y
fr
om

BL
to

PT
(P

<
.0
5
);

th
es
e
ga
in
s
re
m
ai
ne
d
la
rg
el
y

at
fo
llo
w
-u
p.

•
T
he

gr
ou

p
m
ea
n
fo
r

an
xi
et
y
re
du
ce
d
fr
om

BL
(M

=
2
5
.3
,S
D
=
5
.9
0
)
to

PT
(M

=
1
3
,S
D
=
3
.8
2
).

•
T
he

ov
er
al
ll
ev
el
of

di
st
re
ss

w
as

re
du
ce
d
w
he
re
as

th
e
ov
er
al
ll
ev
el
of

gl
ob

al
fu
nc
tio

ni
ng

in
th
e
gr
ou

p
w
as

en
ha
nc
ed

in
th
e
gr
ou

p
at

PT
co
m
pa
re
d
w
ith

BL
.

•
N
o
at
tr
iti
on

•
Sm

al
ls
am

pl
e
si
ze
,n

o
co
nt
ro
l

gr
ou

p,
th
er
eb
y
re
du
ci
ng

th
e

re
lia
bi
lit
y
an
d

ge
ne
ra
lis
ab
ili
ty

of
th
e
st
ud
y

•
N
o
fo
rm

al
di
ag
no

si
s

an
xi
et
y

re
qu
ir
ed

fo
r
pa
rt
ic
ip
at
io
n

•
La
ck

of
co
ns
is
te
nc
y
in

th
e

pr
oc
ed
ur
es

(e
.g
.o

ne
pa
rt
ic
ip
an
t

jo
in
ed

th
e
gr
ou

p
in

th
e
fo
ur
th

w
ee
k)

1.
C
le
ar

ob
je
ct
iv
es

2.
C
le
ar

el
ig
ib
ili
ty

cr
ite

ri
a

3.
R
ep
re
se
nt
at
iv
e
pa
rt
ic
ip
an
ts

4.
A
ll
el
ig
ib
le
pe
rs
on

s
en
ro
lle
d

5.
Su
ffi
ci
en
t
sa
m
pl
e
si
ze

6.
In
te
rv
en
tio

n
7.

O
M

de
fi
ne
d,

va
lid
,r
el
ia
bl
e

8.
A
ss
es
so
r
bl
in
di
ng

9.
Fo

llo
w
-u
p
20
%
or

le
ss
?

10
.S
ta
tis
tic
al
an
al
ys
is

11
.M

ul
tip

le
O
M

12
.I
nd
iv
id
ua
l-l
ev
el
ou

tc
om

e
fo
r
gr
ou

p-
le
ve
li
nt
en
tio

ns
Q
ua
lit
y
ra
tin

Y Y Y N
R

N C
D

Y N Y Y N N
/A

Fa
ir

M
ar
w
oo

d
an
d
H
ew

itt
(2
01
3)

U
K

•
Si
g
re
du
ct
io
n
in

se
lf-
re
po

rt
ed

an
xi
et
y

(G
A
S-
ID
)
fo
r
2
pa
rt
ic
ip
an
ts
.

•
Im

pr
ov
em

en
ts
in

th
e
gr
ou

p
m
ea
ns

in
an
xi
et
y
fr
om

BL
(M

=
2
6
.8
8
,S
D
=
7
.2
5
)
to

PT
(M

=
2
3
.3
8
,S
D
=
7
.4
2
)§
.

•
Im

pr
ov
em

en
ts
in

gr
ou

p
m
ea
ns

in
gl
ob

al
fu
nc
tio

ni
ng

an
d
qu
al
ity

of
lif
e
w
er
e

ob
se
rv
ed

fr
om

BL
to

PT
.

•
So
m
e
pa
rt
ic
ip
an
ts

ha
d
co
m
or
bi
di
tie

s
(a
ut
is
m

sp
ec
tr
um

di
so
rd
er

an
d
de
pr
es
si
on

)
•

C
lin
ic
al
cu
t-
of
fs

fo
r
an
xi
et
y

w
er
e
no

t
pr
ed
et
er
m
in
ed

fo
r
el
ig
ib
ili
ty

•
Sm

al
ls
am

pl
e
si
ze
,

po
te
nt
ia
lly

lim
iti
ng

th
e

ge
ne
ra
lis
ab
ili
ty

of
th
e
st
ud
y

•
N
o
fo
llo
w
-u
p
da
ta

1.
C
le
ar

ob
je
ct
iv
es

2.
C
le
ar

el
ig
ib
ili
ty

cr
ite

ri
a

3.
R
ep
re
se
nt
at
iv
e
pa
rt
ic
ip
an
ts

4.
A
ll
el
ig
ib
le
pe
rs
on

s
en
ro
lle
d

5.
Su
ffi
ci
en
t
sa
m
pl
e
si
ze

6.
In
te
rv
en
tio

n
7.

O
M

de
fi
ne
d,

va
lid
,r
el
ia
bl
e

8.
A
ss
es
so
r
bl
in
di
ng

9.
Fo

llo
w
-u
p
20
%
or

le
ss
?

10
.S
ta
tis
tic
al
an
al
ys
is

11
.M

ul
tip

le
O
M

12
.I
nd
iv
id
ua
l-l
ev
el
ou

tc
om

e
fo
r
gr
ou

p-
le
ve
li
nt
en
tio

ns
Q
ua
lit
y
ra
tin

Y N Y C
D

N Y Y N Y N N N
/A

Po
or

R
ob

er
ts
&
K
w
an

(2
01
8)

A
U
S

•
Si
g
re
du
ct
io
n
in

th
e
pr
op

or
tio

n
of

pa
rt
ic
ip
an
ts
di
ag
no

se
d

as
cl
in
ic
al
ly
an
xi
ou

s
fr
om

BL
to

PT
(7
6
.9
%
–
7
.7
%
).

•
N
o
fo
llo
w
-u
p
ou

tc
om

e
da
ta

•
A
si
ng
le
cl
in
ic
al
ad
m
in
ist
er
ed

th
e

cl
in
ic
al
as
se
ss
m
en
ts
at

BL
an
d
PT

w
ho

w
as

no
t

bl
in
de
d
to

th
e
co
nd
iti
on

1.
C
le
ar

ob
je
ct
iv
es

2.
C
le
ar

el
ig
ib
ili
ty

cr
ite

ri
a

3.
R
ep
re
se
nt
at
iv
e
pa
rt
ic
ip
an
ts

4.
A
ll
el
ig
ib
le
pe
rs
on

s
en
ro
lle
d

5.
Su
ffi
ci
en
t
sa
m
pl
e
si
ze

Y Y Y N
R

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

827

T
ab

le
3.

(C
on
tin

ue
d)

R
ef
er
en

ce
an

d
co

un
tr
y

M
ai
n
fi
nd

in
gs

†
L
im

it
at
io
ns

M
et
ho

do
lo
gi
ca

lq
ua

lit
y‡

•
1
1
pa
rt
ic
ip
an
ts
no

lo
ng
er

m
et

cr
ite

ri
a
fo
r
th
ei
r
pr
im
ar
y

an
xi
et
y
di
ag
no

si
s
at

PT
.

•
Si
g
re
du
ct
io
ns

in
an
xi
et
y

(G
A
S-
ID
)
w
er
e
fo
un
d

fo
r
se
lf-
re
po

rt
(z

=
�3

.0
6
,

P
<

.0
1
)
an
d

in
fo
rm

an
t-
re
po

rt
(z

=
�2

.4
9
,

P
=
.0
1
)
fo
llo
w
in
g

th
e
in
te
rv
en
tio

n.
Bo

th
th
e

ef
fe
ct

si
ze
s
w
er
e
m
od

er
at
e

(r
=
.6
0
fo
r
se
lf-
ra
tin

g
an
d
r
=
.4
9

fo
r
in
fo
rm

an
t
ra
tin

gs
).

•
La
ck

of
m
ul
tip

le
ba
se
lin
es

an
d
a
co
nt
ro
lg
ro
up

6.
In
te
rv
en
tio

n
7.

O
M

de
fi
ne
d,

va
lid
,r
el
ia
bl
e

8.
A
ss
es
so
r
bl
in
di
ng

9.
Fo

llo
w
-u
p
20
%
or

le
ss
?

10
.S
ta
tis
tic
al
an
al
ys
is

11
.M

ul
tip

le
O
M

12
.I
nd
iv
id
ua
l-l
ev
el
ou

tc
om

e
fo
r
gr
ou

p-
le
ve
li
nt
en
tio

ns
Q
ua
lit
y
ra
tin

Y Y N N
R

Y N N
/A

Fa
ir

†

T
he

ou
tc
om

e
m
ea
su
re
s
pr
ov
id
e
ba
se
lin
e
an
d
po

st
-t
re
at
m
en
t
da
ta
.

‡

T
he

m
et
ho

do
lo
gi
ca
lq

ua
lit
y
of

st
ud
ie
s
w
as

as
se
ss
ed

us
in
g
th
e
N
IH

Q
ua
lit
y
A
ss
es
sm

en
t
T
oo

lf
or

Be
fo
re
-A
fte

r
(P
re
-P
os
t)
St
ud
ie
s
W

ith
N
o
C
on

tr
ol

G
ro
up
.1

.C
le
ar

ob
je
ct
iv
es

=
1.

W
as

th
e
st
ud
y
qu
es
tio

n
or

ob
je
ct
iv
e
cl
ea
rl
y
st
at
ed
?;
2.

C
le
ar

el
ig
ib
ili
ty

cr
ite

ri
a
=
W

er
e
el
ig
ib
ili
ty
/s
el
ec
tio

n
cr
ite

ri
a
fo
r
th
e
st
ud
y
po

pu
la
tio

n
pr
es
pe
ci
fi
ed

an
d
cl
ea
rl
y
de
sc
ri
be
d?
;3

.R
ep
re
se
nt
at
iv
e
pa
rt
ic
ip
an
ts

=
W

er
e
th
e
pa
rt
ic
ip
an
ts

in
th
e

st
ud
y
re
pr
es
en
ta
tiv
e
of

th
os
e
w
ho

w
ou

ld
be

el
ig
ib
le
fo
r
th
e
te
st
/s
er
vi
ce
/in
te
rv
en
tio

n
in

th
e
ge
ne
ra
lo

r
cl
in
ic
al
po

pu
la
tio

n
of

in
te
re
st
?;
4.

A
ll
el
ig
ib
le
pe
rs
on

s
en
ro
lle
d
=
W

er
e
al
le
lig
ib
le
pa
rt
ic
ip
an
ts

th
at

m
et

th
e

pr
es
pe
ci
fi
ed

en
tr
y
cr
ite

ri
a
en
ro
lle
d?
;5
.S
uf
fi
ci
en
ts
am

pl
e
si
ze

=
W

as
th
e
sa
m
pl
e
si
ze

su
ffi
ci
en
tly

la
rg
e
to

pr
ov
id
e
co
nfi
de
nc
e
in
th
e
fi
nd
in
gs
?;
6.
In
te
rv
en
tio

n
=
W

as
th
e
te
st
/s
er
vi
ce
/in
te
rv
en
tio

n
cl
ea
rl
y
de
sc
ri
be
d
an
d

de
liv
er
ed

co
ns
is
te
nt
ly
ac
ro
ss
th
e
st
ud
y
po

pu
la
tio

n?
;7

=
O
M

de
fi
ne
d,
va
lid
,r
el
ia
bl
e
=
W

er
e
th
e
ou

tc
om

e
m
ea
su
re
s
pr
es
pe
ci
fi
ed
,c
le
ar
ly
de
fi
ne
d,
va
lid
,r
el
ia
bl
e,
an
d
as
se
ss
ed

co
ns
is
te
nt
ly
ac
ro
ss
al
ls
tu
dy

pa
rt
ic
ip
an
ts
?;

8.
A
ss
es
so
r
bl
in
di
ng

=
W

er
e
th
e
pe
op

le
as
se
ss
in
g
th
e
ou

tc
om

es
bl
in
de
d
to

th
e
pa
rt
ic
ip
an
ts
’e
xp
os
ur
es
/in
te
rv
en
tio

ns
?;
9.
Fo

llo
w
-u
p
20
%
or

le
ss
?=

W
as

th
e
lo
ss
to

fo
llo
w
-u
p
af
te
r
ba
se
lin
e
20
%
or

le
ss
?W

er
e
th
os
e

lo
st
to

fo
llo
w
-u
p
ac
co
un
te
d
fo
r
in

th
e
an
al
ys
is
?;
10
.S
ta
tis
tic
al
an
al
ys
is
=
D
id
th
e
st
at
is
tic
al
m
et
ho

ds
ex
am

in
e
ch
an
ge
s
in

ou
tc
om

e
m
ea
su
re
s
fr
om

be
fo
re

to
af
te
r
th
e
in
te
rv
en
tio

n?
W

er
e
st
at
is
tic
al
te
st
s
do

ne
th
at

pr
ov
id
ed

p
va
lu
es

fo
r
th
e
pr
e-
to
-p
os
t
ch
an
ge
s?
;1

1.
M
ul
tip

le
O
M

=
W

er
e
ou

tc
om

e
m
ea
su
re
s
of

in
te
re
st

ta
ke
n
m
ul
tip

le
tim

es
be
fo
re

th
e
in
te
rv
en
tio

n
an
d
m
ul
tip

le
tim

es
af
te
r
th
e
in
te
rv
en
tio

n
(…

)?
;1

2.
In
di
vi
du
al
-le

ve
lo

ut
co
m
e
fo
r
gr
ou

p-
le
ve
li
nt
en
tio

n
=
If
th
e
in
te
rv
en
tio

n
w
as

co
nd
uc
te
d
at

a
gr
ou

p
le
ve
l(
…
)
di
d
th
e
st
at
is
tic
al
an
al
ys
is
ta
ke

in
to

ac
co
un
t
th
e
us
e
of

in
di
vi
du
al
-le

ve
ld

at
a
to

de
te
rm

in
e
ef
fe
ct
s
at

th
e

gr
ou

p
le
ve
l?

§ A
n
es
tim

at
e
w
as

ca
lc
ul
at
ed

fo
r
th
e
gr
ou

p
m
ea
n
an
d
st
an
da
rd

de
vi
at
io
n.

N
ot
e:
G
A
S-
ID
,G

la
sg
ow

A
nx
ie
ty

Sc
al
e
fo
r
pe
op

le
w
ith

an
In
te
lle
ct
ua
lD

is
ab
ili
ty
(M

in
dh
am

&
Es
pi
e
20
03

);
H
oN

O
S-
LD

H
ea
lth

of
th
e
N
at
io
n
Br
ie
fO

ut
co
m
e
M
ea
su
re

fo
r
Pe
op

le
w
ith

Le
ar
ni
ng

is
ab
ili
tie

s
an
d
M
en
ta
l

H
ea
lth

N
ee
ds

(R
oy

et
al
.2

00
2)
;P

A
S-
A
D
D
,P

sy
ch
ia
tr
ic
A
ss
es
sm

en
t
Sc
he
du
le

fo
r
A
du
lts

w
ith

D
ev
el
op

m
en
ta
lD

is
ab
ili
tie

s
(M

os
s
&
Fr
ie
dl
an
de
r
20
11

);
Q
oL

,Q
ua
lit
y
of

Li
fe

Sc
al
e
(A
nd
re
w
s
&
W

ith
ey

19
76

).
A
U
S,
A
us
tr
al
ia
;B

L,
ba
se
lin
e;
C
BT

,c
og
ni
tiv
e
be
ha
vi
ou

ra
lt
he
ra
py
;C

D
,c
an
no

td
et
er
m
in
e;
M
,g
ro
up

m
ea
n;
N
,n
o;
N
,n
um

be
r
of

pa
rt
ic
ip
an
ts
;N

/A
,n
ot

ap
pl
ic
ab
le
;N

R
,n
ot

re
po

rt
ed
;O

M
,o

ut
co
m
e
m
ea
su
re
;P
T
,p
os
t-

tr
ea
tm

en
t;
SD

,s
ta
nd
ar
d
de
vi
at
io
n;

si
g,
si
gn
ifi
ca
nt
;s
ig
,s
ig
ni
fi
ca
nt
;U

K
,U

ni
te
d
K
in
gd
om

;Y
,y
es
.

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

Blakeley-Smith et al. 2021), or through health records
(Marwood & Hewitt 2013). Douglass et al. (2007)
reported that the ID of clients was largely determined
based on the clinical judgement of the researchers.
Giannaki and Hewitt (2021) and Carrigan and
Allez (2017) did not clarify how the participants’ level

of ID was determined or verified; however, these
participants had confirmed involvement with a
community ID service provider. Overall, the
majority of participants were recruited by
convenience or were referred by professionals to a
private service.

828

FIGURE 1. PRISMA 2009 flow diagram highlights the exclusion of articles at each search stage

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

829

T
ab

le
4

S
ys
te
m
at
ic

re
vi
ew

su
m
m
ar
y
of

fi
n
d
in
gs

fo
r
C
B
T

fo
r
ad

u
lt
s
w
it
h
P
T
S
D

sy
m
pt
om

s
(n

=
1
)

R
ef
er
en

ce
an

d
co

un
tr
y

St
ud

y/
sa
m
pl
in
g
ch

ar
ac

te
ri
st
ic
s

A
nx

ie
ty

co
nd

it
io
ns

In
te
rv
en

ti
on

de
si
gn

an
d
de

ta
ils

M
ea

su
re
s
us
ed

C
ar
ri
ga
n
an
d

A
lle
z
(2
01
7)

U
K

•
N
=
1
m
al
e,
2
6
ye
ar
s
ol
d

•
M
ild

ID
an
d
A
SD

•

C
as
e
st
ud
y

•
PT

SD
sy
m
pt
om

s
•

C
as
e
st
ud
y

•
T
ra
um

a-
fo
cu
se
d
C
BT

w
ith

el
em

en
ts
of

co
gn
iti
ve

th
er
ap
y

ba
se
d
on

th
e
ap
pr
oa
ch

by
(E
hl
er
s
et

al
.2

0
0
5
)

•
1
2
×
6
0
m
in

se
ss
io
ns

ov
er

1
2
w
ee
ks

•
In
di
vi
du
al
se
ss
io
ns
,f
ac
e-
to

fa
ce

in
th
e
co
m
m
un
ity

•
C
lin
ic
ia
n
w
as

a
cl
in
ic
al
ps
yc
ho

lo
gi
st

•
C
R
IE
S-
8
w
hi
ch

is
a

se
lf-
re
po

rt
m
ea
su
re

of
in
tr
us
io
ns

an
d
av
oi
da
nc
e

R
ef
er
en

ce
an

d
co

un
tr
y

M
ai
n
fi
nd

in
gs

†
L
im

it
at
io
ns

M
et
ho

do
lo
gi
ca

lq
ua

lit
y‡

C
ar
ri
ga
n
an
d
A
lle
z
(2
01
7)

U
K

•
T
he

C
R
IE
S-
8
sc
or
e

re
du
ce
d
fr
om

3
2
to

1
1
,

w
hi
ch

w
as

be
lo
w

th
e

cl
in
ic
al
cu
t
of
fo

f1
7
(Y
ul
e
1
9
9
2
).

•
Pa
rt
ic
ip
an
t
an
d
hi
s

pa
re
nt

re
po

rt
ed

im
pr
ov
em

en
ts
in

PT
SD

sy
m
pt
om

•
N
o
fo
rm

al
di
ag
no

si
s
of

ID
,

un
cl
ea
r
w
he
th
er

do
cu
m
en
ta
tio

n
w
as

si
gh
te
d
to

co
nfi
rm

di
ag
no

si
s

•
A
br
ie
fs
cr
ee
ni
ng

to
ol

de
ve
lo
pe
d
fo
r
th
e
ge
ne
ra
l

po
pu
la
tio

n
w
as

us
ed

to
as
se
ss

PT
SD

sy
m
pt
om

s,
an
d
th
er
ef
or
e
m
ay

be
su
bj
ec
t

to
m
ea
su
re
m
en
t
er
ro
r

•
La
ck

of
m
ul
tip

le
ba
se
lin
es

•
N
o
fo
llo
w
-u
p
da
ta

1.
C
le
ar

st
ud
y
qu
es
tio

n
2.

C
le
ar

ca
se

de
fi
ni
tio

n
3.

C
on

se
cu
tiv
e
ca
se
s

4.
C
om

pa
ra
bl
e
su
bj
ec
ts

5.
C
le
ar

in
te
rv
en
tio

n
6.

O
M

de
fi
ne
d,

va
lid

&
re
lia
bl
e

7.
A
de
qu
at
e
fo
llo
w
-u
p
le
ng
th

St
at
is
tic
al
m
et
ho

ds
w
el
l-d

es
cr
ib
ed

9.
R
es
ul
ts

w
el
l-d

es
cr
ib
ed

Q
ua
lit
y
ra
tin

Y Y N
/A

N
/A Y N Y N
/A Y

Po
or

†

T
he

ou
tc
om

e
m
ea
su
re
s
pr
ov
id
e
ba
se
lin
e
an
d
po

st
-t
re
at
m
en
t
da
ta
.

‡

T
he

m
et
ho

do
lo
gi
ca
lq

ua
lit
y
of

st
ud
ie
s
w
as

as
se
ss
ed

us
in
g
th
e
N
IH

Q
ua
lit
y
A
ss
es
sm

en
t
of

C
as
e
Se
ri
es

St
ud
ie
s.
1.

C
le
ar

st
ud
y
qu
es
tio

n
=
W

as
th
e
st
ud
y
qu
es
tio

n
or

ob
je
ct
iv
e
cl
ea
rl
y
st
at
ed
?;
2.

C
le
ar

ca
se

de
fi
ni
tio

n
=
W

as
th
e
st
ud
y
po

pu
la
tio

n
cl
ea
rl
y
an
d
fu
lly

de
sc
ri
be
d,

in
cl
ud
in
g
a
ca
se

de
fi
ni
tio

n?
;3

se
cu
tiv
e
ca
se
s
=
W

er
e
th
e
ca
se
s
co
ns
ec
ut
iv
e?
;4

om
pa
ra
bl
e
su
bj
ec
ts
=
W

er
e
th
e
su
bj
ec
ts

co
m
pa
ra
bl
e?
;5

le
ar

in
te
rv
en
tio

n
=
W

as
th
e
in
te
rv
en
tio

n
cl
ea
rl
y
de
sc
ri
be
d?
;6

M
de
fi
ne
d,
va
lid

&
re
lia
bl
e
=
W

er
e
th
e
ou

tc
om

e
m
ea
su
re
s
cl
ea
rl
y
de
fi
ne
d,

va
lid
,r
el
ia
bl
e,
an
d
im
pl
em

en
te
d
co
ns
is
te
nt
ly
ac
ro
ss

al
ls
tu
dy

pa
rt
ic
ip
an
ts
?;
7.

A
de
qu
at
e
fo
llo
w
-u
p
le
ng
th

=
W

as
th
e
le
ng
th

of
fo
llo
w
-u
p
ad
eq
ua
te
?;
8.

St
at
is
tic
al
m
et
ho

ds
w
el
l-d

es
cr
ib
ed

=
W

er
e
th
e
st
at
is
tic
al
m
et
ho

ds
w
el
l-d

es
cr
ib
ed
?;
9.

R
es
ul
ts

w
el
l-d

es
cr
ib
ed

=
W

er
e
th
e
re
su
lts

w
el
l-

de
sc
ri
be
d?

N
ot
e:
C
R
IE
S-
8,

R
ev
is
ed

C
hi
ld

Im
pa
ct

of
Ev
en
ts

Sc
al
e
(S
m
ith

et
al
.2

00
3)
.

BL
,b
as
el
in
e;
C
BT

,c
og
ni
tiv
e
be
ha
vi
ou

ra
lt
he
ra
py
;C

D
,c
an
no

td
et
er
m
in
e;
M
,g
ro
up

m
ea
n;
m
in
,m

in
ut
es
;N

,n
o;

N
,n
um

be
r
of

pa
rt
ic
ip
an
ts
;N

/A
,n
ot

ap
pl
ic
ab
le
;N

R
,n
ot

re
po

rt
ed
;O

M
,o

ut
co
m
e
m
ea
su
re
;P
T
,p
os
t-

tr
ea
tm

en
t;
SD

,s
ta
nd
ar
d
de
vi
at
io
n;

si
g,
si
gn
ifi
ca
nt
;s
ig
,s
ig
ni
fi
ca
nt
;U

K
,U

ni
te
d
K
in
gd
om

;Y
,y
es
.

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

830

T
ab

le
5

S
ys
te
m
at
ic

re
vi
ew

su
m
m
ar
y
of

fi
n
d
in
gs

fo
r
C
B
T

fo
r
ad

u
lt
s
w
it
h
n
on

-s
pe

ci
fi
ed

an
xi
et
y
(n

=
2
)

R
ef
er
en

ce
an

d
co

un
tr
y

St
ud

y/
sa
m
pl
in
g
ch

ar
ac

te
ri
st
ic
s

A
nx

ie
ty

co
nd

it
io
ns

In
te
rv
en

ti
on

de
si
gn

an
d
de

ta
ils

M
ea

su
re
s
us
ed

Li
nd
sa
y
et

al
.(
19
97

)

U
K

•
N
=
2
,1
9
an
d
2
7
ye
ar
-o
ld

m
al
es

•
M
ild

in
te
lle
ct
ua
ld

is
ab
ili
ty

(IQ
=
6
6
–
6
7
)

•
El
ev
at
ed

le
ve
ls
of

de
pr
es
si
on

fo
r
1
pa
rt
ic
ip
an
t

•

N
on

-s
pe
ci
fi
ed

an
xi
et
y

(e
le
va
te
d
le
ve
ls
of

an
xi
et
y)

•
C
as
e
se
ri
es

•
In
di
vi
du
al
co
gn
iti
ve

fo
r
an
xi
et
y

fo
r
ad
ul
ts
,b

as
ed

up
on

Be
ck

et
al
.’s

(1
9
7
9
)
m
an
ua
l

•
Pa
rt
ic
ip
an
t
1
:4

1
in
di
vi
du
al

se
ss
io
ns

ov
er

1
-y
ea
r
ta
rg
et
ed

an
xi
et
y

•
Pa
rt
ic
ip
an
t
2
:1
4
se
ss
io
ns

ov
er

1
4
w
ee
ks

•
Fo

llo
w
-u
p
at

3
–
an
d
6
-m

on
th
s
PT

fo
r
ea
ch

pa
rt
ic
ip
an
t
re
sp
ec
tiv
el
y

•
BA

I,
a
se
lf-
re
po

rt
m
ea
su
re

of
an
xi
et
y.

•
BD

I,
a
se
lf-
re
po

rt
m
ea
su
re

of
de
pr
es
si
on

St
ua
rt

et
al
.(
20
14

)

U
K

•
N
=
1
fe
m
al
e,
4
0
ye
ar
s
ol
d

•
M
ild

ID
•

A
nx
io
us

an
d
de
pr
es
si
ve

sy
m
pt
om

s
•

Pa
rt
ic
ip
an
t
w
as

re
fe
rr
ed

fr
om

th
ei
r
G
P
to

th
e
C
LD

•
N
on

-s
pe
ci
fi
ed

an
xi
et
y

•
C
as
e
st
ud
y

•
Be

ha
vi
ou

ra
lly

fo
cu
se
d
in
di
vi
du
al
C
BT

•
7
se
ss
io
ns

ov
er

1
2
w
ee
ks

(t
he

du
ra
tio

n
of

se
ss
io
ns

w
as

no
t
re
po

rt
ed
)

•
G
A
S-
ID

se
lf-
re
po

rt
m
ea
su
re

an
xi
et
y

•
G
D
S-
LD

,s
el
f-r
ep
or
t

m
ea
su
re

of
de
pr
es
si
on

R
ef
er
en

ce
an

d
co

un
tr
y

M
ai
n
fi
nd

in
gs

†
L
im

it
at
io
ns

M
et
ho

do
lo
gi
ca

lq
ua

lit
y‡

Li
nd
sa
y
et

al
.(
19
97
)

U
K

•
Si
g
re
du
ct
io
ns

in
an
xi
et
y
fo
r
bo

th
pa
rt
ic
ip
an
ts
;t
he
ir
BA

Is
co
re

re
du
ce
d

fr
om

ve
ry

hi
gh

le
ve
ls
at

BL
to

to
le
ra
bl
e

or
no

rm
al
le
ve
ls
at

PT
.G

ai
ns

w
er
e

m
ai
nt
ai
ne
d
at

fo
llo
w
-u
p
(3
–
6
m
on

th
s

af
te
r
PT

).
•

A
si
g
re
du
ct
io
n
in

an
xi
et
y-
re
la
te
d

co
gn
iti
on

s
w
as

ob
se
rv
ed
.

•
A
si
g
im
pr
ov
em

en
t
in

de
pr
es
si
on

se
ve
ri
ty

w
as

al
so

ob
se
rv
ed

fo
r
on

e
pa
rt
ic
ip
an
t.

•
N
o
fo
rm

al
di
ag
no

si
s
of

an
xi
et
y

•
D
id

no
t
re
po

rt
on

th
e
le
ve
lo

fI
D

•
D
id

no
t
re
po

rt
on

th
e
le
ve
lo

f
tr
ai
ni
ng

of
th
e
fa
ci
lit
at
or
s

1.
C
le
ar

st
ud
y
qu
es
tio

n
2.

C
le
ar

ca
se

de
fi
ni
tio

n
3.

C
on

se
cu
tiv
e
ca
se
s

4.
C
om

pa
ra
bl
e
su
bj
ec
ts

5.
C
le
ar

in
te
rv
en
tio

n
6.

O
M

de
fi
ne
d,

va
lid

&
re
lia
bl
e

7.
A
de
qu
at
e
fo
llo
w
-u
p
le
ng
th

8.
St
at
is
tic
al
m
et
ho

ds
w
el
l-d

es
cr
ib
ed

9.
R
es
ul
ts

w
el
l-d

es
cr
ib
ed

Q
ua
lit
y
ra
tin

Y N N
R Y Y Y Y N
/A Y

G
oo

d
St
ua
rt

et
al
.(
20
14
)

U
K

•
T
he

an
xi
et
y
se
ve
ri
ty

sc
or
e
re
du
ce
d

fr
om

BL
to

PT
;h

ow
ev
er
,i
t
w
as

st
ill
ab
ov
e

th
e
cl
in
ic
al
cu
t-
of
fp

oi
nt

at
PT

.
•

T
he

de
pr
es
si
on

se
ve
ri
ty

sc
or
e
re
du
ce
d

fr
om

BL
to

PT
;h

ow
ev
er
,i
t
w
as

st
ill

ab
ov
e
th
e
cl
in
ic
al
cu
t-
of
fp

oi
nt

at
PT

•
In
su
ffi
ci
en
t
de
ta
il
re
ga
rd
in
g
th
e

tr
ea
tm

en
t
co

m
po

ne
nt
s

w
as

pr
ov
id
ed

•
T
he
re

w
as

no
fo
llo
w
-u
p
ou

tc
om

e
da
ta

•
La
ck

of
m
ul
tip

le
ba
se
lin
e

•
N
o
fo
rm

al
di
ag
no

si
s
of

an
xi
et
y

1.
C
le
ar

st
ud
y
qu
es
tio

n
2.

C
le
ar

ca
se

de
fi
ni
tio

n
3.

C
on

se
cu
tiv
e
ca
se
s

4.
C
om

pa
ra
bl
e
su
bj
ec
ts

5.
C
le
ar

in
te
rv
en
tio

n
6.

O
M

de
fi
ne
d,

va
lid

&
re
lia
bl
e

7.
A
de
qu
at
e
fo
llo
w
-u
p
le
ng
th

Y Y N
/A

N
/A

Y Y N

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

Elevated anxiety symptoms were largely
determined using predetermined clinical cut-offs on
standardised measures of anxiety symptomatology.
One study reported that eligible participants
demonstrated ‘anxiety issues’ in need of
management, but did not elaborate on how this was
determined (Marwood & Hewitt 2013). Two studies
utilised a clinical diagnostic interview to determine
anxiety diagnoses (Phillips & Klein-Tasman 2009;
Roberts & Kwan 2018). Participants presented with a
variety of anxious symptoms that were often
associated with generalised anxiety, specific phobia
and social anxiety.

Methodological quality

Tables 2–5 demonstrate the study strengths and
weaknesses of the included studies, based on the NIH
quality assessment tools. As can be seen in
Tables 2–5, overall, two studies were classified as
‘good’, three studies were rated as ‘fair’ and four
studies were rated as ‘poor’ on the overall quality
ratings. Methodological strengths of the reviewed
studies included the following: low attrition rates
[80% (n = 4 out of 5) of pre–post studies];
representative samples [100% (n = 5 out of 5)]; clear
study objectives [100% (n = 9 out of 9) of all studies];
and clear selection criteria for participants [80%
(n = 4 out of 5)]. Sixty per cent of studies (n = 3 out of
5) included appropriate statistical analyses.
Weaknesses of the reviewed studies included the
following: lack of multiple baseline [0% (n = 5 out of
5)] and lack of blinded assessors [0% (n = 5 out of 5)].

Cognitive behavioural therapy delivery

Table 6 summarises the main features of each of the
reviewed studies, such as therapy format (individual
or group therapy), participant characteristics (e.g. age
and ID levels), CBT treatment components utilised
and types of modifications made. The reviewed
studies used CBT interventions that ranged from 6 to
41 sessions in total, with a duration of 1–2 h per
session. As can be seen from Table 6, four studies
utilised individual CBT sessions, and the remaining
five adopted a group-based CBT delivery. The group
interventions included compulsory or optional
support persons in therapy. All interventions were
facilitated by a therapist. The qualifications of the
therapist varied across studies and included registered

831

T
ab

le
5.

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or

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t
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St
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=
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es
.

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

832

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is
ab
ili
ty
.

Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

clinical psychologists (Carrigan & Allez 2017),
assistant or trainee psychologists (Douglass
et al. 2007; Marwood & Hewitt 2013; Stuart
et al. 2014; Giannaki & Hewitt 2021), learning
disability nurses and occupational therapists
(Douglass et al. 2007). Four studies did not specify
the qualifications or training of the therapists (Lindsay
et al. 1997; Phillips & Klein-Tasman 2009; Roberts &
Kwan 2018; Blakeley-Smith et al. 2021).

Three studies reported that participants continued
taking prescribed medication for anxiety or comorbid
low mood throughout the study; however, the type
and dose remained consistent for a considerable time
prior and during the intervention (Marwood &
Hewitt 2013; Stuart et al. 2014; Blakeley-Smith
et al. 2021). The remainder of the studies did not
report on medication use.

Child studies

Mixed anxiety

Amongst studies with child participants, one included
participants aged 12–19 years (Phillips & Klein-
Tasman 2009; Blakeley-Smith et al. 2021) and the
other 13 years (Phillips & Klein-Tasman 2009), with
various anxiety disorders and fears (e.g. generalised
anxiety, separation anxiety and specific phobia) (refer
to Table 2). Blakeley-Smith et al. (2021) included
children/adolescents with a comorbid diagnosis of
ASD and Phillips and Klein-Tasman (2009) included
adolescents with comorbid diagnoses of Williams
syndrome, ADHD and oppositional defiant disorder
(ODD; Phillips & Klein-Tasman 2009).

Treatment components and adaptations. Several
components were included across the two studies to
treat various anxiety disorders; these included
psychoeducation, relaxation, exposure, identifying
unhelpful thoughts, thought replacement, cognitive
restructuring and strategies to promote emotion
regulation (refer to Table 6). However, Phillips and
Klein-Tasman (2009) reported that exposure and
cognitive restructuring were not routinely used or
focused on.

Adaptations that were commonly applied across the
two studies to accommodate for the needs of the
children/adolescents included adopting a slower pace,
rehearsing, involving parents in the intervention, and
tailored support for problem behaviours.

Blakeley-Smith et al. (2021) reported that they
adapted the intervention based off stakeholder input
gained through informal focus groups, parent
interviews and treatment acceptability ratings.
Various modifications to the programme included
reducing the length of sessions, having smaller
groups, greater parental involvement in sessions, and
providing information sessions to parents on various
topics (e.g. the difficulty detecting anxiety in
individuals with ID and ASD, and the interplay
between anxiety and problem behaviour). They also
reported including visual supports to teach strategies,
video modelling, hands on activities and
reinforcement of brave behaviour. On the other hand,
Phillips and Klein-Tasman (2009) reported including
techniques to encourage participants to cope with
teasing to assist them with their anxiety in social
situations and strategies to manage oppositional
behaviours and emotional outbursts.

Strategies were tailored to the
children’s/adolescents’ cognitive abilities.
Blakeley-Smith et al. adapted the delivery of strategies
based on the participants’ expressive language ability.
For example, participants with communication
difficulties were provided helpful thoughts (e.g. ‘I can
do this, I’m brave’) with a visual structure instead of
delivering cognitive restructuring (‘fight fear with
facts’). Similarly, Phillips and Klein-Tasman (2009)
delivered more straightforward behavioural strategies,
such as thought replacement (‘adaptive self-
statements’) instead of cognitive restructuring when
participants had difficulties comprehending the
material.

Treatment outcomes. Across the child/adolescent
studies, there were positive results on the effectiveness
of CBT on anxiety. Blakeley-Smith et al. (2021) found
that following the intervention, there were significant
improvements in the group mean of anxiety and
minimal and moderate effect sizes on parent-reported
measures of anxiety [e.g. Anxiety Depression and
Mood Scale (ωp

2 = .45) and the total FSSC-R
(ωp

2 = .20)]. Moreover, there were significant
reductions in the total score and separation anxiety
subscale of the SCARED-P, but not in the other
subscales; they proposed that this may be because
some domains of anxiety (e.g. generalised or social
anxiety) are more difficult for parents to observe,
relying more heavily on a child’s verbalisation of

833
Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

worry. Phillips and Klein-Tasman (2009) also found
improvements in anxiety severity across some
measures whereas others indicated no change or an
exacerbation of symptoms. Following the
intervention, the two participants no longer met the
diagnostic criteria for various anxiety disorders
recognised at pre-treatment; however, some remained
clinical (Phillips & Klein-Tasman 2009).

Additional outcomes. Parent acceptability ratings,
attendance and completion rates indicated that
Blakeley-Smith et al.’s (2021) intervention was
feasible to implement and valued by families. They
also reported a significant reduction in symptoms of
depression (ωp

2 = .23), mood symptoms (ωp
2 = .20)

and lethargy (ωp
2 = .14) in the group following a CBT

intervention, compared with baseline; still, these
effects sizes were only minimal. However, significant
reductions in symptoms of irritability were not
observed, suggesting that problem behaviours were
not impacted by the intervention. Phillips and Klein-
Tasman (2009) also found significant improvements
in emotional–behavioural difficulties, where one
participant no longer met the criteria for ODD
following treatment; however, it should be noted a
considerable portion of the intervention focused on
strategies specifically addressing emotional outbursts.

Adult studies

Generalised anxiety or mixed anxiety

Three studies included adults with diagnoses or
symptoms of generalised anxiety, specific phobia,
social anxiety or OCD (Marwood & Hewitt 2013;
Roberts & Kwan 2018; Giannaki & Hewitt 2021) and
one study included adults experiencing generalised
anxiety (Douglass et al. 2007; refer to Table 3).
Marwood and Hewitt (2013) included adult
participants with comorbid diagnoses of ASD and
depression.

Treatment component and adaptations. Various
treatment components were included across the adult
studies with generalised and mixed anxiety, such as
psychoeducation and relaxation. Other behavioural
strategies, such as distraction and thought
replacement, were reported less (Douglass et al. 2007;
Marwood & Hewitt 2013). While identifying
unhelpful thoughts was a common component, only

one study included cognitive restructuring, whereby
unhelpful thoughts were actively challenged (Roberts
& Kwan 2018). Moreover, only two studies (Douglass
et al. 2007; Roberts & Kwan 2018) incorporated
exposure, providing minimal detail on this
component; it was, however, unclear whether
Douglass et al. (2007) only delivered this component
to one participant.

Various modifications to the interventions for
anxiety were referenced across the adult studies.
Some studies modified treatments based off
recommendations in the literature for adults with ID
(e.g. Whitehouse et al. 2006) or the clinician’s
previous work with the population (Roberts &
Kwan 2018). Common adaptations applied across
studies involved incorporating visual supports,
roleplays, rehearsing strategies, simplifying language
and including a support person. Studies proposed
that including a support person who knew the
participant well, was motivated and consistent was
beneficial to treatment outcomes (Douglass
et al. 2007; Marwood & Hewitt 2013). Other
modifications that were used less included using
games and stories to teach materials, having shorter
sessions, adopting a slower pace and using concrete
examples (Douglass et al. 2007; Giannaki &
Hewitt 2021).

Across studies cognitive components were
modified to cater for a participant’s cognitive
capacity. Roberts and Kwan (2018) incorporated
activities, roleplays and metaphors (e.g. changing red
to green traffic light thoughts) to adapt cognitive
challenging to meet the needs of adults with mild ID.
Individuals with moderate ID benefited from
additional modifications, such as extensive modelling,
rehearsing and prompting. Douglass et al. (2007)
endorsed a flexible approach when delivering
cognitive strategies. When participants had difficulties
identifying negative thoughts, roleplays were offered
(which was of limited benefit) and participants were
encouraged to practise ‘generic coping statements’.

Treatment outcomes. Across the adult studies
examining the effectiveness of CBT for mixed anxiety
presentations, significant reductions in self- and
informant-reported anxiety scores were found.
Giannaki and Hewitt (2021) found that all four
participants in the study demonstrated significant
improvements following treatment, which were

834
Journal of Intellectual Disability Research VOLUME 67 PART 9 SEPTEMBER 2023

G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

largely maintained at follow-up. Correspondingly,
Roberts and Kwan (2018) found moderate effect sizes
for the improvements in self (r = .60) and informant
ratings (r = .49) of anxiety severity for participants
with mild to moderate ID following treatment. They
also found that there was a significant reduction in the
proportion of participants diagnosed with an anxiety
disorder following the intervention (7.7%; n = 1)
compared with that prior to the intervention (7.69%;
n = 10).

However, some studies reported mixed results on
the effectiveness of CBT on anxiety in adults with ID.
For example, Douglass et al. (2007) found a
significant reduction in anxiety for two out of six
participants who presented with borderline–moderate
ID; whereas, slight increases in anxiety were reported
for three out of six participants. Similarly, Marwood
and Hewitt (2013) observed significant reductions in
anxiety for two out of eight participants with mild ID;
however, slight increases in anxiety were observed for
three participants. Marwood and Hewitt (2013)
suggested results may have been impacted by the
sensitivity of the measure used.

Additional outcomes. Studies reported improvements
across additional measures, such as global
functioning, distress, quality of life and mood.
Giannaki and Hewitt (2021) observed significant
improvements in the overall level of distress for most
participants following the intervention, which was
largely maintained at follow-up. In addition,
significant improvements in global functioning were
observed for half of the participants following the
intervention. Marwood and Hewitt (2013) also
observed improvements in the participants’ quality of
life and global functioning following treatment.
Furthermore, the completion rates across studies
indicated that the interventions were well tolerated
(Douglass et al. 2007; Giannaki & Hewitt 2021);
however, two studies did not report on attrition rates
(Marwood & Hewitt 2013; Roberts & Kwan 2018).
Douglass et al. (2007) also found that participants
developed coping skills following the intervention and
that carers developed a greater understanding of the
participants’ difficulties, according to qualitative
feedback.

Studies reported on the participants’ ability to learn
and demonstrate cognitive strategies. Giannaki and
Hewitt (2021) found that during the post-treatment

interviews, no participant demonstrated an
understanding of the impact of unhelpful thoughts on
anxiety; they proposed this reflected an inability to
link thoughts and emotions. Contrastingly, Roberts
and Kwan (2018) found that most participants with
mild ID were able to demonstrate competence with
linking thoughts and emotions and other skills
associated with cognitive restructuring (e.g. gather
evidence on whether a thought is realistic, generate a
more helpful or realistic belief). However, individuals
with moderate ID demonstrated limited or no
competence across most of these skills (besides
identifying unhelpful and helpful thoughts).
Therefore, a participant’s proficiency with cognitive
restructuring appeared to be impacted by their level of
ID.

Post-traumatic stress disorder

Carrigan and Allez (2017) delivered a trauma-focused
CBT intervention to a young man with mild ID and
ASD and symptoms consistent with PTSD (see
Table 4). The intervention incorporated elements of
cognitive therapy for PTSD.

Treatment component and adaptations. Carrigan and
Allez (2017) delivered a CBT intervention for PTSD,
which included psychoeducation on trauma and its
sequelae (using a simplified model), cognitive
restructuring, behavioural experiments and imaginal
reliving. Strategies to address anger outbursts were
also introduced towards the beginning of treatment.
The authors described making only minimal
modifications to cognitive therapy for PTSD. They
found that with careful use of Socratic questioning,
simplifying the language and explaining metaphors,
they were able to help the participant overcome
difficulties with applying abstract concepts to his own
situation and to see alternate viewpoints when
engaging in cognitive restructuring.

Treatment outcomes. There were improvements in the
participants’ symptomatology following the
intervention, whereby the severity of PTSD
symptoms fell within the normal range on a screening
measure (Carrigan & Allez 2017). This corresponded
with qualitative improvements in the participants’
symptomatology (e.g. improved sleep, reduced

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nightmares and avoidance) as reported by the
participant and their parent.

Non-specified anxiety

Two studies (Lindsay et al. 1997; Stuart et al. 2014)
included adult participants with elevated anxiety that
was not specified or diagnosed; these participants also
presented with low mood, which was not formally
assessed (see Table 5).

Treatment components and adaptations. Lindsay
et al. (1997) reported delivering cognitive therapy
based on the treatment by Beck et al. (1979) whereas
Stuart and colleagues described delivering a
behaviourally focused CBT intervention. The
treatment in both studies included various
components which included psychoeducation on the
link between thoughts, feelings and behaviours, and
noticing or identifying unhelpful thoughts. Lindsay
et al.’s (1997) intervention focused on cognitive
strategies, consistent with cognitive restructuring;
whereas Stuart et al. (2014) focused on behavioural
strategies, such as behavioural activation and
relaxation.

Lindsay et al. (1997) and Stuart et al. (2014)
described adopting various modifications, which
included simplifying language, encouraging repetition
and having a more activity-based approach. Lindsay
et al. (1997) also included adaptions to help
participants to elicit thoughts, practise more adaptive
ways of thinking and overcome difficulties with
abstract thought; these included using role plays,
reversing the roles of therapist and client, plotting the
sequence of events leading to anxiety and looking at
photos of anxiety provoking situations (which may
bear some resemblance to exposure practises).

Treatment and additional outcomes. Across the studies
treating non-specified anxiety in adults with ID
(Lindsay et al. 1997; Stuart et al. 2014), participants
demonstrated improvements in the severity of anxiety
and depression. Following intervention, Lindsay
et al. (1997) found that one participant’s symptoms of
anxiety and depression fell within the normal range,
whereas Stuart et al. (2014) observed that the
participants’ anxiety and low mood remained above
the clinical cut-off.

Discussion

This systematic review explored the literature on the
effectiveness of CBT for individuals with ID and
anxiety. It sought to update the field to include more
recent studies and to adopt a more stringent inclusion
criteria to focus on studies that target anxiety (rather
than transdiagnostic groups), thereby providing a
more focused review on anxiety compared with
previous reviews. It was also the first systematic
review to examine the effectiveness of CBT for
children/adolescents with ID and anxiety.

Across the nine studies reviewed, CBT
interventions were found to have a positive effect on
the severity levels of anxiety in children/adolescents
and adults with ID; seven studies reported significant
reductions in anxiety for 25%–100% of participants
(N = 60) following a CBT intervention. These
findings are encouraging; however, in light of the
absence of any control groups and other
methodological shortcomings, the conclusions that
can be drawn are limited. The findings highlight that
CBT for children/adolescents and adults with anxiety
and mild ID may be feasible and tolerable for a variety
of anxiety disorders. Positive outcomes were reported
in line with previous reviews on the effectiveness of
CBT for adults with ID and anxiety or depression
(Unwin et al. 2016; Dagnan et al. 2018). Moreover,
improvements generalised to overall functioning,
general distress levels, quality of life and mood following
the intervention. The results highlight that
children/adolescents with various presentations of
anxiety and comorbidities can tolerate and benefit from
a CBT intervention that is tailored to their cognitive and
behavioural needs. It also highlights the importance of a
flexible approach in the delivery of strategies.

The studies that showed the most promising results
(moderate effect sizes) (Roberts & Kwan 2018;
Blakeley-Smith et al. 2021; Giannaki & Hewitt 2021)
tended to be the more recent and methodologically
rigorous studies, incorporating various cognitive and
behavioural components of CBT and more
modifications. Interestingly, Blakeley-Smith
et al. (2021) and Roberts and Kwan (2018) were the
only studies that routinely delivered exposure and
cognitive restructuring or thought replacement. In
light of the encouraging results, it may indicate the
importance of these components in treating anxiety
for adults and children with anxiety and ID; this is

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G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

consistent with findings in the TD literature that
exposure and cognitive restructuring are key
components in treating anxiety (Kaczkurkin &
Foa 2015). However, additional case studies that
included cognitive techniques (e.g. cognitive
restructuring) in the absence of exposure
demonstrated positive results indicating emerging
evidence for cognitive components for individuals
with mild ID (Lindsay et al. 1997; Carrigan &
Allez 2017). Across the studies, individuals with mild
ID and some with moderate ID appeared to benefit
from learning about the link between thoughts,
feelings and behaviours, strategies to identify
unhelpful thoughts and relaxation strategies to
understand and manage anxiety.

Pleasingly, the components of CBT were adapted
to the needs of participants with ID across all studies.
There was considerable overlap in the adaptations
used across studies, regardless of the participants’ age
or anxiety disorder. Many of the studies reported
utilising adaptations, such as rehearsing techniques,
involving a parent/support person, utilising smaller
groups and adapting language. These modifications
were consistent with the recommendations from the
literature (Hronis et al. 2017). Nevertheless, many of
the included studies lacked sufficient detail regarding
the nature of the modifications, which poses
challenges for the replication and development of
treatment modifications. Moreover, several studies
included modules or strategies in interventions to
accommodate comorbidities, problem behaviours
and difficulties with emotion regulation; this resulted
in significant improvements in behaviours that
challenge in some cases (e.g. Phillips & Klein-
Tasman 2009). Blakeley-Smith et al. (2021) however
proposed that the anxiety intervention was not helpful
in targeting problem behaviour and suggested an
additional module addressing these concerns may be
warranted for some individuals prior to the CBT
anxiety intervention. Therefore, future studies may
benefit from tailoring intervention to the participants’
cognitive capacity, comorbidities and emotion
regulation concerns.

Across the studies, it was apparent that a flexible
approach towards the delivery of cognitive skills was
beneficial to accommodate for the age and the
cognitive capacity of each person. Some
children/adolescents and adults with mild ID (or who

were verbally fluent) were found to effectively engage
with and implement key components of cognitive
restructuring; this included individuals presenting
with a variety of anxiety disorders (e.g. generalised
anxiety, social anxiety and PTSD). The use of
Socratic questioning was found to be important in
facilitating the process of challenging negative
thoughts and generating more helpful thoughts.
Participants with a moderate ID (or emerging
language skills) were often able to identify helpful and
unhelpful thoughts with certain accommodations but
struggled with the use of more conceptual strategies,
such as cognitive restructuring. Participants with a
moderate ID tended to benefit from a more directive
and simplified approach involving the use of thought
replacement, whereby participants reminded
themselves of coping statements. They also benefited
from extensive modelling, rehearsing, prompting and
the use of visual aids, regardless of their age.
Therefore, cognitive strategies, such as cognitive
restructuring, appear to be beneficial and feasible for
children and adolescents with mild ID with the use of
appropriate modifications and a flexible approach.

Strengths of the studies include using measures
that were standardised, valid and reliable, having low
attrition rates, and including participants with
elevated levels of anxiety. In addition, most of the
studies used a measure of anxiety that was developed
for the ID population. However, a number of
limitations were observed. For example, the studies
lacked a control condition and utilised small sample
sizes, which underpowered the results. The majority
of the studies did not include follow-up assessment to
ascertain the long-term maintenance of the
intervention, so this remains uncertain. Most of the
studies relied upon self-report measures, and no
studies included blinded assessors, which increased
the risk of bias. Many studies did not utilise
appropriate statistical analyses or multiple baseline
outcome data, which is important as it allows for
inferences to be made about the effectiveness of an
intervention. Therefore, despite some strengths, there
were considerable methodological limitations across
the studies reviewed, so current conclusions are
preliminary.

The studies included in this review differed across
several domains, which may have affected treatment
outcomes. First, there was variability in the inclusion
criteria for participants across studies, such that some

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anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

studies required a clinical diagnosis of an anxiety
disorder, whereas others required elevated anxiety
symptomatology based on questionnaire data.
Consequently, some studies may have included
participants with subclinical anxiety, resulting in
limited reductions in anxiety due to a floor effect.
Also, the majority of studies relied upon self-report
measures of anxiety, some of which had not been
validated in the ID population (e.g. Carrigan &
Allez 2017). While self-report measures are desirable
in measuring internal states, such as anxiety, the
validity of an individual’s self-report may be impacted
by factors associated with having an ID; these factors
include difficulties with memory, social desirability,
response bias and acquiescence (Willner 2005).
These challenges in assessment may be alleviated in
part by collecting information from multiple
informants; however, only two studies included in this
review adopted this approach (Phillips & Klein-
Tasman 2009; Roberts & Kwan 2018). Therefore,
these methodological and assessment limitations may
have impacted treatment outcomes.

There was also variability across studies in terms of
the delivery of interventions. There was unclear
terminology used in interventions across studies. For
example, some studies reported including the
technique ‘positive self-talk’ (Douglass et al. 2007)
while others referred to ‘helpful thoughts’ (Blakeley-
Smith et al. 2021), ‘adaptive self-statements’(Phillips
& Klein-Tasman 2009) or ‘cognitive challenging’
(Roberts & Kwan 2018). Therefore, the line
delineating between specific techniques was at times
blurred, especially in cases where there was limited
information on the interventions delivered. Finally,
there was variability across studies in terms of the skill
and training of therapists. Some therapists were
trainee psychologists, while others were occupational
therapists, endorsed clinical psychologists, or in some
cases, it was not reported. Therefore, the outcomes of
CBT interventions may have been influenced by the
level of training that practitioners received in CBT
and in working with individuals with ID. Thus, the
studies included have a number of shortcomings and
disparities, which may have impacted the treatment
findings.

Future research may benefit from addressing these
discrepancies and limitations by (1) incorporating
more rigorous methodologies, which include a formal
diagnosis of anxiety and ID; (2) utilising clear and

universally accepted descriptors of interventions
including the treatment components; (3) providing
clear details around the procedural modifications
made to the delivery of CBT; (4) including follow-up
outcome measures and/or multiple outcome data; (5)
collecting information from unbiased assessors and/or
multiple informants; (6) validating and adapting
existing measures of anxiety in the ID population; (7)
exploring what modifications to CBT interventions
are helpful for individuals with varying levels of ID,
particularly through focus groups; (8) utilising
large-scale RCTs to evaluate the effectiveness of CBT
for the ID population and to explore which CBT
components are most effective in treating anxiety and
which adaptations may be necessary for varying levels
of ID; (9) evaluating more flexible interventions that
may be adapted to the verbal competencies of the
participants, as seen in the intervention delivered by
Blakeley-Smith et al. (2021); and (10) developing
evidence-manualised treatments that are tailored to
the needs of individuals with mild or moderate ID.

This systematic review employed rigorous criteria
to identify eligible studies. Eligible studies were
required to present pre- and post-outcome measures
of anxiety and did not include interventions, which
targeted mixed presentations (i.e. conditions other
than anxiety). However, there were several limitations
of this systematic review. First, only studies in English
were considered, and consequently, most studies
were completed in the UK, with some in the USA and
Australia. Therefore, the findings of this review may
have limited generalisability to other regions or cul-
tures. Additionally, the inclusion criteria for the
presence of ID allowed for participants who had been
referred from an ID service provider; therefore, par-
ticipants may have been included that are not truly
representative of people with ID. Furthermore, the
search terms for ID were narrow and may have re-
sulted in some papers examining other related con-
ditions (e.g. Fragile X syndrome) being missed. Most
of the studies included in this review were composed
of participants with a mild ID. Therefore, the findings
of the present review may have limited generalisability
to participants with moderate or severe ID, and even
borderline impaired IQ. Studies were also included
that reported on comorbid ASD diagnosis; it is un-
clear whether the treatment modifications may gen-
eralise to the broader ID population due to the
distinct profile of ASD.

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G. Fynn et al. • The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and
anxiety: a systematic review

Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

The current systematic review explored the
literature on the effectiveness of CBT for anxiety in
individuals with ID, an area that is grossly under-
researched. Findings suggest that CBT is a promising
treatment for individuals with mild ID and anxiety.
Although strong recommendations regarding
treatment effectiveness cannot be made at this time
due to the limited number of studies and
methodological limitations in the research, there is
tentative evidence for techniques such as cognitive
restructuring and thought replacement and
modifications such as visual aids, modelling and
smaller groups, at least for those aged 12 years and
over. The current review highlights a clear need for
future studies to incorporate more scientifically
rigorous methodologies to address the limitations
identified in this review and identified gaps in the
literature. It also reveals that there is a lack of
emphasis on the ID population in the mental health
literature and that there is a need for more training for
practitioners working alongside individuals with ID.
Most pertinently, research needs to focus on the
development of evidence-based treatment protocols
and clinical practise guidelines. Studies on the
effectiveness of CBT for different levels of ID with
various modifications will better inform the
recommendations for treatments for individuals with
ID and anxiety. Ultimately, this will assist individuals
with ID experiencing anxiety to have access to
effective treatments that are tailored to their ability
levels and their needs.

Acknowledgements

We extend our gratitude to the reviewers and editors
for their feedback.

Open access publishing facilitated by Macquarie
University, as part of the Wiley – Macquarie
University agreement via the Council of Australian
University Librarians.

Source of funding

No external funding was received for the research
reported in the paper.

Conflict of interest

There are no conflicts of interest. This is a systematic
review and no human ethics approval was required.

Data availability statement

Data available on request.

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Accepted 12 May 2023

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The effectiveness of cognitive behavioural therapy for individuals with an intellectual disability and anxiety: a systematic review

Introduction

Materials and methods

Eligibility criteria

Inclusion and exclusion criteria

Information sources

Search strategy

Study selection

Data collection process and synthesis of results

Methodological quality

Results

Study selection

Study characteristics

Participants

Methodological quality

Cognitive behavioural therapy delivery

Child studies

Mixed anxiety

Treatment components and adaptations

Treatment outcomes

Additional outcomes

Adult studies

Generalised anxiety or mixed anxiety

Treatment component and adaptations

Treatment outcomes

Additional outcomes

Post&hyphen;traumatic stress disorder

Treatment component and adaptations

Treatment outcomes

Non&hyphen;specified anxiety

Treatment components and adaptations

Treatment and additional outcomes

Discussion

Acknowledgements

Source of funding

Conflict of interest

Data availability statement

References

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