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Third-Wave Therapies and Adults with Intellectual Disabilities: A Systematic Review

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Title: Third-Wave Therapies and Adults with Intellectual Disabilities: A Systematic Review
Language: English
Authors: Patterson, Christopher Wynne (ORCID 0000-0003-1718-8559), Williams, Jonathan, Jones, Robert
Source: Journal of Applied Research in Intellectual Disabilities. Nov 2019 32(6):1295-1309.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA
Peer Reviewed: Y
Page Count: 15
Publication Date: 2019
Document Type: Journal Articles
Information Analyses
Descriptors: Adults, Intellectual Disability, Outcomes of Treatment, Research Reports, Behavior Modification, Metacognition, Altruism, Mental Health, Symptoms (Individual Disorders), Smoking, Psychotherapy
DOI: 10.1111/jar.12619
ISSN: 1360-2322
Abstract: Background: Third-wave therapies appear to produce positive outcomes for people without intellectual disabilities. This systematic review aimed to establish which third-wave therapies have been adapted for adults with intellectual disabilities and whether they produced positive outcomes. Method: Four databases were searched systematically (PsycINFO, Web of Science, MEDLINE and PubMed), yielding 1,395 results. Twenty studies (N = 109) met the present review's inclusion/exclusion criteria. Results: Included studies used mindfulness-based approaches, dialectical behaviour therapy, compassion focused therapy and acceptance and commitment therapy. Due to considerable heterogeneity in the designs and outcome measures used, a meta-analysis was not possible. Conclusions: Evidence indicated that third-wave therapies improved mental health symptoms for some and improved challenging/offending behaviour, smoking and mindfulness/acceptance skills for most. These findings must be interpreted with caution due to the low methodological quality of included studies. Future research should build on the current evidence base, using scientifically rigorous designs and standardized measures.
Abstractor: As Provided
Entry Date: 2019
Accession Number: EJ1231093
Database: ERIC
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  Value: <anid>AN0139027377;e0301nov.19;2019Oct11.03:21;v2.2.500</anid> <title id="AN0139027377-1">Third‐wave therapies and adults with intellectual disabilities: A systematic review </title> <p>Background: Third‐wave therapies appear to produce positive outcomes for people without intellectual disabilities. This systematic review aimed to establish which third‐wave therapies have been adapted for adults with intellectual disabilities and whether they produced positive outcomes. Method: Four databases were searched systematically (PsycINFO, Web of Science, MEDLINE and PubMed), yielding 1,395 results. Twenty studies (N = 109) met the present review's inclusion/exclusion criteria. Results: Included studies used mindfulness‐based approaches, dialectical behaviour therapy, compassion focused therapy and acceptance and commitment therapy. Due to considerable heterogeneity in the designs and outcome measures used, a meta‐analysis was not possible. Conclusions: Evidence indicated that third‐wave therapies improved mental health symptoms for some and improved challenging/offending behaviour, smoking and mindfulness/acceptance skills for most. These findings must be interpreted with caution due to the low methodological quality of included studies. Future research should build on the current evidence base, using scientifically rigorous designs and standardized measures.</p> <p>Keywords: aggression; intellectual disabilities; mental health problems; mindfulness/acceptance; systematic review; third‐wave therapies</p> <hd id="AN0139027377-2">INTRODUCTION</hd> <p>In 2004, Hayes' landmark paper reported the emergence of a new wave of behaviour therapy, the third‐wave. According to Hayes ([<reflink idref="bib33" id="ref1">33</reflink>]), the first wave was characterized by the application of behavioural interventions to treat certain mental health problems (e.g., exposure for specific phobias). In contrast, cognitive theorists argued that the relationship between environment and behaviour is more complex than this (Bandura, Blanchard, & Ritter, [<reflink idref="bib21" id="ref2">21</reflink>]; Beck, [<reflink idref="bib22" id="ref3">22</reflink>]). They theorized that cognition served as the mediator between the environment and behaviour (and emotion), and believed that illogical thinking was the cause of maladaptive behaviour and emotional suffering. This cognitive revolution was the catalyst for the second wave of behaviour therapy, namely cognitive behaviour therapy (CBT; Beck, [<reflink idref="bib22" id="ref4">22</reflink>]). While CBT retained elements of behaviourism, it focused on challenging illogical thinking to evoke change (Meichenbaum, [<reflink idref="bib42" id="ref5">42</reflink>]). Following its inception, CBT became the subject of considerable research attention. By the early 2000s, CBT had developed a considerable evidence base (e.g., Butler, Chapman, Forman, & Beck, [<reflink idref="bib25" id="ref6">25</reflink>]) and established itself as the most widely used form of psychotherapy.</p> <p>Considering the success of CBT, the emergence of a third wave of behaviour therapy was surprising to many. This paradigmatic shift was prompted by a critical appraisal of its reported outcomes and evidence indicating that some of its propositions were possibly unsound (Hayes, [<reflink idref="bib33" id="ref7">33</reflink>]). A series of component analysis studies critically examined CBT's effectiveness (e.g., Borkovec, Newman, Pincus, & Lytle, [<reflink idref="bib23" id="ref8">23</reflink>]) and questioned whether the purely cognitive components added any extra value to therapy.</p> <p>Many questioned the proposition that changes in illogical thoughts preceded changes in symptoms (Longmore & Worrell, [<reflink idref="bib40" id="ref9">40</reflink>]). Clinical research reported that the process of challenging illogical thinking was often failing to produce an emotional shift for clients: a phenomenon that became known as the "head to heart problem" (Branch & Wilson, [<reflink idref="bib24" id="ref10">24</reflink>]). The field of cognitive neuroscience has gone someway to explain this phenomenon (Cozolino, [<reflink idref="bib29" id="ref11">29</reflink>]; Longmore & Worrell, [<reflink idref="bib40" id="ref12">40</reflink>]; Teasdale, [<reflink idref="bib52" id="ref13">52</reflink>]). According to Teasdale ([<reflink idref="bib52" id="ref14">52</reflink>]), the head to heart problem is a consequence of CBT solely focusing on altering a client's propositional meanings (explicit memory system; semantic) through exposing them to the logical flaws in their thinking. Teasdale ([<reflink idref="bib52" id="ref15">52</reflink>]) highlighted that CBT fails to engage a client's emotional processes as a result of ignoring their implicational meanings (implicit memory system; emotional). It is this process that results in clients being able to acknowledge that their thinking is illogical, but feeling no different emotionally as a result.</p> <p>Although the same issues are relevant to adults with intellectual disabilities, it is only in recent years that attempts have been made to adapt these therapies. Considerable effort was afforded to adapting second‐wave therapies such as CBT for people with intellectual disabilities. Although it has been reported that people with intellectual disabilities can benefit from CBT as long as necessary adaptations are made (Taylor et al., [<reflink idref="bib51" id="ref16">51</reflink>]), Sturmey ([<reflink idref="bib50" id="ref17">50</reflink>]) argued that CBT is reliant upon clients possessing high‐level communication and abstract reasoning ability, as they are required to verbally report on their thoughts and feelings, and weigh evidence for and against thoughts (Sturmey, [<reflink idref="bib50" id="ref18">50</reflink>]). Reduced ability in these areas is likely to act as a barrier to people with intellectual disabilities engaging meaningfully with CBT (Boulton, Williams, & Jones, [<reflink idref="bib3" id="ref19">3</reflink>]; Chinn, Abraham, Burke, & Davies, [<reflink idref="bib28" id="ref20">28</reflink>]).</p> <p>Third‐wave therapies address these issues by focusing on clients' implicational meanings using acceptance, mindfulness, cognitive defusion, dialectics, values, spirituality and relationship (Hayes, [<reflink idref="bib33" id="ref21">33</reflink>]): areas that were previously neglected, as they were viewed as unscientific. According to Hayes ([<reflink idref="bib33" id="ref22">33</reflink>]), third‐wave therapies also focus on "the context and functions of psychological phenomena (not just their form); emphasize contextual and experiential change strategies (instead of more direct and didactic ones); and seek the construction of broad, flexible and effective repertoires (over an eliminative approach to narrowly defined problems)." Originally, Hayes, Masuda, and De Mey ([<reflink idref="bib34" id="ref23">34</reflink>]) cited acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, [<reflink idref="bib35" id="ref24">35</reflink>]), dialectical behaviour therapy (DBT; Linehan, [<reflink idref="bib39" id="ref25">39</reflink>]) and mindfulness‐based cognitive therapy (MBCT; Teasdale et al., [<reflink idref="bib53" id="ref26">53</reflink>]) as examples of third‐wave therapies (Hayes, [<reflink idref="bib33" id="ref27">33</reflink>]). Importantly, however, whether or not engaging in these processes also requires similar levels of communication and abstract reasoning ability—cited by Sturmey ([<reflink idref="bib50" id="ref28">50</reflink>]) as criticisms of CBT—is an empirical question.</p> <p>Two systematic reviews have examined the use of third‐wave therapies with the intellectual disability population. Chapman et al. ([<reflink idref="bib27" id="ref29">27</reflink>]) reviewed the use of mindfulness‐based approaches with people with intellectual disabilities, as well as parents of children with intellectual disabilities and staff supporting people with intellectual disabilities. Although they reported consistent positive effects for mindfulness, they stated that their findings must be interpreted with caution due to the low methodological quality of included studies. McNair, Woodrow, and Hare ([<reflink idref="bib41" id="ref30">41</reflink>]) reviewed studies reporting on the use of DBT with people with intellectual disabilities, concluding that additional high‐quality research is needed before deciding whether DBT is an effective intervention when used with the intellectual disability population.</p> <p>The present review had two main aims: (a) to ascertain which third‐wave therapies had been used with adults with intellectual disabilities and (b) to establish how effective third‐wave therapies, as a collective, have been when used with adults with intellectual disabilities. This review, therefore, expands on reviews by Chapman et al. ([<reflink idref="bib27" id="ref31">27</reflink>]) and McNair et al. ([<reflink idref="bib41" id="ref32">41</reflink>]), which only reviewed the use of individual third‐wave therapies (e.g., DBT only) with people with intellectual disabilities.</p> <hd id="AN0139027377-3">METHODS</hd> <p>This systematic review was conducted in accordance with PRISMA guidelines for guidelines and was registered with Prospero (project number: CRD42018110443).</p> <hd id="AN0139027377-4">Search strategy</hd> <p>PsycINFO, Web of Science, MEDLINE and PubMed were searched systematically on 23 April 2018, using the following search terms: 'intellectual disabil*' 'learning disabil*' 'mental retard*'; and 'mindfulness', 'acceptance', 'dialectical', 'compassion', 'metacognitive', 'behavio* activation'; or 'MBCT', 'ACT', 'DBT', and 'CFT'. Studies had to be written in English and published in a peer‐reviewed journal. No limit was set on publication date. As illustrated in Figure , this initial search returned 1,395 studies.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/E03/01nov19/jar12619-fig-0001.jpg?ephost1=dGJyMMvl7ESepq84yOvsOLCmsE6epq5Srqa4SK6WxWXS" alt="jar12619-fig-0001.jpg" title="PRISMA flow of studies through the systematic review" /> </p> <p></p> <p>Eleven additional papers were identified through: searching the reference lists of unsystematic reviews of psychological therapies for people with intellectual disabilities (Leoni, Corti, & Cavagnola, [<reflink idref="bib38" id="ref33">38</reflink>]) or systematic reviews of particular third‐wave therapies for people with intellectual disabilities, such as mindfulness‐based approaches (Chapman et al., [<reflink idref="bib27" id="ref34">27</reflink>]; Hwang & Kearney, [<reflink idref="bib36" id="ref35">36</reflink>]) and DBT (McNair et al., [<reflink idref="bib41" id="ref36">41</reflink>]); hand searching journals of interest; and contacting key authors in the field.</p> <p>After removing 82 duplicates, 1,321 studies remained. Then, the titles and abstracts of the remaining studies were screened to remove any obviously inappropriate studies. Next, the full texts of 63 studies were read. At this stage, 43 studies were excluded. The first author was responsible for carrying out this process. The second and third authors were consulted regarding four papers, which reported on interventions that were amalgamations of different third‐wave therapies, as the first author was unsure as to whether they met the review's inclusion/exclusion criteria or not. Thorough discussion resulted in these papers being excluded, as all three authors agreed that they were reporting on interventions that were not recognized as third‐wave therapies.</p> <hd id="AN0139027377-6">Inclusion criteria</hd> <p></p> <ulist> <item> Studies with participants aged 18 years or over.</item> <p></p> <item> Studies with samples comprised of adults with intellectual disabilities.</item> <p></p> <item> Quantitative studies, measuring the effect of an intervention (i.e., pre‐ and post‐measurement).</item> <p></p> <item> Studies reporting on third‐wave therapies.</item> </ulist> <hd id="AN0139027377-7">Exclusion criteria</hd> <p></p> <ulist> <item> Studies with participants under the age of 18 years.</item> <p></p> <item> Studies with samples that included individuals with IQs of 70 and above.</item> <p></p> <item> Studies with samples including individuals with "borderline" intellectual disabilities.</item> <p></p> <item> Non‐primary research (e.g., review papers).</item> <p></p> <item> Unplanned interventions.</item> <p></p> <item> Studies reporting on an intervention that included an element inconsistent with the third‐wave therapy definition (e.g., studies that included cognitive restructuring).</item> </ulist> <hd id="AN0139027377-8">QUALITY APPRAISAL</hd> <p>As this review included a mixture of studies using single‐case study and group designs, it was necessary to use a quality appraisal tool that was designed specifically to assess both of these methodologies. Examination of existing reviews (Chapman et al., [<reflink idref="bib27" id="ref37">27</reflink>]; McNair et al., [<reflink idref="bib41" id="ref38">41</reflink>]) revealed that Reichow, Volkmar, and Cicchetti's ([<reflink idref="bib47" id="ref39">47</reflink>]) evaluative method for determining evidence‐based practices in Autism had been used to assess the quality of single‐case and group studies reporting on the use of psychological therapies with people with intellectual disabilities. Other tools have been used to assess the quality of studies included in reviews of psychological therapies for people with intellectual disabilities. For example, Patterson ([<reflink idref="bib46" id="ref40">46</reflink>]), Nicoll, Beail, and Saxon ([<reflink idref="bib44" id="ref41">44</reflink>]) and Shepherd and Beail ([<reflink idref="bib49" id="ref42">49</reflink>]) all used Cahill's, Barkham, and Stiles ([<reflink idref="bib26" id="ref43">26</reflink>]) adaptation of Downs and Black's ([<reflink idref="bib31" id="ref44">31</reflink>]) Methodological Quality Checklist. However, Cahill et al.'s ([<reflink idref="bib26" id="ref45">26</reflink>]) adaptation was not deemed appropriate for this review, as some of its criteria seemed irrelevant to studies employing single‐case study designs.</p> <p>Reichow et al.'s ([<reflink idref="bib47" id="ref46">47</reflink>]) tool uses different criteria for single‐case and group study designs. However, both sets of studies are scored against primary and secondary indicators of quality. Studies are given scores of "unacceptable," "adequate" and "high" for each criterion. Then, unacceptable, adequate and high ratings are tallied for each study to compute an overall research report strength: "weak" (high‐quality ratings on less than half of the primary and secondary indicators), "adequate" (high‐quality ratings on most primary indicators and about half of the secondary indicators) or "strong" (high‐quality ratings on all primary indicators and most secondary indicators). Reichow et al. ([<reflink idref="bib47" id="ref47">47</reflink>]) also developed a means of determining the overall quality of an evidence base. The two possible outcomes are "established" and "promising." To be considered established, an evidence base must have substantial number of single‐case and/or group studies that have strong research report strength. However, a lower number of single‐case and/or group studies with adequate research report strength can be considered promising.</p> <p>Table provides a more in‐depth summary of each study's ratings on Reichow et al.'s ([<reflink idref="bib47" id="ref48">47</reflink>]) primary and secondary quality indicators. Out of the 11 studies that employed a group design, 10 studies were rated as having "weak" research report strength and one was rated as having "adequate" strength. In terms of primary indicators, participant characteristics, comparison condition, use of statistical tests mainly received unacceptable ratings. This suggests that group studies did not (a) provide sufficient demographic and clinical information about participants, (b) employ control groups and (c) apply appropriate statistical tests to measure the effectiveness of interventions. However, independent variable, dependent variable and link between research question and analysis mostly received acceptable and high ratings. This means that group studies provided sufficient information regarding their intervention (i.e., to allow for replication) and outcome measures, and chose appropriate outcome measures given their stated aims.</p> <p>Breakdown of study scores on the quality appraisal tool</p> <p> <ephtml> <table><thead valign="top"><tr><th align="left"> </th><th align="left">Primary quality indicators</th><th align="left">Secondary quality indicators</th><th align="left">Quality</th></tr><tr><th align="left">Participant characteristics</th><th align="left">Independent variable</th><th align="left">Comparison condition</th><th align="left">Dependent variable</th><th align="left">Link between research question and analysis</th><th align="left">Use of statistical tests</th><th align="left">Random assignment</th><th align="left">Inter‐observer agreement</th><th align="left">Blind raters</th><th align="left">Fidelity</th><th align="left">Attrition</th><th align="left">Generalization and/or maintenance</th><th align="left">Effect size</th><th align="left">Social validity</th></tr></thead><tbody><tr><td align="left">ACT</td></tr><tr><td align="left">Brown and Hooper (<xref ref-type="bibr" rid="bibr4">4</xref>)</td><td align="left">U</td><td align="left">A</td><td align="left">U</td><td align="left">A</td><td align="left">A</td><td align="left">U</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">N</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Pankey and Hayes (<xref ref-type="bibr" rid="bibr45">45</xref>)</td><td align="left">A</td><td align="left">A</td><td align="left">U</td><td align="left">U</td><td align="left">A</td><td align="left">U</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">N</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">DBT</td></tr><tr><td align="left">Ashworth et al. (<xref ref-type="bibr" rid="bibr2">2</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">U</td><td align="left">H</td><td align="left">A</td><td align="left">U</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">Weak</td></tr><tr><td align="left">Crossland et al. (<xref ref-type="bibr" rid="bibr8">8</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">U</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">N</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Hall et al. (<xref ref-type="bibr" rid="bibr10">10</xref>)</td><td align="left">U</td><td align="left">A</td><td align="left">U</td><td align="left">A</td><td align="left">A</td><td align="left">U</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Lew et al. (<xref ref-type="bibr" rid="bibr12">12</xref>)</td><td align="left">U</td><td align="left">A</td><td align="left">U</td><td align="left">A</td><td align="left">H</td><td align="left">U</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Sakdalan et al. (<xref ref-type="bibr" rid="bibr13">13</xref>)</td><td align="left">U</td><td align="left">A</td><td align="left">U</td><td align="left">A</td><td align="left">H</td><td align="left">U</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Mindfulness</td></tr><tr><td align="left">Chilvers et al. (<xref ref-type="bibr" rid="bibr5">5</xref>)</td><td align="left">H</td><td align="left">A</td><td align="left">U</td><td align="left">A</td><td align="left">H</td><td align="left">H</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">E</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr14">14</xref>)</td><td align="left">A</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">E</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">E</td><td align="left">E</td><td align="left">N</td><td align="left">E</td><td align="left">Adequate</td></tr><tr><td align="left">CFT</td></tr><tr><td align="left">Clapton et al. (<xref ref-type="bibr" rid="bibr6">6</xref>)</td><td align="left">A</td><td align="left">H</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">Weak</td></tr><tr><td align="left">Cooper and Frearson (<xref ref-type="bibr" rid="bibr7">7</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">U</td><td align="left">H</td><td align="left">U</td><td align="left">U</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">N</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Hardiman et al. (<xref ref-type="bibr" rid="bibr11">11</xref>)</td><td align="left">U</td><td align="left">A</td><td align="left">U</td><td align="left">A</td><td align="left">H</td><td align="left">U</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">N</td><td align="left">N</td><td align="left">Weak</td></tr><tr><td align="left">Total</td><td align="left">U = 8</td><td align="left">U = 0</td><td align="left">U = 11</td><td align="left">U = 1</td><td align="left">U = 1</td><td align="left">U = 9</td><td align="left">N = 11</td><td align="left">N = 12</td><td align="left">N = 12</td><td align="left">N = 11</td><td align="left">N = 11</td><td align="left">N = 6</td><td align="left">N = 11</td><td align="left">N = 3</td><td align="left"> </td></tr><tr><td align="left"> </td><td align="left">A = 3</td><td align="left">A = 7</td><td align="left">A = 0</td><td align="left">A = 6</td><td align="left">A = 4</td><td align="left">A = 0</td><td align="left">E = 1</td><td align="left">E = 0</td><td align="left">E = 0</td><td align="left">E = 1</td><td align="left">E = 1</td><td align="left">E = 6</td><td align="left">E = 1</td><td align="left">E = 9</td><td align="left"> </td></tr><tr><td align="left"> </td><td align="left">H = 1</td><td align="left">H = 5</td><td align="left">H = 1</td><td align="left">H = 5</td><td align="left">H = 7</td><td align="left">H = 3</td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td></tr></tbody></table> </ephtml> </p> <p>Breakdown of study scores on the quality appraisal tool</p> <p> <ephtml> <table><thead valign="top"><tr><th align="left"> </th><th align="left">Primary quality indicators</th><th align="left">Secondary quality indicators</th><th align="left">Quality</th></tr><tr><th align="left">Participant characteristics</th><th align="left">Independent variable</th><th align="left">Dependent variable</th><th align="left">Baseline condition</th><th align="left">Visual analysis</th><th align="left">Experimental control</th><th align="left">Inter‐observer agreement</th><th align="left">Kappa</th><th align="left">Fidelity</th><th align="left">Blind raters</th><th align="left">Generalization and/or maintenance</th><th align="left">Social validity</th></tr></thead><tbody><tr><td align="left">Mindfulness</td></tr><tr><td align="left">Adkins et al. (<xref ref-type="bibr" rid="bibr1">1</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr15">15</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">E</td><td align="left">E</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr16">16</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">E</td><td align="left">E</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">*Singh, Lancioni, Winton, Singh, Singh, et al. (<xref ref-type="bibr" rid="bibr19">19</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">E</td><td align="left">E</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr17">17</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">E</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr20">20</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">E</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">*Singh, Lancioni, Winton, Singh, Adkins, et al. (<xref ref-type="bibr" rid="bibr18">18</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">DBT</td></tr><tr><td align="left">Florez and Bethay (<xref ref-type="bibr" rid="bibr9">9</xref>)</td><td align="left">U</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">H</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">E</td><td align="left">E</td><td align="left">Weak</td></tr><tr><td align="left">Total</td><td align="left">U = 8</td><td align="left">U = 0</td><td align="left">U = 0</td><td align="left">U = 0</td><td align="left">U = 0</td><td align="left">U = 0</td><td align="left">N = 3</td><td align="left">N = 5</td><td align="left">N = 8</td><td align="left">N = 8</td><td align="left">N = 2</td><td align="left">N = 0</td><td align="left"> </td></tr><tr><td align="left"> </td><td align="left">A = 0</td><td align="left">A = 0</td><td align="left">A = 0</td><td align="left">A = 0</td><td align="left">A = 0</td><td align="left">A = 0</td><td align="left">E = 5</td><td align="left">E = 3</td><td align="left">E = 0</td><td align="left">E = 0</td><td align="left">E = 6</td><td align="left">E = 8</td><td align="left"> </td></tr><tr><td align="left"> </td><td align="left">H = 0</td><td align="left">H = 8</td><td align="left">H = 8</td><td align="left">H = 8</td><td align="left">H = 8</td><td align="left">H = 8</td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td><td align="left"> </td></tr></tbody></table> </ephtml> </p> <p>In terms of secondary indicators, there was little if no evidence of random assignment, inter‐observer agreement, blind raters, fidelity, attrition and effect size. Given that only one study utilized the randomized controlled trial (RCT) design, it is unsurprising to find that there was little evidence of random assignment and blind raters. The lack of control conditions, random assignment and blind raters makes it difficult to establish the true effect of an intervention without the influence of individual differences and biased scoring on outcome measures. There was some evidence of generalization, meaning that participants were followed up to establish whether their outcomes were stable. Group studies consistently demonstrated evidence of social validity.</p> <p>All nine studies that employed a single‐case design were rated as having "weak" research report strength. In terms of primary indicators, there was only one area that received solely weak ratings, participant characteristics. The other primary indicators (independent variable, dependent variable, baseline condition, visual analysis and experimental control) all received high ratings. This means that single‐case design studies described their interventions and outcomes in sufficient detail to allow for replication; were well controlled; and provided necessary data visually. In regard to secondary indicators, there was no evidence of fidelity or blind raters, and little evidence of kappa. There was some evidence of inter‐observer agreement and generalization. Similar to the group studies, single‐case design studies obtained high ratings for social validity. Due to having only one study with adequate research report strength, the evidence base for third‐wave therapies for adults with intellectual disabilities cannot yet be considered established or promising. This means "practices should be employed with caution and should be closely monitored until a greater accumulation of evidence is present" (Reichow et al., [<reflink idref="bib47" id="ref49">47</reflink>]; p. 1315).</p> <hd id="AN0139027377-9">RESULTS</hd> <p>Twenty studies met the inclusion/exclusion criteria. Table provides summaries for each study.</p> <p>Data extraction form</p> <p> <ephtml> <table><thead valign="top"><tr><th align="left">Reference/country</th><th align="left">Study design</th><th align="left">Participant(s)/setting</th><th align="left">Intervention</th><th align="left">Outcomes measured</th><th align="left">Rigour</th></tr></thead><tbody><tr><td align="left">Adkins et al. (<xref ref-type="bibr" rid="bibr1">1</xref>);USA</td><td align="left">Multiple baseline</td><td align="left">N = 3 (2 = male)Age: mean = 29.7 (range = 22–42)Intellectual disabilities: mildPresenting problems: maladaptive behaviour causing their placement; and obsessive–compulsive disorder, anger, and depressionSetting: community</td><td align="left">MindfulnessFormat: individualManual: Soles of the FeetLength: 1 hrFrequency: training, 5 per weekDuration: training, up to 5 weeks; practice, up to 26 weeks</td><td align="left">Behavioural measures:<list list-type="Bullet"><list-item><p>Target behaviour</p></list-item><list-item><p>Other behaviour</p></list-item></list>Subjective measures:<list list-type="Bullet"><list-item><p>Subjective Units of Distress Scale</p></list-item><list-item><p>Yale‐Brown Obsessive–Compulsive Scale</p></list-item><list-item><p>Beck Depression Inventory –Second Edition</p></list-item><list-item><p>State Trait Anxiety Index</p></list-item></list>Follow‐up: 9–12 weeks</td><td align="left">Weak</td></tr><tr><td align="left">Ashworth et al. (<xref ref-type="bibr" rid="bibr2">2</xref>);UK</td><td align="left">Case study</td><td align="left">N: 1 (1 = male)Age: not reportedIntellectual disabilities: mild (IQ: 67/69)Presenting problems: emotionally unstable personality disorder; extensive offending history (i.e., arson); and aggression and self‐harming behaviourSetting: inpatient</td><td align="left">Dialectical behaviour therapyFormat: group and individualManual: I Can Feel GoodLength: 2 hrFrequency: 1 per weekDuration: 47 weeks</td><td align="left">Behavioural measure:<list list-type="Bullet"><list-item><p>Observations</p></list-item></list>Subjective measures:<list list-type="Bullet"><list-item><p>Emotional Problems Scale‐Behaviour Report Scale</p></list-item><list-item><p>Cognitive and Affective Mindfulness Scale‐Revised</p></list-item><list-item><p>Emotional Control Questionnaire</p></list-item><list-item><p>Coping Response inventory</p></list-item><list-item><p>Chart of Interpersonal Reactions in Closed Living Environments</p></list-item></list>Follow‐up: none</td><td align="left">Weak</td></tr><tr><td align="left">Brown and Hooper (<xref ref-type="bibr" rid="bibr4">4</xref>);UK</td><td align="left">Case study</td><td align="left">N: 1 (0 = male)Age: mean = 18 (range = 18)Intellectual disabilities: IQ = 44Presenting problems: anxious and obsessive thoughts.Setting: community</td><td align="left">Acceptance and commitment therapyFormat: individualManual: noneLength: not reportedFrequency: 2 per monthDuration: 6 months</td><td align="left">Subjective measure:<list list-type="Bullet"><list-item><p>Adapted version of the Acceptance and Action Questionnaire – 9</p></list-item></list>Behavioural measure:<list list-type="Bullet"><list-item><p>Parents' observations</p></list-item></list>Follow‐up: 4 months</td><td align="left">Weak</td></tr><tr><td align="left">Chilvers et al. (<xref ref-type="bibr" rid="bibr5">5</xref>);UK</td><td align="left">Single group pre–post</td><td align="left">N: 15 (0 = male)Age: range = 18–47Intellectual disabilities: mild–moderatePresenting problems: psychosis, mood disorders and autism spectrum disorder.Setting: inpatient</td><td align="left">MindfulnessFormat: groupManual: noneLength: 30 minFrequency: 2 per weekDuration: 26 weeks</td><td align="left">Behavioural measures:Proxy measures of institutional aggression:<list list-type="Bullet"><list-item><p>Observations</p></list-item><list-item><p>Physical intervention</p></list-item><list-item><p>Seclusions</p></list-item></list>Follow‐up: none</td><td align="left">Weak</td></tr><tr><td align="left">Clapton et al. (<xref ref-type="bibr" rid="bibr6">6</xref>);UK</td><td align="left">Single group pre–post</td><td align="left">N: 6 (2 = male)Age: mean age = 38.5 (SD = 15.6)Intellectual disabilities: mild (IQ: 51–69)Presenting problems: anxiety and mixed anxiety and depressionSetting: community</td><td align="left">Compassion focused therapyFormat: groupManual: noneLength: 90 minFrequency: not reportedDuration: 6 sessions</td><td align="left">Subjective measures:<list list-type="Bullet"><list-item><p>CFT‐ID Session Feasibility and Acceptability Measure</p></list-item><list-item><p>Self‐Compassion Scale‐Short Form</p></list-item><list-item><p>Psychological Therapy Outcome Scale–Intellectual Disabilities</p></list-item><list-item><p>The adapted Social Comparison Scale</p></list-item></list>Follow‐up: none</td><td align="left">Weak</td></tr><tr><td align="left">Cooper and Frearson (<xref ref-type="bibr" rid="bibr7">7</xref>);UK</td><td align="left">Single‐case AB</td><td align="left">N: 1 (1 = male)Age: "40s"Intellectual disabilities: moderatePresenting problems: low mood and overeatingSetting: community</td><td align="left">Compassion focused therapyFormat: individualManual: noneLength: 1 hrFrequency: not reportedDuration: 13 sessions</td><td align="left">Subjective measures:<list list-type="Bullet"><list-item><p>CORE‐LD</p></list-item><list-item><p>Forms of Self‐criticizing and Self‐reassuring Scale</p></list-item><list-item><p>Idiosyncratic mood monitoring scale</p></list-item></list>Follow‐up: 1 week</td><td align="left">Weak</td></tr><tr><td align="left">Crossland et al. (<xref ref-type="bibr" rid="bibr8">8</xref>);UK</td><td align="left">Single group pre–post</td><td align="left">N: 4 (1 = male)Age: range = 24–48Intellectual disabilities: not reportedPresenting problems:Interpersonal differences and emotion regulation difficultiesSetting: community</td><td align="left">Dialectical behaviour therapyFormat: groupManual: I Can Feel GoodLength: not reportedFrequency: 1 per weekDuration: 18 weeks</td><td align="left">Subjective measures:<list list-type="Bullet"><list-item><p>Health of the Nation Outcome Scales for People with Learning Disabilities</p></list-item><list-item><p>Psychological Therapy Outcome Scale–Intellectual Disabilities</p></list-item></list>Follow‐up: 4 months</td><td align="left">Weak</td></tr><tr><td align="left">Florez and Bethay (<xref ref-type="bibr" rid="bibr9">9</xref>);USA</td><td align="left">Single‐case ABAB</td><td align="left">N: 1 (0 = male)Age: 28Intellectual disabilities: mildPresenting problems: challenging behaviours, emotional dysregulation, generalized anxiety disorder, intermittent explosive disorder, uncooperative behaviour, aggression, self‐injury and elopement.Setting: community</td><td align="left">Dialectical behaviour therapyFormat: group and individualManual: noneLength: 45 minFrequency: 2 per weekDuration: 1 year</td><td align="left">Behavioural measures:<list list-type="Bullet"><list-item><p>Frequency of challenging behaviour</p></list-item></list>Follow‐up: 1 year</td><td align="left">Weak</td></tr><tr><td align="left">Hall et al. (<xref ref-type="bibr" rid="bibr10">10</xref>);UK</td><td align="left">Single group pre–post</td><td align="left">N: 7 (gender not reported)Age: not reportedIntellectual disabilities: not reportedPresenting problems: not reportedSetting: community</td><td align="left">Dialectical behaviour therapyFormat: groupManual: noneLength: not reportedFrequency: not reportedDuration: not reported</td><td align="left">Subjective measures:<list list-type="Bullet"><list-item><p>Glasgow Depression Scale – Learning Disability</p></list-item><list-item><p>Glasgow Anxiety Scale–Intellectual Disability</p></list-item><list-item><p>Cognitive and Affective Mindfulness Scale‐Revised</p></list-item></list>Follow‐up: none</td><td align="left">Weak</td></tr><tr><td align="left">Hardiman et al. (<xref ref-type="bibr" rid="bibr11">11</xref>);UK</td><td align="left">Single group pre–post</td><td align="left">N: 3 (1 = male)Age: range = 31–48Intellectual disabilities: mild–moderatePresenting problem: clinically significant anxietySetting: community</td><td align="left">Compassion focused therapyFormat: not reportedManual: noneLength: not reportedFrequency: not reportedDuration: 12–15 weeks</td><td align="left">Subjective measures:<list list-type="Bullet"><list-item><p>Self‐compassion scale</p></list-item><list-item><p>Glasgow Anxiety Scale–Intellectual Disability</p></list-item></list>Follow‐up: 3 months</td><td align="left">Weak</td></tr><tr><td align="left">Lew et al. (<xref ref-type="bibr" rid="bibr12">12</xref>);UK</td><td align="left">Single group pre–post</td><td align="left">N: 8 (0 = male)Age: range = 25–61Intellectual disabilities: mild–moderatePresenting problems:axis 1 diagnosis of mental disorder, additional need issues, considered as high risk.Setting: community</td><td align="left">Dialectical behaviour therapyFormat: group and individualManual: noneLength: group, 2 hr; individual, 30–60 minFrequency: group, 1 per week; individual, 2 per weekDuration: 69 weeks</td><td align="left">Subjective measures:<list list-type="Bullet"><list-item><p>Adapted version of Youth Risk Behaviour Survey</p></list-item></list>Follow‐up: none</td><td align="left">Weak</td></tr><tr><td align="left">Pankey and Hayes (<xref ref-type="bibr" rid="bibr45">45</xref>);USA</td><td align="left">Case study</td><td align="left">N: 1 (0 = male)Age: mean = 22Intellectual disabilities: mild (IQ: 58)Presenting problem: undifferentiated psychosisSetting: community</td><td align="left">Acceptance and commitment therapyFormat: individualManual: noneLength: not reportedFrequency: not reportedDuration: 4 sessions</td><td align="left">Behavioural measures:<list list-type="Bullet"><list-item><p>Compliance with medication</p></list-item><list-item><p>Eating</p></list-item><list-item><p>Ceasing taking apart appliances</p></list-item><list-item><p>Sleeping</p></list-item></list>Subjective measures:<list list-type="Bullet"><list-item><p>Believability</p></list-item><list-item><p>Distress</p></list-item><list-item><p>Frequency of symptoms</p></list-item><list-item><p>Simple ACT process measure</p></list-item></list>Follow‐up: 1 month</td><td align="left">Weak</td></tr><tr><td align="left">Sakdalan et al. (<xref ref-type="bibr" rid="bibr13">13</xref>);New Zealand</td><td align="left">Single group pre–post</td><td align="left">N: 6 (5 = male)Age: range = 23–29Intellectual disabilities: mild–moderatePresenting problem: violent offending behaviourSetting: inpatient</td><td align="left">Dialectical behaviour therapyFormat: groupManual: noneLength: 90 minFrequency: not reportedDuration: 13 weeks</td><td align="left">Subjective measures:<list list-type="Bullet"><list-item><p>Short‐term Assessment of Risk and Reliability</p></list-item><list-item><p>Vineland Adaptive Behaviour Scales ‐Second Edition</p></list-item><list-item><p>Health of the Nation Outcomes Scale for People with Learning Disabilities</p></list-item><list-item><p>DBT assessment and feedback form</p></list-item></list>Follow‐up: none</td><td align="left">Weak</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr14">14</xref>);USA</td><td align="left">Randomized controlled trial</td><td align="left">Experimental groupN = 25 (20 = male)Age: mean = 32.6 (SD = 10.3)Control groupN: 26 (21 = male)Age: mean = 34.4 (SD = 10.5)Intellectual disabilities: mildPresenting problem: smokingSetting: community</td><td align="left">MindfulnessFormat: individualManual: Soles of the FeetLength: training, 30 minFrequency: training, 2 per dayDuration: training, 5 days; total intervention, 36 weeks</td><td align="left">Behavioural measures:<list list-type="Bullet"><list-item><p>Number of cigarettes smoked</p></list-item></list>Follow‐up: 1 year</td><td align="left">Adequate</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr15">15</xref>);USA</td><td align="left">Multiple baseline</td><td align="left">N: 3 (2 = male)Age: range = 27–43Intellectual disabilities: moderatePresenting problems: at risk of losing their community placements because of their aggressive behaviour, bipolar disorder, schizophrenia, psychotic disorder, and post‐traumatic stress disorder.Setting: community</td><td align="left">MindfulnessFormat: individualManual: Soles of the FeetLength: not reportedFrequency: not reportedDuration: 35 weeks</td><td align="left">Behavioural measures:<list list-type="Bullet"><list-item><p>Physical aggression</p></list-item></list>Follow‐up: up to 2 years</td><td align="left">Weak</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr16">16</xref>);USA</td><td align="left">Changing criterion</td><td align="left">N: 3 (3 = male)Age: mean = 27 (range = 23–31)Intellectual disabilities: mildPresenting problems: long‐term smokingSetting: community</td><td align="left">MindfulnessFormat: individualManual: Soles of the FeetLength: training, 30 minFrequency: training, 2 per dayDuration: training, 5 days; total intervention, up to 24 weeks</td><td align="left">Behavioural measures:<list list-type="Bullet"><list-item><p>Number of cigarettes being smoked per day</p></list-item></list>Follow‐up: 3 years</td><td align="left">Weak</td></tr><tr><td align="left">*Singh, Lancioni, Winton, Singh, Singh, et al. (<xref ref-type="bibr" rid="bibr19">19</xref>);USA</td><td align="left">Changing criterion</td><td align="left">N: 1 (1 = male)Age: mean = 31Intellectual disabilities: mildPresenting problem: smokingSetting: community</td><td align="left">MindfulnessFormat: individualManual: Soles of the FeetLength: training, 30 minFrequency: training, 2 per dayDuration: training, 5 days; total intervention, 12 weeks</td><td align="left">Behavioural measures:<list list-type="Bullet"><list-item><p>Number of cigarettes smoked each day</p></list-item></list>Follow‐up: 3 years</td><td align="left">Weak</td></tr><tr><td align="left">*Singh, Lancioni, Winton, Singh, Adkins, et al. (<xref ref-type="bibr" rid="bibr18">18</xref>);USA</td><td align="left">Case study</td><td align="left">N: 3 (3 = male)Age: mean = 23.3 (range = 23–34)Intellectual disabilities: mildPresenting problem: sexual offendingSetting: inpatient</td><td align="left">MindfulnessFormat: individualManual: Soles of the FeetLength: 30–60 minFrequency: 4 per weekDuration: up to 40 weeks</td><td align="left">Subjective measures:<list list-type="Bullet"><list-item><p>Self‐report data on the level of sexual arousal</p></list-item></list>Follow‐up: none</td><td align="left">Weak</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr17">17</xref>);USA</td><td align="left">Multiple baseline</td><td align="left">N: 6 (6 = male)Age: mean = (range = 23–36)Intellectual disabilities: mildPresenting problem: physical aggressionSetting: inpatient</td><td align="left">MindfulnessFormat: individualManual: Soles of the FeetLength: not reportedFrequency: not reportedDuration: 27 months</td><td align="left">Behavioural measures:<list list-type="Bullet"><list-item><p>Physical aggression</p></list-item></list>Follow‐up: none</td><td align="left">Weak</td></tr><tr><td align="left">Singh et al. (<xref ref-type="bibr" rid="bibr20">20</xref>);USA</td><td align="left">Case study</td><td align="left">N: 1 (1 = male)Age: mean = 27Intellectual disabilities: mildPresenting problem: conduct disorderSetting: inpatient</td><td align="left">MindfulnessFormat: individualManual: Soles of the FeetLength: training, 30 minFrequency: training, 2 per dayDuration: training, 5 days</td><td align="left">Behavioural measures:<list list-type="Bullet"><list-item><p>Physical aggression</p></list-item><list-item><p>Verbal aggression</p></list-item><list-item><p>Incidents</p></list-item><list-item><p>Self‐control</p></list-item><list-item><p>PRN</p></list-item><list-item><p>Physical restraints</p></list-item><list-item><p>Injuries</p></list-item><list-item><p>Socially integrated activities</p></list-item><list-item><p>Physically integrated activities</p></list-item></list>Follow‐up: 12 months</td><td align="left">Weak</td></tr></tbody></table> </ephtml> </p> <hd id="AN0139027377-10">Design</hd> <p>A range of study designs was employed. One study employed the "gold standard" RCT design. Seven studies employed a single group pre‐ and post‐test design. Five studies used a case study design. The remaining seven studies used single‐case designs: multiple baseline (<emph>N</emph> = 3), changing criterion (<emph>N</emph> = 2) or AB/ABAB single‐case designs (<emph>N</emph> = 2). As identified in the quality appraisal, twelve studies measured generalization by conducting follow‐up assessments (range: one week to three years). Nearly all of the studies were conducted in either the USA (<emph>N</emph> = 10) or the UK (<emph>N</emph> = 9). The remaining study was conducted in New Zealand. Samples were typically recruited from either the community (<emph>N</emph> = 14) or inpatient settings (<emph>N</emph> = 6).</p> <hd id="AN0139027377-11">Participant group</hd> <p>In total, these studies reported on 109 participants. Out of the 102 participants whose gender was reported, 60 (58.8%) were female. Participants' ages ranged from 18 to 61; however, three studies failed to report age. Although only four studies reported on IQ (range: 44–69), all studies reported that participants had been diagnosed with an intellectual disabilities/were accessing an intellectual disability service. Presenting problems ranged from psychological distress/mental health problems, to challenging/offending behaviour, to smoking.</p> <hd id="AN0139027377-12">Intervention</hd> <p>The breakdown of interventions was as follows: nine (45%) used a mindfulness‐based approach; six (30%) used DBT; three (15%) used CFT; and two (10%) used ACT. As identified by the quality appraisal, only one study (Singh et al., [<reflink idref="bib14" id="ref50">14</reflink>]) employed fidelity checks. This means that there is no way of knowing whether the interventions described in the rest of the studies contained the necessary elements and were delivered as prescribed. While over half of the interventions were conducted on an individual basis (<emph>N</emph> = 11; 55%), under a quarter were conducted on a group basis (<emph>N</emph> = 5; 25%). Out of the remaining studies, three (15%) included both individual and group components, and one (5%) did not report this information. In terms of duration, 16 studies reported the number of weeks whereas three reported the number of sessions. One study did not provide details on the format of their intervention. Those that reported the number of weeks ranged from one week to 117 weeks (<emph>M</emph> = 34.7). Studies that reported the number of sessions lasted between four and thirteen sessions (<emph>M</emph> = 7.7). Sessions lasted between 30 and 120 min.</p> <p>Only one of the approaches identified in this review was specifically developed for people with intellectual disabilities, SoF. This manualized mindfulness‐based approach (Singh, Wahler, Adkins, & Myers, [<reflink idref="bib20" id="ref51">20</reflink>]) involves teaching people with intellectual disabilities to notice signs of difficult private experience and rapidly shift their attention to the sensations in the soles of their feet. Teaching is conducted on a one‐to‐one basis for 30 min a day once a week. Then, people with intellectual disabilities are encouraged and supported to maintain daily practice for a substantive period of time. The other approaches were adapted from mainstream.</p> <p>Prior to describing the DBT approaches found in the review, it is important to note that to be considered DBT an intervention must contain individual therapy, group skills training, team consult and 24‐hr telephone support. While some of the DBT interventions in this review contained all of these elements, some did not. Despite this, two studies followed a manualized approach ("I Can Feel Good"; Ingamells & Morrissey, [<reflink idref="bib37" id="ref52">37</reflink>]).</p> <hd id="AN0139027377-13">Common adaptations</hd> <p></p> <ulist> <item> Simplifying language</item> <p></p> <item> Making abstract concepts more concrete</item> <p></p> <item> Chunking information</item> <p></p> <item> Using physical/visual prompts</item> <p></p> <item> Providing additional time to process information</item> <p></p> <item> Checking whether participants understood</item> <p></p> <item> Using role play and experiential exercises</item> <p></p> <item> Reducing the duration of sessions</item> <p></p> <item> Involving carers.</item> </ulist> <hd id="AN0139027377-14">Outcome measures</hd> <p>To evaluate the effectiveness of interventions, studies used either behavioural (<emph>N</emph> = 8), subjective (<emph>N</emph> = 8) or a combination of behavioural and subjective measures (<emph>N</emph> = 4). Behavioural measures were used when the target of the intervention was behaviour change, for example, reducing incidents of aggression or the number of cigarettes smoked. Subjective measures were used when intervention was targeting psychological constructs (e.g., psychological distress). In total, 29 different subjective measures were used as follows: 21 were self‐report; eight were informant‐report. Despite the use of behavioural and subjective measures (self‐report and informant‐report), there was little evidence of inter‐observer agreement or blind raters, as highlighted in the quality appraisal section. Resultantly, it is difficult to ascertain the extent to which individual differences and cognitive biases influenced scoring. The majority of the identified subjective measures were only found in single studies (<emph>N</emph> = 25). The most frequently used subjective measures were as follows (psychometric properties presented in parentheses):</p> <p></p> <ulist> <item> Glasgow Anxiety Scale–Intellectual Disability (GAS‐ID; Mindham & Espie, [<reflink idref="bib43" id="ref53">43</reflink>]): internal consistency = 0.93; test‐rest‐reliability = 0.93; concurrent validity = 0.75</item> <p></p> <item> Psychological Therapy Outcome Scale–Intellectual Disabilities (PTOS‐ID; Vlissides, Beail, Jackson, Williams, & Golding, [<reflink idref="bib54" id="ref54">54</reflink>]): internal consistency = 0.76–0.81; concurrent validity = 0.85</item> <p></p> <item> Health of the Nation Outcome Scales for People with Learning Disabilities (HONOS‐LD; Roy, Matthews, Clifford, Fowler, & Martin, [<reflink idref="bib48" id="ref55">48</reflink>]): internal consistency = 0.96; concurrent validity = 0.66–0.76</item> <p></p> <item> Cognitive and Affective Mindfulness Scale‐Revised (CAMS‐R; Feldman, Hayes, Kumar, Greeson, & Laurenceau, [<reflink idref="bib32" id="ref56">32</reflink>]): internal consistency = 0.76; concurrent validity = 0.66.</item> </ulist> <p>The GAS‐ID, PTOS‐ID and HONOS‐LD were among the 12 subjective measures with robust psychometric properties that were specifically developed for people with intellectual disabilities. Notably, the GAS‐ID and PTOS‐ID are self‐report, whereas the HONOS‐LD is informant‐report. The CAMS‐R was one of the seventeen measures that were originally developed for people without intellectual disabilities (four of which were adapted for use with people with intellectual disabilities).</p> <hd id="AN0139027377-15">Effectiveness</hd> <p>In the quality appraisal section, it was highlighted that very few studies used appropriate statistical tests and only two studies (Chilvers, Thomas, & Stanbury, [<reflink idref="bib5" id="ref57">5</reflink>]; Singh et al., [<reflink idref="bib14" id="ref58">14</reflink>]) reported effect sizes. However, significance levels and effect sizes will be presented, when possible, to aid the reader's interpretation. In addition, all reported findings should be interpreted with caution as all but one of the studies (Singh et al., [<reflink idref="bib14" id="ref59">14</reflink>]) included in this review obtained weak ratings on the quality appraisal.</p> <hd id="AN0139027377-16">Challenging/offending behaviour</hd> <p>Results from two single‐case design (multiple baseline) studies indicated that participants were able reduce their aggressive behaviour to "near zero‐levels" in the community after completing the Soles of the Feet (SoF) mindfulness intervention (Adkins, Singh, Winton, McKeegan, & Singh, [<reflink idref="bib1" id="ref60">1</reflink>]; Singh et al., [<reflink idref="bib15" id="ref61">15</reflink>]). Prior to this intervention, these participants' placements were at risk due to the severity of their aggression. Chilvers et al. ([<reflink idref="bib5" id="ref62">5</reflink>]) and Singh et al. ([<reflink idref="bib17" id="ref63">17</reflink>]) reported similar findings when mindfulness‐based approaches were used to treat aggression in inpatient settings. Aggression reduced significantly in both of these studies following intervention, as evidenced by reduced observations (<emph>r</emph> = −0.47), physical interventions (<emph>r</emph> = −0.45) and seclusions (<emph>r</emph> = −0.42) in Chilvers et al.'s ([<reflink idref="bib5" id="ref64">5</reflink>]) study; and reduced emergency medication, physical restraint and injuries in Singh et al.'s ([<reflink idref="bib17" id="ref65">17</reflink>]) study. Benefit–cost analysis revealed a 95.7% reduction in workforce costs (i.e., sickness and injury) following Singh et al.'s ([<reflink idref="bib17" id="ref66">17</reflink>]) mindfulness intervention.</p> <p>Florez and Bethay ([<reflink idref="bib9" id="ref67">9</reflink>]) described the outcome of their DBT programme with an individual with an adult with a complex presentation (i.e., emotional dysregulation, generalized anxiety disorder and intermittent explosive disorder) who was exhibiting "challenging behaviour" (i.e., aggression and self‐harm) in the community. Results from their single‐case design study (ABAB) indicated that DBT eliminated their participant's challenging behaviour to zero, twice and within two months of implementation.</p> <p>Two studies conducted by Singh and colleagues (*Singh, Lancioni, Winton, Singh, Adkins, et al., [<reflink idref="bib18" id="ref68">18</reflink>]; Singh et al., [<reflink idref="bib20" id="ref69">20</reflink>]) examined the use of their SoF intervention in inpatient settings. They wanted to establish whether this intervention could increase self‐control in individuals with offending histories. Singh et al.'s ([<reflink idref="bib20" id="ref70">20</reflink>]) participant managed to stop themselves from displaying aggression for six months, which enabled them to step down into a community setting. At follow‐up, one year later, their participant was still living in the community, as they had not exhibited any aggression. Results from *Singh, Lancioni, Winton, Singh, Adkins, et al. ([<reflink idref="bib18" id="ref71">18</reflink>]) single‐case design (changing criterion) suggested that their participants were able to regulate their deviant sexual arousal better following the SoF intervention. Moreover, Sakdalan, Shaw, and Collier ([<reflink idref="bib13" id="ref72">13</reflink>]) and Lew, Matta, Tripp‐Tebo, and Watts ([<reflink idref="bib12" id="ref73">12</reflink>]) investigated whether DBT could reduce participants' level of risk. Notably, these studies used considerably different formats: Sakdalan et al.'s ([<reflink idref="bib13" id="ref74">13</reflink>]) intervention was administered in a group format over 13 weeks, whereas Lew et al.'s ([<reflink idref="bib12" id="ref75">12</reflink>]) intervention comprised both group and individual work over 69 weeks. Despite this, they both reported considerable reductions on measures of risk following intervention.</p> <hd id="AN0139027377-17">Psychological distress and mental health problems</hd> <p>The picture is mixed when it comes to the impact that third‐wave therapies have when used with people with intellectual disabilities who are experiencing psychological distress and, or, mental health problems. For instance, Hall, Bork, Craven, and Woodrow ([<reflink idref="bib10" id="ref76">10</reflink>]) and Hardiman, Willmoth, and Walsh ([<reflink idref="bib11" id="ref77">11</reflink>]) both reported that scores on measures of anxiety and depression improved following intervention. Similarly, Crossland, Hewitt, and Walden ([<reflink idref="bib8" id="ref78">8</reflink>]) reported that all four of their participants demonstrated improvements on the psychological distress scale of the PTOS‐ID following group DBT.</p> <p>However, only two out of Adkins et al.'s ([<reflink idref="bib1" id="ref79">1</reflink>]) three participants reported reductions on measures of anxiety, depression and obsessive–compulsive disorder symptoms following SoF, and although Pankey and Hayes' ([<reflink idref="bib45" id="ref80">45</reflink>]) intervention reduced the level of distress their participant experienced as a result of their hallucinations, it did not stop the participant from experiencing hallucinations. It is important to note that two studies did not find any improvement on subjective measures of psychological distress/mental health problems following intervention (Ashworth, Mooney, & Tully, [<reflink idref="bib2" id="ref81">2</reflink>]; Cooper & Frearson, [<reflink idref="bib7" id="ref82">7</reflink>]). In fact, Cooper and Frearson ([<reflink idref="bib7" id="ref83">7</reflink>]) reported that their participant's scores on both an idiosyncratic mood measure worsened throughout their intervention.</p> <hd id="AN0139027377-18">Smoking reduction</hd> <p>Results from the only study that received an adequate rating on the quality appraisal, Singh et al.'s ([<reflink idref="bib14" id="ref84">14</reflink>]) RCT, indicated that SoF effected a statistically significant reduction in smoking when compared to treatment as usual (<emph>p</emph> < 0.05, <emph>d</emph> = 0.70) (Singh et al., [<reflink idref="bib14" id="ref85">14</reflink>]). Follow‐up revealed that, compared to those in the TAU group, those in the mindfulness group were significantly more successful in abstaining from smoking at one‐year follow‐up. Singh et al.'s ([<reflink idref="bib14" id="ref86">14</reflink>]) results were supported by results from two single‐case design studies (changing criterion) conducted by the same researchers (Singh et al., [<reflink idref="bib16" id="ref87">16</reflink>]; *Singh, Lancioni, Winton, Singh, Singh, et al., [<reflink idref="bib19" id="ref88">19</reflink>]) using the same mindfulness intervention (SoF). *Singh, Lancioni, Winton, Singh, Singh, et al. ([<reflink idref="bib19" id="ref89">19</reflink>]) reported that their participant was able to reduce the number of cigarettes he smoked from an average of 12 a day at baseline to zero within three months. Furthermore, Singh et al.'s ([<reflink idref="bib16" id="ref90">16</reflink>]) three participants were able to reduce their cigarette smoking from daily averages of 28.4, 34.8 and 13.8 at baseline to zero within 111, 165 and 77 days, respectively. Follow‐up data, collected every three months, showed that the participants in both of these studies (Singh et al., [<reflink idref="bib16" id="ref91">16</reflink>]; *Singh, Lancioni, Winton, Singh, Singh, et al., [<reflink idref="bib19" id="ref92">19</reflink>]) were able to abstain from smoking for three years.</p> <hd id="AN0139027377-19">Psychological skills</hd> <p>Results from several studies using a range of third‐wave therapies converge to indicate that such interventions can significantly increase various psychological skills: acceptance and non‐judgement towards experience (Hall et al., [<reflink idref="bib10" id="ref93">10</reflink>]); self‐compassion (Hardiman et al., [<reflink idref="bib11" id="ref94">11</reflink>]); reduced in self‐criticism and unfavourable social comparisons (Clapton, Williams, Griffith, & Jones, [<reflink idref="bib6" id="ref95">6</reflink>]); willingness to experience aversive cognitions and emotions (Brown & Hooper, [<reflink idref="bib4" id="ref96">4</reflink>]; Pankey & Hayes, [<reflink idref="bib45" id="ref97">45</reflink>]); defusing from aversive cognitions and emotions (Pankey & Hayes, [<reflink idref="bib45" id="ref98">45</reflink>]); and taking action to meet behavioural goals (Pankey & Hayes, [<reflink idref="bib45" id="ref99">45</reflink>]).</p> <hd id="AN0139027377-20">DISCUSSION</hd> <p>This systematic review identified 20 studies reporting on third‐wave therapies for adults with intellectual disabilities. The most researched third‐wave therapy with this population was mindfulness. Other third‐wave therapies that have been used with adults with intellectual disabilities, but researched to a lesser extent, are DBT, CFT and ACT. Third‐wave therapies were delivered across a range of formats. Mindfulness and ACT were typically delivered on an individual basis, whereas DBT and CFT were delivered on both individual and group bases. There was marked variation in the length of interventions; however, on average, they lasted 35 weeks/8 sessions. Sessions lasted between 30 and 120 min. Shorter sessions were associated with interventions that were conducted on an individual basis (i.e., mindfulness), and longer sessions were associated with interventions conducted on a group basis (i.e., DBT). Only one intervention was designed specifically for people with intellectual disabilities, SoF. All other interventions were adapted from mainstream. Common adaptations accounted for reduced language abilities, less abstract thinking, poorer working memory and slower processing speed.</p> <p>Interventions were used to treat a number of problems, ranging from mental health problems/psychological distress, to challenging/offending behaviour, to smoking. In terms of mental health problems and psychological distress, the evidence for third‐wave therapies was mixed: third‐wave therapies improved some symptoms of mental health for some adults with intellectual disabilities. Conversely, third‐wave therapies were shown to be highly effective at reducing challenging and offending behaviour in the community, enabling participants to maintain "at‐risk" placements. Similarly, inpatient studies reported third‐wave therapies improved participants' aggression and self‐control. Some participants were able to stop displaying aggression for six months following intervention, enabling them to be transitioned into the community. Inpatient services reportedly used lower levels of observation, physical restraint, emergency medication and seclusion following intervention, resulting in a significant reduction (95.7%) in workforce costs (e.g., sickness and injury). Third‐wave therapies (i.e., SoF) were shown to be highly effective when used to help people with intellectual disabilities stop smoking. Results from a RCT demonstrated that the SoF produced a significant reduction in smoking compared to TAU. Two other studies reported that their participants were able to stop smoking altogether following the SoF intervention, maintaining this at three‐year follow‐up.</p> <p>Moreover, third‐wave therapies have been used to increase the use of a range of psychological skills with the adult intellectual disability population, including non‐judgement and acceptance, self‐compassion, reduced self‐criticism, unfavourable social comparison, willingness to experience aversive cognitions and emotions, defusing from aversive cognitions and emotions, and taking action to meet behavioural goals.</p> <hd id="AN0139027377-21">Limitations</hd> <p>A comprehensive evaluation of the methodological quality of the included studies revealed that the current evidence base is not yet at the stage where it can be considered established or promising (Reichow et al., [<reflink idref="bib47" id="ref100">47</reflink>]). The majority of studies, single case and group, were found to have weak research report strength. As such, findings reported in the present review should be interpreted with caution.</p> <p>Due to the considerable heterogeneity in the designs and outcomes used by studies, it was not possible to conduct a meta‐analysis. Meta‐analysis would have strengthened this review, as it would have enabled individual study effects to be pooled together to increase statistical power, which would have, in turn, helped generate an overall effect size that could have been generalized to the wider adult intellectual disability population. Moreover, meta‐analysis enables the investigation of publication bias, but at present, there is no way of knowing how publication bias might have influenced the results of this review, as research reporting that certain third‐wave interventions are ineffective might not have been published (i.e., the file‐drawer problem). This issue has been encountered in other reviews (e.g., Chapman et al., [<reflink idref="bib27" id="ref101">27</reflink>]; Dagnan, Jackson, & Eastlake, [<reflink idref="bib30" id="ref102">30</reflink>]).</p> <p>While the majority of studies recruited participants in the mild intellectual disability range, some recruited participants in the moderate intellectual disability range. The results of the present review, therefore, cannot be reliably extrapolated to adults with severe or profound intellectual disabilities. Sturmey ([<reflink idref="bib50" id="ref103">50</reflink>]) raised this issue in his critique: people with more significant degrees of intellectual disabilities, who have significantly limited language and abstract reasoning abilities, may not benefit from psychological therapies.</p> <hd id="AN0139027377-22">Comparison with previous reviews</hd> <p>The results from the present review are consistent with the results reported in previous reviews (Chapman et al., [<reflink idref="bib27" id="ref104">27</reflink>]; Hwang & Kearney, [<reflink idref="bib36" id="ref105">36</reflink>]): although third‐wave therapies have been found to produce positive outcomes for some clinical presentations, such a finding cannot be reliably extrapolated due to the poor methodological rigour of studies.</p> <hd id="AN0139027377-23">Research implications</hd> <p>It is important to consider that the different third‐wave therapies are at different stages in their empirical evaluation. While research is still attempting to establish whether ACT and CFT can be adapted for use with adults with intellectual disabilities, it has already been established that mindfulness‐based approaches and DBT are feasible with this population. For example, mindfulness and DBT both have manuals. Moreover, Singh et al.'s ([<reflink idref="bib17" id="ref106">17</reflink>]) study has suggested that third‐wave therapies may be cost‐effective. Researchers should continue to develop the evidence base for each of the third‐wave therapies evaluated in this review. Research on mindfulness‐based approaches and DBT should continue to focus on establishing whether these interventions are more effective than other evidence‐based interventions (i.e., CBT) and/or TAU using RCTs. The utility of future research will be maximized by employing more rigorous designs and using standardized outcome measures with sound psychometric properties, as this will enable a meta‐analysis to be conducted. Notably, several outcome measures with sound psychometric properties that can be used with people with intellectual disabilities have been identified (Vlissides, Golding, & Beail, [<reflink idref="bib55" id="ref107">55</reflink>]).</p> <p>Additionally, it is vitally important qualitative methodology is used to ask adults with intellectual disabilities about their experiences of third‐wave therapies. Only so much can be learnt from looking at changes in behaviour and scores on subjective measures. The invaluable views of adults with intellectual disabilities who have attended groups will help to identify (a) whether the different third‐wave therapies have been adapted sufficiently, and (b) which aspects of these interventions are most/least helpful.</p> <hd id="AN0139027377-24">Clinical implications</hd> <p>Results of this review's quality appraisal suggested that practice should wait for substantive high‐quality research evidence indicating that third‐wave therapies are effective when used with people with intellectual disabilities. However, the dissemination of this finding may be too late to halt the practice of third‐wave therapies with people with intellectual disabilities. Instead, it may be more useful to point practitioners towards the best evidence identified in this review. The only study that received an adequate research report strength rating and reported a significant effect was Singh et al.'s ([<reflink idref="bib14" id="ref108">14</reflink>]) RCT on the use of SoF to stop smoking.</p> <hd id="AN0139027377-25">CONCLUSION</hd> <p>The present review has found a number of third‐wave therapies that have been used with adults with intellectual disabilities. In terms of effectiveness, available evidence indicates that, as a collective, they can (a) sometimes improve symptoms associated with some mental health problems, (b) significantly reduce challenging behaviour and aggression across a range of settings, (c) stop smoking altogether and (d) increase a range of mindfulness skills. However, findings from the present review should be interpreted with caution due to the poor methodologies of included studies.</p> <ref id="AN0139027377-26"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref60" type="bt">1</bibl> <bibtext> *indicates that the papers were included in the systematic review.</bibtext> </blist> </ref> <ref id="AN0139027377-27"> <title> REFERENCES </title> <blist> <bibtext> *Adkins, A. D., Singh, A. N., Winton, A. S. W., McKeegan, G. F., & Singh, J. (2010). Using a mindfulness‐based procedure in the community: Translating research to practicee. Journal of Child and Family Studies, 19 (2), 175 – 183. https://doi.org/10.1007/s10826-009-9348-9</bibtext> </blist> <blist> <bibl id="bib2" idref="ref81" type="bt">2</bibl> <bibtext> *Ashworth, S., Mooney, P., & Tully, R. J. (2017). A case study demonstrating the effectiveness of an adapted‐DBT program upon increasing adaptive emotion management skills, with an individual diagnosed with mild learning disability and emotionally unstable personality disorder. Journal of Forensic Psychology Research and Practice, 17 (1), 38 – 60. https://doi.org/10.1080/15228932.2017.1251098</bibtext> </blist> <blist> <bibl id="bib3" idref="ref19" type="bt">3</bibl> <bibtext> *Boulton, N. E., Williams, J., & Jones, R. S. (2018). Could participant‐produced photography augment therapeutic interventions for people with intellectual disabilities? A systematic review of the available evidence. Journal of Intellectual Disabilities, 22 (1), 74 – 95. https://doi.org/10.1177/1744629516663027</bibtext> </blist> <blist> <bibl id="bib4" idref="ref96" type="bt">4</bibl> <bibtext> *Brown, F. J., & Hooper, S. (2009). Acceptance and commitment therapy (ACT) with a learning disabled young person experiencing anxious and obsessive thoughts. 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  Data: Third-Wave Therapies and Adults with Intellectual Disabilities: A Systematic Review
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  Data: <searchLink fieldCode="AR" term="%22Patterson%2C+Christopher+Wynne%22">Patterson, Christopher Wynne</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-1718-8559">0000-0003-1718-8559</externalLink>)<br /><searchLink fieldCode="AR" term="%22Williams%2C+Jonathan%22">Williams, Jonathan</searchLink><br /><searchLink fieldCode="AR" term="%22Jones%2C+Robert%22">Jones, Robert</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Applied+Research+in+Intellectual+Disabilities%22"><i>Journal of Applied Research in Intellectual Disabilities</i></searchLink>. Nov 2019 32(6):1295-1309.
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  Data: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA
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  Data: 15
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  Data: Journal Articles<br />Information Analyses
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  Data: <searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Intellectual+Disability%22">Intellectual Disability</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Treatment%22">Outcomes of Treatment</searchLink><br /><searchLink fieldCode="DE" term="%22Research+Reports%22">Research Reports</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Modification%22">Behavior Modification</searchLink><br /><searchLink fieldCode="DE" term="%22Metacognition%22">Metacognition</searchLink><br /><searchLink fieldCode="DE" term="%22Altruism%22">Altruism</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Smoking%22">Smoking</searchLink><br /><searchLink fieldCode="DE" term="%22Psychotherapy%22">Psychotherapy</searchLink>
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  Data: 10.1111/jar.12619
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  Data: 1360-2322
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  Data: Background: Third-wave therapies appear to produce positive outcomes for people without intellectual disabilities. This systematic review aimed to establish which third-wave therapies have been adapted for adults with intellectual disabilities and whether they produced positive outcomes. Method: Four databases were searched systematically (PsycINFO, Web of Science, MEDLINE and PubMed), yielding 1,395 results. Twenty studies (N = 109) met the present review's inclusion/exclusion criteria. Results: Included studies used mindfulness-based approaches, dialectical behaviour therapy, compassion focused therapy and acceptance and commitment therapy. Due to considerable heterogeneity in the designs and outcome measures used, a meta-analysis was not possible. Conclusions: Evidence indicated that third-wave therapies improved mental health symptoms for some and improved challenging/offending behaviour, smoking and mindfulness/acceptance skills for most. These findings must be interpreted with caution due to the low methodological quality of included studies. Future research should build on the current evidence base, using scientifically rigorous designs and standardized measures.
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        Type: general
      – SubjectFull: Intellectual Disability
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      – SubjectFull: Outcomes of Treatment
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      – SubjectFull: Behavior Modification
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      – SubjectFull: Altruism
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      – SubjectFull: Symptoms (Individual Disorders)
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      – SubjectFull: Smoking
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      – SubjectFull: Psychotherapy
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      – TitleFull: Third-Wave Therapies and Adults with Intellectual Disabilities: A Systematic Review
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          Numbering:
            – Type: volume
              Value: 32
            – Type: issue
              Value: 6
          Titles:
            – TitleFull: Journal of Applied Research in Intellectual Disabilities
              Type: main
ResultId 1