Facing your fears together: development and efficacy of peer-mentored CBT in adolescents with mild intellectual disability

Background and aim: The overall aim of this project is to create a tailored and personalized CBT intervention for adolescents with Mild Intellectual Disability (MID) with anxiety disorders. There are no effective interventions for anxiety problems in adolescents with MID, while anxiety disorders are more prevalent than in typically developing adolescent. Personalized approaches are necessary because of large heterogeneity in IQ scores, adaptive skills and comorbid problems. Research on CBT for anxiety shows much lower response rates in individuals with MID. In this project I propose to create an effective treatment for anxiety in MID by optimizing CBT delivery to the special needs of MID clients and by enhancing CBT efficacy by using peer-influence as an unexplored, potentially powerful port-of-entry for interventions specific to this group. This is based on my experimental research where I show that adolescents with MID are extremely sensitive to peer-feedback. Hence the key objective of the proposed project is to develop and test a novel intervention: Peer-mentored CBT. Based on my extensive experience with this challenging group I am convinced that inclusion of peers can significantly improve treatment. Intervention: I have based the intervention on intensive exposure therapy as this fit well with what we know works with adolescents with MID. Among other things it is focused on learning through doing which is essential to learning new skills in the MID group. The intervention includes three intensive exposure sessions. To enhance efficacy I will include peer-mentoring in two of these sessions. Based on the literature on peer influence in adolescents the first exposure session includes peer-modelling, and the second exposure session includes peer-feedback. In the third and final exposure session clients will practice exposure without the peer present. The peer-mentors are clients who themselves have finished the peer-mentored CBT. The decision to ask former clients as peer-mentors was based on discussions with former clients and an experienced expert (‘ervaringsdeskundige’) who has MID herself. Project overview: In this project I will first refine the proposed intervention using input from therapists and clients and will test efficacy using a baseline-controlled study with the following research questions: -Is peer-mentored CBT successful in reducing anxiety symptoms in adolescents with MID? -Are individual differences in treatment success predicted by individual differences in participant characteristics such as IQ, gender, adaptive skills, resistance to peer-influence, attachment to peers and social extinction-learning rate? -Is peer mentoring successful in consolidating treatment effects for the peer-mentor as evidenced by further reduction in anxiety or avoidance or an increase in self-efficacy? I will finish the project by conducting in-dept interviews to obtain rich information on the experiences of clients and therapists during the intervention and will use this to further refine the manual for peer-mentored CBT. If proven effective, I will make the manual available to therapists. Bridging the gap between science and practice: These ideas were developed in discussion with clients and form a bridge between science and practice. They arise out of the need to improve mental health care for an understudied group. The ideas are therefore perfectly aligned with the goal of this call. By working with a team of clinicians, scientist-practitioners and scientists I will ensure the sound development, testing and implementation of this novel intervention both clinically and scientifically. Personal motivation: The topic is close to my heart; from my clinical work it is clear to me that we may not be taking optimal care of adolescents with MID and psychiatric problems. Especially for affective problems and anxiety we lack targeted effective interventions that fulfil the needs of this group. Furthermore, they often feel misunderstood by their adult therapists, especially as standardized treatments may not meet their special needs. The lack of knowledge on what works for adolescents with MID is staggering. I see it as my personal mission to improve this situation through opinion pieces, symposia and book about enhancing inclusive education for MID. My next step is to focus efforts on state-of-the art enhancements of anxiety treatment. I am certain that including peer-mentors and advanced measurement tactics like rich multiple daily measured time-series will improve mental-healthcare for adolescents with MID in a meaningful way.