Linda Clare

University of Toronto, Toronto, Ontario, Canada

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Publications (155)340.19 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Insufficient attention has been paid to the influence of psychological and social factors on discrepancy-based measures of awareness. The present study tested a biopsychosocial model of awareness in early-stage dementia by gathering evidence regarding the relative contributions of neuropsychological, individual psychological and social factors to the level of scoring on measures used to index awareness. Awareness was assessed in relation to memory, activities of daily living and social functioning in 101 individuals with early-stage dementia participating in the Memory Impairment and Dementia Awareness (MIDAS) Study. People with dementia (PwD) and carers also completed measures of individual psychological and social variables, and PwD completed measures of neuropsychological functioning. Scores on discrepancy-based indices of awareness and on the self-ratings and informant ratings contributing to these indices were associated with a range of factors including neuropsychological functioning of PwD, individual traits and dispositions and current affective functioning of PwD, socio-demographic characteristics of PwD and carers, carer well-being and carer perceptions of PwD and of quality of relationship with PwD. Patterns of association varied across domains of functioning. The findings support the relevance of a biopsychosocial approach to understanding the factors that influence unawareness of impairment in dementia.
    International Journal of Geriatric Psychiatry 03/2011; 27(2):167-77. · 2.98 Impact Factor
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    ABSTRACT: To determine whether people with dementia (PwD), and carers of PwD, show a processing bias to dementia-related words in an emotional Stroop task, and if so, whether the presence of such a bias is related to level of explicit awareness of the condition. Seventy-nine people with early stage Alzheimer's disease (AD), vascular or mixed dementia, and their carers, completed an emotional Stroop task. Time taken to colour-name dementia-related and neutral words was compared within and between groups. Additionally, as a comparison, ratings of the awareness of the condition shown by PwD were made on the basis of a detailed interview with each PwD and his/her carer. PwD and carers showed the same level of increase in response times to salient compared to neutral words. In the PwD this effect was unrelated to the degree of awareness that they demonstrated regarding the condition. The emotional Stroop effect in response to dementia-related words in PwD indicates that preserved implicit awareness of the condition can be elicited even where there is reduced explicit awareness.
    International Journal of Geriatric Psychiatry 01/2011; 26(1):92-9. · 2.98 Impact Factor
  • Lisa S. Caddell, Linda Clare
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    ABSTRACT: Research suggests that the onset and progression of dementia may pose a threat to a person’s sense of identity. This qualitative study used Interpretative Phenomenological Analysis to explore participants’ perceptions of the impact of dementia on their identity. Participants were ten people with dementia. The four themes emerging from the data represented participants’ views on aspects of their current identities, whether they believed that dementia would alter their identities in the future, perceptions of how dementia had affected their lifestyle, and relationships with friends and family. The analysis suggested that for the most part, participants felt that little had changed with respect to their identities as a whole, but most identified features of themselves that were different than they had been prior to the onset of dementia. Thus it appeared that participants were in a state of flux, experiencing both continuity and change in their sense of identity simultaneously.
    Dementia 01/2011; 10(3):379-398.
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    ABSTRACT: Evidence from some, but not all non-randomised studies suggest the possibility that cognitive training may influence cognitive functioning in older people. Due to the differences among cognitive training interventions reported in the literature, giving a general overview of the current literature remains difficult. To systematically review the literature and summarize the effect of cognitive training interventions on various domains of cognitive function (ie memory, executive function, attention and speed) in healthy older people and in people with mild cognitive impairment. The CDCIG Specialized Register was searched on 30 September 2007 for all years up to December 2005. The Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL were searched separately on 30 September 2007 to find trials with healthy people. These results were supplemented by searches from January 1970 to September 2007 in PsychInfo/Psyndex, ISI Web of Knowledge and PubMed. RCTs of interventions evaluating the effectiveness of cognitive training for healthy older people and people with mild cognitive impairment from 1970 to 2007 that met inclusion criteria were selected. Authors independently extracted data and assessed trial quality. Meta-analysis was performed when appropriate. Only data on memory training could be pooled for analysis. Within this domain, training interventions were grouped according to several outcome variables. Results showed that for healthy older adults, immediate and delayed verbal recall improved significantly through training compared to a no-treatment control condition. We did not find any specific memory training effects though as the improvements observed did not exceed the improvement in the active control condition. For individuals with mild cognitive impairment, our analyses demonstrate the same pattern. Thus, there is currently little evidence on the effectiveness and specificity of memory interventions for healthy older adults and individuals with mild cognitive impairment. There is evidence that cognitive interventions do lead to performance gains but none of the effects observed could be attributable specifically to cognitive training, as the improvements observed did not exceed the improvement in active control conditions. This does not mean that longer, more intense or different interventions might not be effective, but that those which have been reported thus far have only limited effect. We therefore suggest more standardized study protocols in order to maximize comparability of studies and to maximize the possibility of data pooling - also in other cognitive domains than memory.
    Cochrane database of systematic reviews (Online) 01/2011; · 5.70 Impact Factor
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    ABSTRACT: Delirium is a state of confusion characterized by an acute and fluctuating decline in cognitive functioning. Delirium is common and deadly in older adults with dementia, and is often referred to as delirium superimposed on dementia, or DSD. Interventions that treat DSD are not well-developed because the mechanisms involved in its etiology are not completely understood. We have developed a theory-based intervention for DSD that is derived from the literature on cognitive reserve and based on our prior interdisciplinary work on delirium, recreational activities, and cognitive stimulation in people with dementia. Our preliminary work indicate that use of simple, cognitively stimulating activities may help resolve delirium by helping to focus inattention, the primary neuropsychological deficit in delirium. Our primary aim in this trial is to test the efficacy of Recreational Stimulation for Elders as a Vehicle to resolve DSD (RESERVE- DSD). This randomized repeated measures clinical trial will involve participants being recruited and enrolled at the time of admission to post acute care. We will randomize 256 subjects to intervention (RESERVE-DSD) or control (usual care). Intervention subjects will receive 30-minute sessions of tailored cognitively stimulating recreational activities for up to 30 days. We hypothesize that subjects who receive RESERVE-DSD will have: decreased severity and duration of delirium; greater gains in attention, orientation, memory, abstract thinking, and executive functioning; and greater gains in physical function compared to subjects with DSD who receive usual care. We will also evaluate potential moderators of intervention efficacy (lifetime of complex mental activities and APOE status). Our secondary aim is to describe the costs associated with RESERVE-DSD. Our theory-based intervention, which uses simple, inexpensive recreational activities for delivering cognitive stimulation, is innovative because, to our knowledge it has not been tested as a treatment for DSD. This novel intervention for DSD builds on our prior delirium, recreational activity and cognitive stimulation research, and draws support from cognitive reserve theory. identifier: NCT01267682
    Trials 01/2011; 12:119. · 2.21 Impact Factor
  • Alzheimers & Dementia - ALZHEIMERS DEMENT. 01/2011; 7(4).
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    Linda Clare
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    ABSTRACT: Neuropsychological assessment is a systematic approach to evaluating a patient's cognitive functioning and identifying the nature, extent and severity of any impairments. Standardized tests provide results that can be compared with normative data to provide a profile of the patient's strengths and difficulties. This chapter outlines the principles of neuropsychological testing, explains the use of normative data, and describes the way in which standardized tests are used to identify and characterise impairments. The aims and scope of neuropsychological assessment of the older person are discussed, and the process of assessment is described. The information provided by a neuropsychological assessment can make an important contribution to decisions about diagnosis, management and intervention.
    12/2010: pages 135 - 140; , ISBN: 9780470669600
  • Lisa Caddell, Linda Clare
    Gerontological Society of America 2010; 11/2010
  • Jeanette M Thom, Linda Clare
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    ABSTRACT: Evidence suggests that exercise and some cognition-focused intervention approaches can be used to elicit functional improvements in older people and, to some degree, those diagnosed with dementia. Independently, the two intervention types have been found to improve functional performance in people with dementia. The mechanisms underpinning these improvements come from comparable and diverse pathways. This suggests that it may be beneficial for the two intervention types to be coupled as part of regular care in individuals with a range of cognitive impairments. The aims of this review are threefold. The first aim is to present evidence to support the use for combining exercise and cognition-focused interventions. This will be achieved by reviewing the mechanisms of both approaches in improving functional performance in older people and in people with dementia and summarising recent progress. The increased risk of depression, falls and cardiovascular disease risk in people with dementia will also be highlighted. The second aim is to discuss the parameters of the two approaches that should be considered when combining them in terms of possible efficient models, especially in relation to exercise protocols as this is where the current literature shows the most promising outcomes. Maximisation of the efficacy of preventative and treatment interventions which focus on both cognitive functioning and physical health should lead to improving and extending functional independence. Key aspects of any combined intervention would involve the inclusion of both cardiovascular and other types of exercises, including falls reduction, and exercises addressing memory and executive function via goal setting in the real-life context. The third aim is to explore some of the issues that may arise when attempting to incorporate interventions into the regular treatment of people with dementia. Consideration must also be given to caregivers and the education of health professionals as well as to the mode of intervention itself. Further research is necessary in order to discern the most effective types of both intervention models. Provision of combined interventions might enhance the improvements in functional independence in people with dementia over and above the interventions being used separately.
    Gerontology 10/2010; 57(3):265-75. · 2.68 Impact Factor
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    ABSTRACT: Delirium is a common neuropsychiatric syndrome that occurs most frequently in older adults with dementia and is referred to as delirium superimposed on dementia (DSD). Our aim in this pilot project was to demonstrate that implementation of cognitively stimulating activities is clinically feasible and has potential to reduce delirium severity and duration and functional loss in post-acute care settings. We randomized newly admitted participants with DSD to treatment (n = 11) and control (n = 5) conditions and conducted daily blinded assessments of delirium, delirium severity, and functional status for up to 30 days. The control group had a significantly greater decrease in physical function and mental status over time compared with the intervention group. Delirium, severity of delirium, and attention approached significance, and improvement over time favored the intervention group. Although not statistically significant, a difference in mean (7.0 versus 3.27) and median (7.0 versus 3.0) days with delirium was found, with the control group having more days of delirium.
    Research in Gerontological Nursing 10/2010; 4(3):161-7. · 0.66 Impact Factor
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    ABSTRACT: To provide evidence regarding the clinical efficacy of cognitive rehabilitation (CR) in early-stage Alzheimer disease (AD). Single-blind randomized controlled trial comparing CR with relaxation therapy and no treatment. Outpatient, community-based setting. Sixty-nine individuals (41 women, 28 men; mean age 77.78 years, standard deviation 6.32, range = 56-89) with a diagnosis of AD or mixed AD and vascular dementia and a Mini-Mental State Examination score of 18 or above, and receiving a stable dose of acetylcholinesterase-inhibiting medication. Forty-four family carers also contributed. Eight weekly individual sessions of CR consisting of personalized interventions to address individually relevant goals supported by components addressing practical aids and strategies, techniques for learning new information, practice in maintaining attention and concentration, and techniques for stress management. The primary outcomes were goal performance and satisfaction, assessed using the Canadian Occupational Performance Measure. Questionnaires assessing mood, quality of life and career strain, and a brief neuropsychological test battery were also administered. A subset of participants underwent functional magnetic resonance imaging (fMRI). CR produced significant improvement in ratings of goal performance and satisfaction, whereas scores in the other two groups did not change. Behavioral changes in the CR group were supported by fMRI data for a subset of participants. The findings support the clinical efficacy of CR in early-stage AD. CR offers a means of assisting people with early-stage AD and their families in managing the effects of the condition.
    The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry 10/2010; 18(10):928-39. · 3.35 Impact Factor
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    ABSTRACT: It has been suggested that “memory retraining” has no lasting effect beyond the end of the treatment session (Rabins, 1996). Although this is contradicted by cognitive rehabilitation studies showing that gains can be demonstrated and maintained, few researchers have presented long-term follow-up data. Recent studies (Clare, Wilson, Breen, & Hodges, 1999; Clare et al., 2000) have provided post-intervention follow-up data for one participant that was collected over a 9 month period, during which performance on trained face-name associations remained at ceiling levels. This paper reports a further, naturalistic follow-up of this participant over an additional period of two years, during which his recall of 10 trained face-name associations was evaluated and compared to performance on three untrained, previously-known items retained as part of the full set of stimulus materials throughout the whole study. Recall remained relatively stable over year 1 and showed a modest decline for both trained and previouslyknown items during year 2. Differences between year 1 and year 2 were significant only for untrained items. At the end of year 2, performance on trained items remained well above initial baseline levels. These results are discussed in the context of information derived from neuropsychological assessment, scans and self-report measures. It is argued, on the basis of the results presented here, that long-term maintenance of gains resulting from targeted cognitive rehabilitation interventions is possible, and that in view of this it will be important to evaluate the broader impact of cognitive rehabilitation interventions on quality of life and on the progression of dementia.
    Neuropsychological Rehabilitation 09/2010; 11(3):477-494. · 2.01 Impact Factor
  • Linda Clare, Bob Woods
    Neuropsychological Rehabilitation 09/2010; July(2001):193-196. · 2.01 Impact Factor
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    ABSTRACT: To compare memory evaluations in healthy older people and people with Alzheimer's disease (AD) and present standardised individual and dyadic methods for classifying degree of memory awareness in the participants with dementia. Cross-sectional study evaluating awareness of memory functioning and performance and providing normative data for healthy individuals and couples, together with comparison data from people with AD. As a group, older people are reasonably accurate raters of their own memory functioning and performance, although considerable individual differences can be observed, and control dyads show good comparative accuracy. Comparing normative data from the control group to data from participants with AD confirms that significant overestimation is a frequent feature among people with dementia, with approximately two-thirds showing this pattern, although significant under-estimation is also reliably observed in a small proportion of people with dementia. Different types of measure elicit different profiles of memory awareness in participants with dementia. Normative data from older individuals and couples provides useful percentile-based indices for determining level of memory awareness in people with dementia.
    Aging Neuropsychology and Cognition 03/2010; 17(4):462-91. · 1.07 Impact Factor
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    ABSTRACT: Delirium superimposed on dementia (DSD) accelerates the trajectory of functional decline and results in prolonged hospitalization, re-hospitalization, premature nursing home placement, and death. In this article we propose a theory-based intervention for DSD that is derived from the literature on cognitive reserve and neuroplasticity. We begin by defining cognitive reserve, the guiding framework for our hypothesis. We review the pathophysiology and neuropsychology of delirium noting the similarities with dementia-these two conditions reflecting acute and chronic reductions in cognitive reserve, respectively. We then review the evidence for activity-dependent plasticity as a possible mechanism for sparing cognitive reserve in dementia and its potential for addressing DSD. Cognitive training (CT) in the form of stimulating activities has been shown to evoke cognitive processing and facilitate plasticity in dementia. Because of the similarities between dementia and delirium, the use of recreational activities as a vehicle for supporting attentional capacity, and delivering cognitive stimulation, may hold promise for the resolution of DSD. Based on integrated evidence from the literature, we hypothesize that engagement in cognitively stimulating recreational activities will help reduce delirium severity and duration in persons with dementia while providing improved quality of life and reduced costs of care.
    Aging and Mental Health 03/2010; 14(2):232-42. · 1.68 Impact Factor
  • Linda Clare
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    ABSTRACT: Although awareness has been extensively researched in relation to people with dementia, studies have focussed mainly on people who have dementia of mild to moderate severity. Consequently, relatively little is known about awareness in people with severe dementia, and there is no clear conceptual framework to indicate how this should be understood or investigated. This review presents a conceptual framework for considering awareness in people with moderate to severe dementia which distinguishes fundamental awareness of sensory and perceptual stimuli and three levels of awareness involving more complex cognitive operations, termed 'on-line monitoring', 'evaluative judgement' and 'meta-representation', and provides an integration of the available evidence regarding each level. Findings indicate that sensory and perceptual awareness can be detected even in people with very severe or end-stage dementia, while some aspects of complex awareness may be retained into the severe stages. The environmental context and the nature of caregiving interactions influence the extent to which awareness is expressed. There may be scope for enhancing the expression of some aspects of awareness in people with moderate to severe dementia, but this should only be undertaken where it is likely to improve quality of life. Understanding more about awareness is an important element in the provision of high-quality care for people with moderate to severe dementia.
    Aging and Mental Health 01/2010; 14(1):20-32. · 1.68 Impact Factor
  • Alzheimers & Dementia - ALZHEIMERS DEMENT. 01/2010; 6(4).
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    ABSTRACT: Nonpharmacological therapies (NPTs) can improve the quality of life (QoL) of people with Alzheimer's disease (AD) and their carers. The objective of this study was to evaluate the best evidence on the effects of NPTs in AD and related disorders (ADRD) by performing a systematic review and meta-analysis of the entire field. Existing reviews and major electronic databases were searched for randomized controlled trials (RCTs). The deadline for study inclusion was September 15, 2008. Intervention categories and outcome domains were predefined by consensus. Two researchers working together detected 1,313 candidate studies of which 179 RCTs belonging to 26 intervention categories were selected. Cognitive deterioration had to be documented in all participants, and degenerative etiology (indicating dementia) had to be present or presumed in at least 80% of the subjects. Evidence tables, meta-analysis and summaries of results were elaborated by the first author and reviewed by author subgroups. Methods for rating level of evidence and grading practice recommendations were adapted from the Oxford Center for Evidence-Based Medicine. Grade A treatment recommendation was achieved for institutionalization delay (multicomponent interventions for the caregiver, CG). Grade B recommendation was reached for the person with dementia (PWD) for: improvement in cognition (cognitive training, cognitive stimulation, multicomponent interventions for the PWD); activities of daily living (ADL) (ADL training, multicomponent interventions for the PWD); behavior (cognitive stimulation, multicomponent interventions for the PWD, behavioral interventions, professional CG training); mood (multicomponent interventions for the PWD); QoL (multicomponent interventions for PWD and CG) and restraint prevention (professional CG training); for the CG, grade B was also reached for: CG mood (CG education, CG support, multicomponent interventions for the CG); CG psychological well-being (cognitive stimulation, multicomponent interventions for the CG); CG QoL (multicomponent interventions for PWD and CG). NPTs emerge as a useful, versatile and potentially cost-effective approach to improve outcomes and QoL in ADRD for both the PWD and CG.
    Dementia and Geriatric Cognitive Disorders 01/2010; 30(2):161-78. · 2.79 Impact Factor
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    ABSTRACT: Quality of residential care for people with severe dementia is in urgent need of improvement. One reason for this may be the assumption that people with severe dementia are unaware of what is happening to them. However, there is converging evidence to suggest that global assumptions of unawareness are inappropriate. This trial platform study aims to assist care staff in perceiving and responding to subtle signs of awareness and thus enhance their practice. In Stage One, a measure of awareness in severe dementia will be developed. Two focus groups and an expert panel will contribute to item and scale development. In Stage Two observational data will be used to further develop the measure. Working in four care homes, we will recruit 40 individuals with severe dementia who have no, or very limited, verbal communication. Data on inter-rater reliability and frequency of all items and exploratory factor analysis will be used to identify items to be retained. Test-retest and inter-rater reliability for the new measure will be calculated. Correlations with scores for well-being and behaviour and with proxy ratings of quality of life will provide an indication of concurrent validity. In Stage Three the new measure will be used in a single blind cluster randomised trial. Eight care homes will participate, with 10 residents recruited in each giving a total sample of 80 people with severe dementia. Homes will be randomised to intervention or usual care conditions. In the intervention condition, staff will receive training in using the new measure and will undertake observations of designated residents. For residents with dementia, outcomes will be assessed in terms of change from baseline in scores for behaviour, well-being and quality of life. For care staff, outcomes will be assessed in terms of change from baseline in scores for attitudes, care practice, and well-being. The results will inform the design of a larger-scale trial intended to provide definitive evidence about the benefits of increasing the sensitivity of care staff to signs of awareness in residents with severe dementia. ISRCTN59507580
    Trials 01/2010; 11:73. · 2.21 Impact Factor
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    ABSTRACT: Research evidence from observational studies suggests that cognitive activity reduces the risk of cognitive impairment in later life as well as the rate of cognitive decline of people with dementia. The Promoting Healthy Ageing with Cognitive Exercise (PACE) study has been designed to determine whether a cognitive activity intervention decreases the rate of cognitive decline amongst older adults with mild cognitive impairment (MCI). The study will recruit 160 community-dwelling men and women aged 65 years of age or over with mild cognitive impairment (MCI). Participants will be randomly allocated to two treatment groups: non-specific education and cognitive activity. The intervention will consist of ten 90-minute sessions delivered twice per week over a period of five weeks. The primary outcome measure of the study is the change from baseline in the total score on the Cambridge Cognitive Score (CAMCOG). Secondary outcomes of interest include changes in memory, attention, executive functions, mood and quality of life. Primary endpoints will be collected 12, 52 and 104 weeks after the baseline assessment. The proposed project will produce the best available evidence on the merits of increased cognitive activity as a strategy to prevent cognitive decline among older adults with MCI. We anticipate that the results of this study will have implications for the development of evidence-based preventive strategies to reduce the rate of cognitive decline amongst older people at risk of dementia. ACTRN12608000556347.
    Trials 12/2009; 10:114. · 2.21 Impact Factor

Publication Stats

3k Citations
340.19 Total Impact Points


  • 2014
    • University of Toronto
      • Department of Psychology
      Toronto, Ontario, Canada
    • Betsi Cadwaladr University Health Board
      Bangon, Wales, United Kingdom
  • 2004–2014
    • Bangor University
      • School of Psychology
      Bangon, Wales, United Kingdom
  • 2013
    • Australian National University
      • Centre for Research on Ageing, Health & Wellbeing (CRAHW)
      Canberra, Australian Capital Territory, Australia
  • 2011–2013
    • La Trobe University
      • Faculty of Science, Technology and Engineering
      Melbourne, Victoria, Australia
    • MRC Cognition and Brain Sciences Unit
      Cambridge, England, United Kingdom
  • 2009–2013
    • University of Western Australia
      • • Western Australian Centre for Health and Ageing
      • • School of Psychiatry and Clinical Neurosciences
      Perth, Western Australia, Australia
    • Hinchingbrooke Health Care NHS Trust
      Huntingdon, England, United Kingdom
    • University of Zurich
      Zürich, Zurich, Switzerland
  • 2012
    • Lancaster University
      • Spectrum Centre for Mental Health Research
      Lancaster, ENG, United Kingdom
  • 2008
    • West London Mental Health NHS Trust
      Londinium, England, United Kingdom
  • 2004–2008
    • University of Wales
      Cardiff, Wales, United Kingdom
  • 2007
    • Humboldt-Universität zu Berlin
      • Department of Psychology
      Berlin, Land Berlin, Germany
  • 2006–2007
    • University of Queensland 
      • • Department of Occupational Therapy
      • • School of Health and Rehabilitation Sciences
      Brisbane, Queensland, Australia
    • Griffith University
      • School of Applied Psychology
      Brisbane, Queensland, Australia
    • University of Birmingham
      • School of Psychology
      Birmingham, ENG, United Kingdom
  • 2005
    • Sapienza University of Rome
      Roma, Latium, Italy
  • 2000–2003
    • University College London
      • Department of Clinical, Educational and Health Psychology
      London, ENG, United Kingdom