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I undertook my placement in a day centre for adults with intellectual disabilities. Mount Eagle Lodge is also a residential home to 4 clients and has one respite bed. There is a wide range of intellectual disabilities that are cared for in this centre ranging from Down syndrome to autism to different behavioural problems.
The client that I was working with was an adult male in his mid-fifties. He has been diagnosed as having ASD (Autistic Spectrum Disorder). ASD is a developmental disability which affects the function of some parts of the brain and central nervous system (Gallaher, 2009). This client is prone to phases of anxiety which manifests in poor mobility, repetitive conversations and episodes of soiling himself. Due to his high level of hyper-activity and anxiety the client was given a number of exercises to complete two times daily as part of the Handle Program to relax and calm him. In particular Client A had problems with repetitiveness, both in speech and mannerisms, and constantly needs reassurance in himself. This Client's anxiety is at a severely high level and the simplest of things could send him into an erratic frenzy.
What is the HANDLE program?
The intervention which I have chosen for my intervention paper is 'The Handle Program'. The 'HANDLE' (Holistic Approach to Neuro-Development and Learning Efficiency) is an integrated program devised of a series of exercises that helps the left and right sides of the brain to work together. It is a simple, empowering, non-medicated approach to dealing with neurodevelopmental irregularities, such as learning disabilities, ADHD, autism and brain injuries, which is designed to enhance neurological systems that are causing learning, social or life difficulties (The HANDLE Institute, 2012). As no two cases of learning disabilities are the same, the exercises used for each case is also unique to the client. The program is devised especially for the client and designed to reach that individual's needs. The client's case is first analysed by a HANDLE professional and it is that person that decides what exercises should be done to meet the individual's needs.
The exercises used, although simple in nature, are used as a developmental tool treating the individual's problems at the core rather than offering a short term solution. Bluestone, the creator of the HANDLE program, theorised that the program relies on the perception that the individual's body will make its needs, weaknesses and strengths known, and that it is the HANDLE practitioner's job to interpret the indications the body has given in order to generate a comprehensive guide to the individual's neurodevelopmental profile (Enhanced Learning and Growth, 2012).
In the case of the client in which I was working with the HANDLE program was preformed twice daily, one in the morning and once in the afternoon. Different exercises are carried out in the morning and in the afternoon. As part of my placement I undertook the position of the morning HANDLE practitioner. This involved me carrying out the exercise plan that had been created for the individual each morning. This involved me carrying out the exercise plan that had been created for the individual each morning. It was important that the activities be carried out in a quiet, relaxed environment thus we used the 'relaxation room' to perform the activities.
Explanation of Intervention
The program carried out included a number of exercises each with their own benefits and reasons for being part of an individual's program. The client in which I was working with completed a total of ten simple exercises as part of his routine, this included: The Peace-Maker, Side-to-Side tip, Accentuation, Face tapping, Head tapping, Crazy Straw, Hug and Tug, Association, Three Quarter Head Roll, Circles and Slap and Clap. The activities involved in the program are part of an integrated system, if one activity is stopped then it could subsequently have a negative effect on another activity.
The Exercises and their benefits
Accentuation: This is a rhythmical activity. The idea of the exercise is to incorporate a simple everyday nursery rhyme into a simple rhythm that the client must repeat by slapping the palms of his hands on his legs e.g. 'This old man' to the rhythm of left, left, right. Although simple in nature the activity is highly beneficial. The benefits include enhanced differentiation of movement, reinforce laterality and helps to balance bodily functions such as respiration and elimination. The latter benefit being the main reason as to why this exercise was incorporated into my client's HANDLE program. This exercise for the client proved hard at first, and was one of the longest to get a handle on due to the rhythm that needs to be followed. The client in the past has had a problem with soiling himself when becoming overly anxious, frustrated or excited. Although there has not been a huge progress in this area, there is signs of improvement.
Side-to-Side Tip: This exercise is done by supporting either side of the client's head and moving the head downward on each side, this is held for 3 seconds on each side. The reason for this exercise is to improve the vestibular system or the human balance system. This is an important aspect of the program for this client as his balance is very poor and in instances of anxiety and manic behaviour it becomes worse. As well as enhancing balance, it also is used as a tool to sharpen hearing and the ability to keep the eyes focused. This exercise was used in the morning for the benefits of balance and focus. This exercise was harder to perform with the client as he would did not like anyone to touch his head. Therefore it had to be done a certain way in order for the client to allow the activity to be completed. Ryaskin (2004) holds the concept that many people within the autism spectrum often have an aversion to touch. In my client's case, he had an aversion to touching his head. Although not simply done, we were able to come up with a compromise and allowed the client to demonstrate how he would be comfortable doing the exercise.
Face-Tapping: This is done by using two fingers on each hand and rapidly and rhythmically alternating between hands. This activity does not cause pain or discomfort to the client.
This activity is generally to relax the client. When performed correctly the client usually appears relaxed and clam, however if it is done wrong the client would become agitated and as a result start showing erratic tendencies. The exercises organises, awakens and relaxes the trigeminal nerve (The HANDLE Institute)- this is the nerves that is responsible for sensation in the face. There are many benefits that come with this exercise including enhanced speech production, relief from face tics and also gives rise to a sense of calmness as well as opening the sinuses. Similar to the above exercise, the client was showed resistance to this exercise in the beginning. However when carried out carefully and gently a number of times when he allowed it, he became less and less resistant.
Hug and Tug: This exercise, for the client which I was working with, was carried out in two steps. Firstly it was done with the practitioner and then by himself. How this works is the client, while sitting, holds their hands in front of them. They then link their index fingers, they then squeeze and pull the interlocked fingers whilst saying something that they'd like to achieve e.g. 'I will where my black shoes'. This is then repeated with each of the fingers.
This activity is used to enhance interhemispheric integration and articulation (The HANDLE Istitute). The 'Hug and Tug' improves the muscle tone of the fingers as well as promoting differentiation of the fingers and each hand to the client and also helps to relax and focus the individual. The main reason for using this exercise was the fact that the game is used as a memory technique and stimulates the brain to memorise the command that is being said e.g. 'I will wear my black shoes'. The repetition used whilst 'tugging' on the fingers becomes a mnemonic for the client. This is the exercise where most improvement has been shown. Approximatly two weeks from the beginning of the program the client began 'wearing his black shoes' and achieved one of his goals. The phrase that is being used can be changed throughout the program.
Slap and Clap: This exercise is quite similar to the clapping games that are played throughout childhood. The activity involves two people, the client and the practitioner, sitting opposite. Both clap hands in front of their chest and then reach out to clap each of their hands together. This is an activity that had to be worked on with my client as he did not understand the concept of the exercise. It took us almost three to four weeks before he was able to fully carry out this activity.
The purpose of using this activity is to improve differentiation and also improving visual spatial skills (The HANDLE Institute). This activity though it proved hard for the client at first, ended up having a big effect on him. For the client this turned out to be a fun and exciting game. Though it is hard to say if the activity is showing progress, it works in conjunction with the other activities, therefore it may be showing improvement in the client through the other activities.
Why the exercises were used?
Each exercise that is used has its own benefits for the client. The activities which I have outlined are the ones that I found to be the most beneficial to my client, as mentioned before each case is different therefore different exercises will be more beneficial to different clients.
Activities such 'accentuation', 'hug and tug' and 'slap and clap' are all rhythmical exercises which help with rhythm difficulties often found in people with autism as well as improving verbal skills. Quill (1995) speculated the idea that many people with autism have problems with rhythm. In the case my client, it is not the generating of rhythm that he has a problem with but the inability to sync his rhythm with another's. Quill (1995) theorised that the reason for this may be related to speech problems. This is what these activities promote as well as the relaxation benefits; enhanced verbal communication is also promoted.
All the activities that are used in the client's HANDLE have calming and relaxing advantages. This in theory was the main reason for starting the program with the client, to help him relax. However the program has proved to be more beneficial than originally had been thought. The client's behaviour is a lot easier to handle. His episodes anxiety, although still severely high and at times disabling, has become less common throughout the day.
Evaluation & Recommendations
How well the program is working depends on perception of the progress being made. As the program is client centred the progress cannot be measured on scale or timeframe but to the client's perceived behaviour by the HANDLE practitioner. There is no scale to measure how well this program is working and therefore important that the client's daily behaviour is monitored in order for the effects, if any, of the program. In the case of this client, the progress being made was slow but also very affective and more beneficial than we had originally planned. Of the four goals that were hoped to be achieved by the six month evaluation only two has been met so far. However the goals that have been achieved have been emphasised as the most important.
What worked and what didn't?
It is hard to say what worked well and what did not due to the complexity and uniqueness of each case. I did find however that a lot of the exercises that were carried out were likely to be carried out differently by different practitioners. The program was carried out by a number of different staff as it had to be undertaken twice daily. In the morning the practitioner (whilst on placement, I was the morning practitioner) remained a constant however in the evening the practitioner was constantly changing depending on the residential staff of the evening. This in my view confused the client in some of the exercises as he was instructed to carry out two different techniques and due to the '3 strikes' rule he was being chastised for doing it wrong. Therefore to a certain extent this was a major downfall to the program and as a result it was the client that suffered.
I found that the program would work better if the HANDLE practitioner remained a constant. This is due to the fact that if the client is unfamiliar with you he does tend to get upset, frustrated, anxious or confused. This is often an implication of weak communication associated with adults with ASD (autistic spectrum disorder) (Gallaher, T.). It is important that the client's need for familiarity is met and adhered to as routine and repetition are an important factor in the client's day to day living. Boutot and Tincani (2009) theorised that people with autism, at any age, may use repetition and familiarity as a way of coping with a seemingly chaotic world. Thus using this sense of familiarity may improve the effects of the program for the client.
I also found that there were times when the client was too anxious to perform the exercises and rather than waiting until he had calmed down slightly, it was instructed that we continue with the exercises. This resulted in the client not focusing on the exercises and rushing through them thus not gaining any benefits. It was instructed that the program be carried out at the beginning of the client's day and because the client, even if anxious or unsteady, never refused the program was always carried out at this time. The client's anxiety could be at such a profound stage that he would not be able to sit still but he would insist on completing the program, however rather than allowing a sufficient amount of time for each activity, he would rush through each one. When asked if he'd like to stop and continue later, he get frustrated and insist he was feeling fine. This was a drawback to performing the program as he was not concentrating and therefore not attaining any of the benefits.
The use of the quiet and relaxed room to perform the activity proved to work every well throughout the process of the program. The familiar room made the client more relaxed as well as make the activities easier as phrases such as 'look to the door' and 'look towards the lamp' were used instead of directions. Simple phrases such as these made the activities easier for the client as when given directions to do something he doesn't understand he gets frustrated and upset. Dodd (2004) remarked that most people with autism are visual learners and as such using visual aids to assist the individual's learning is beneficial to those that cannot fully understand verbal instruction. It has proven easier to ask the client to look at the lamp rather than saying look left or right.
My role was to help the client to perform the set about tasks. In the beginning of the program the task seemed as though it would be easily accomplished however I did not plan on the emotional toll that would come with the job. I found myself becoming unsure of myself and as a result of this began getting frustrated with myself because I could not carry out the task right. This is one of my biggest weaknesses when it comes to working on something is that is not familiar to me. However, I did find the ability to ask for help from another member of staff and found that it was not that I could not perform the task right, it was the fact that everyone had a different view of how the task should be carried out. The fact that I was able to ask for help surprised me as that is a weakness that I have often shown in situations that I am finding difficult. Asking another member of staff proved to be beneficial however as it encouraged all the team to come together and discussed how we each performed the activities and how we could work together to find ensure that we were carrying the activities in the same way.
Since the beginning of the programme with the client, there has been significant changes noted the behaviour of the client. Although the HANDLE programme is a long process, the results are obvious in the change of mannerisms and behaviour. And though changes weren't seen until after the first month at least, there was a change in his behaviour which in retrospect proves that the program is having some effect on the client. He appears more relaxed throughout the day and if his behaviour does become erratic, calming him is a lot easier. Therefore I would recommend that the use of the HANDLE is continued as the change in the client's behaviour is becoming more and more apparent.
What I would recommend, personally, is that if there is a day when the client seems unable to perform the activities that the program should not be done that day. Performing the activities when the client is anxious and stressed is not beneficial to the client and is only stressful to his system. I simply find that performing the activities is futile when his body is already under stress.
In regards to the person performing the activities with the client, I would feel that a constant practitioner would be beneficial to the client. This applies to the client which I was working with and may not apply to all cases. As mentioned before this is due to the different ways that staff perform the activities and how the client is easily confused by this.
It would also be advised that material be provided regarding information about the program. There was little to no information provided in the service for staff or students to read about the program and its benefits. I did conduct my own research on the program before taking on the role of HANDLE practitioner because of this fact. I would find that it would be a better way of getting information rather than one staff member passing on information to another.
Personally I found the HANDLE program to be a great asset to the client. Though it is stressed that little improvement has been made, the changes are clear to those that have known the client. The non-medicated approach has proven its worth to the client and I find works a lot better than a number of other techniques that had been used to assess the problem of his behaviour.
In conclusion I would recommend that the HANDLE program be continued as there has been progress made with the client. Although the progress made may seem minor to some in the case of the client it has made huge improvements on his behaviour.