rtportfolio.wcu.edu … · web viewintellectual disability treatment plan. gretchen gragg. western...

Running head: INTELLECTUAL DISABILITY 1

Intellectual Disability Treatment Plan

Gretchen Gragg

Western Carolina University

INTELLECTUAL DISABILITY 2

ABSTRACT: This resident (Awesome) is a 38 year-old male who is currently diagnosed with moderate Mental Retardation, Pervasive Developmental Disorder, Autism, a history of Chronic Undifferentiated Schizophrenia, Irritable Bowel Syndrome, GERD, Allergic Rhinitis, acute Tinea Pedis, left Nephrolithiasis- non-destructing stone lower pole left kidney, mild Bilateral hip DJD, and s/p Laparoscopic Cholecystecomy- 2/14/2011.

KEYWORDS: Mental Retardation (MR), Pervasive Developmental Disorder, Autism, Undifferentiated Schizophrenia, Irritable Bowel Syndrome (IBS), Gastroesophageal Reflux Disease (GERD), Allergic Rhinitis, and Tinea Pedis.

PURPOSE STATEMENT: The purpose of this case study is to further understand the diagnoses of this 38 year-old male who was placed in J. Iverson Riddle Developmental Center (JIRDC) on March 30, 2011 and to accommodate Awesome’s Recreation Therapy needs.

DIAGNOSIS and LITERATURE REVIEW: ACCORDING to MERCK MANUAL of MEDICAL INFORMATION 2nd HOME EDITION*Mental Retardation (MR) - Mental retardation is significantly subaverage intellectual functioning present from birth or early infancy, causing limitations in the ability to conduct normal activities of daily living. (Beers, 2003, p. 1626)

Levels of Mental Retardation/Intellectual DisabilityLevel Intelligence

Quotient (IQ) Range

Ability at Preschool Age (Birth to 6 Years)

Ability at School Age (6 to 20 Years)

Ability at Adult Age (21 Years and Older)

Mild 52-69 Slightly impaired motor coordinationOften not diagnosed until later ageCan develop social and communication skills

Can be expected to learn appropriate social skillsCan learn up to about the 6th-grade level by late teens

May need guidance and assistance during times of unusual social or economic stressCan usually achieve enough social and vocational skills for self-support

Moderate 36-51 Poor social awarenessFair motor coordinationCan profit from training in self-helpCan talk or learn to communicate

Can progress to elementary school level in schoolworkMay learn to travel alone in familiar placesCan learn some social and occupational skills

Needs supervision and guidance when under mild social or economic stressMay achieve self-support by doing unskilled or semiskilled work under sheltered conditions

Severe 20-35 Able to learn some self-help skillsHas limited speech skillsPoor motor coordinationCan say a few words

Can learn simple health habitsBenefits from habit trainingCan talk or learn to communicate

Can develop some useful self-protection skills in controlled environmentMay contribute partially to self-care under complete supervision

Profound 19 or below Little motor coordinationMay need nursing careExtreme cognitive limitation

Limited communication skillsSome motor coordination

Usually needs nursing careMay achieve very limited self-care

(Merck Sharp &Dohme Corp., 2010-2011)*Pervasive Developmental Disorder (PDD) - Children who have significantly impaired social interactions or stereotyped behaviors without all of the features of autism or Asperger’s disorder are considered to have pervasive developmental disorder not otherwise specified. (Beers, 2003, p. 1631)

*Autism - Autism is a disorder in which young children cannot develop normal social relationships, uses language abnormally or not at all, behaves in compulsive and ritualistic ways, and may fail to develop normal intelligence. (Beers, 2003, p. 1630)

*Schizophrenia (Undifferentiated)- Schizophrenia is a mental disorder characterized by loss of contact with reality (psychosis), hallucinations (usually hearing voices), delusions (false beliefs), abnormal thinking, flattened affect (restricted range of emotions), diminished motivation, and disturbed work and social functioning. Undifferentiated schizophrenia is characterized by a mixture of symptoms from the other subtypes: delusions and hallucinations, thought disorder and bizarre behavior, and negative symptoms. (Beers, 2003, p. 640 & 642)


*Irritable Bowel Syndrome (IBS) - Irritable bowel syndrome is a disorder of mobility of the entire digestive tract that causes abdominal pain, constipation, or diarrhea. (Beers, 2003, p. 756)

* Gastroesophageal Reflux Disease (GERD)- In gastroesophageal reflux (gastroesophageal reflux disease), stomach acid and enzymes flow backward form the stomach into the esophagus, causing inflammation and pain in the esophagus. (Beers, 2003, p. 717)

*Allergic Rhinitis- Allergic rhinitis is caused by a reaction of the body’s immune system to an environmental trigger. The most common environmental triggers include dust, molds, pollens, grasses, trees, and animals.

*Tinea Pedis- Athlete’s foot (tinea pedis) is a common fungal infection that usually appears during warm weather. (Beers, 2003, p. 1225)

*Nephrolithiasis- The process of stone formation. (Beers, 2003, p. 864)

ADMISSION HISTORY:

Date of Birth: xx-xx-1973

Date of Admission: 3-30-2011

Length of Stay: Regular transition meetings are held to determine whether or not Awesome is ready to go into the community. This is determined by his progress and appropriate placement in the community.

IDENTIFYING INFORMATION:

Awesome is a 38-year-old male who is single and likes to be dressed nice throughout the day. He was brought to this residential developmental center from a group home in central NC on March 30, 2011. He has lived in group homes since 2001. When Awesome first came to this facility he reportedly, according to staff, looked like a mountain man with a full head of long hair and full beard. Since he moved to J. Iverson Riddle Developmental Center, Awesome has really opened up to the staff and helps out in any way he can. He is very close to his mother and sister who are very involved in his treatment and visit him often.

Awesome is currently working in the in a resource center onsite. He assists with doing loopers and crushing cans and bottles for recycling. He also sweeps the floor and helps make the dog biscuits. He pours the already measured ingredients, helps mix the dough, helps roll the dough out for the dog biscuits, cuts out the dough with a cookie cutter, counts the dog biscuits using a stencil, and holds the bag the dog biscuits go in while someone ties it closed. He can sew and will fold wash cloths as well.

BIRTH AND DEVELOPMENTAL HISTORY:

Awesome was the product of a normal pregnancy weighing 8.5 pounds when he was born. He was born vaginally with forceps 1 week early. APGAR scores were good and there were no postnatal problems. During the prenatal period, 3 weeks before birth, his mother became very ill with severe flu like


symptoms and didn’t take any medications. Awesome was a good eater, was not picky, and gained weight quickly. At 6 months of age, Awesome became constipated and he had to be manually disimpacted. He reportedly walked and talked at the high end of the normal range of the developmental milestones. At 1 year old, Awesome began saying single words but did not build on the words. His hearing tests were within normal limits. At age 2, his mother began to wonder if something was wrong because he did not progress as his older sister had. It was reported that at well baby visits, where he would receive immunizations, he would become sick several days to a week afterwards with fever. His arms would get red at the injection sites as well.

PAST MEDICAL HISTORY:

Awesome has no history of seizures. Since an early age, he has a long history of digestive problems varying from constipation to diarrhea. He has a history of allergies to tree pollen, dust, and dander confirmed by skin test results. He has never received immunotherapy. He also has an allergy to eggs, which “cause his eyes to glaze over”, and reportedly has not had any eggs since the ages of 5 or 6. Awesome has an allergy to milk and milk products, which “causes increased secretions and rhinorrhea”. In the past, he has been treated with multiple antihistamines but Benadryl has historically been the most effective antihistamine.

Awesome was diagnosed with PDD at the age of 3 years old. He learned to read and write and do simple math by attending special education classes in public school. The first medication he ever received was an antibiotic for a sinus infection at the age of 5. By the age of 14, he developed longer periods of psychomotor retardation and aggressive behavior. At the age of 14, Awesome was diagnosed with autism and prescribe Mellaril as his first psychotropic medication. He showed some improvement for several years but developed sexual aggressiveness in the form of hugging and grabbing in a nonspecific manner and the Mellaril was discontinued. Reportedly, by the end of high school, Awesome had declined to a point where he could no longer read, write, or do simple math. He attended some work placements with a one on one worker but he was no longer able to participate in the work program. In his mid twenties, he was restarted on Mellaril and this caused him to not be able to urinate. He also redeveloped sexual aggressiveness and was described as annoying to women. The Mellaril was discontinued and both of these symptoms stopped within a few days. He was later treated with Lithium for bipolar depression but the medication was not effective so it was discontinued.

He moved from the Midwest to the Southeastern US in 1993 and was off all of his medications until about 1996. He lived at home and was on a regular diet during this time period. In 1997, he began to develop aggressive behaviors such as hitting, pushing, throwing things, and grabbing people’s shirts. He was prescribed Risperidone for several months but it made him angry and worsened his aggression. He was taken off of Risperidone. At one point, he was given a sublingual dose of Haldol at 1/10 th the usual minimum dose and it worked very well. During this time he was able to work at restaurant with a job coach. In 2001, he moved into a group home in a neighboring state due to the deteriorating health of his parents. He reportedly did well in this group home for several years and was receiving 10 milligrams of Abilify and varying doses of Ativan due to his agitation. He had been on Abilify and Ativan for most of the last 10 years, which his mother felt were the more effective medications he had been tried on. He complained of headaches when his dose of Ativan was wearing off and would sometimes hit his head. His father died from non-Hodgkin’s lymphoma in approximately 2006.

In 2007, Awesome moved to North Carolina where he first lived with his mother while she arranged his residential placement. He was retried on Haldol with a range of 1 to 5 milligrams daily. His mother


reported that this trial was disastrous because his agitation and aggression increased. His mother reported an incident in a group home where a resident physically abused Awesome. Due to this abuse, Awesome learned negative behaviors to defend himself. On February 28, 2008, a psychological evaluation was done on Awesome. It was reported that on a Wechsler Adult Intelligent Scale his verbal IQ was 55, performance IQ was 50, and a full scale IQ was 52. He moved into a DDA group home with cap services. Due to deteriorating behavior such as aggression and refusal to bathe it was recommended on March 10, 2008 that he start on 5 milligrams of Zyprexa and to increase it to 10 milligrams after three days. It was not clear whether the medication was ever started or due to the mothers request that Awesome not receive it.

From March 17, 2010 to May 4, 2010, Awesome had his first psychiatric hospitalization for escalating aggression, refusal to bathe, eat, or use the bathroom. He had supposedly been unresponsive to his medication adjustments. When Awesome was discharged, he was receiving 100 milligrams of Zoloft, 300 milligrams of Lamictal, and 20 milligrams of Abilify. Also, he was receiving 120 milligrams of Inderal LA along with Flonase, Claritin, Prilosec, Metamucil, Mirilax, Colace, and Lactulose. He continued to have problems in the group home and had numerous medication adjustments. On a physical exam done in September 2010, he weighed 214 pounds and was on an 1800 to 2000 calorie diet per day. Around October or November 2010, Awesome would stay in bed until 2 p.m. or later and refused breakfast and lunch. Some days he would stay in bed all day long and be incontinent of urine and feces. He was also refusing to take baths for up to weeks at a time and developed some skin breakdown. Due to his refusal to get out of bed, to participate in activities of daily living, SIB (Self Injurious Behaviors), property destruction, and aggressiveness towards staff it was recommended that Awesome be tapered off of Zoloft and to start 25 milligrams of Clozaril three times a day for one week (then to increase it to 100milligrams hs (at bedtime)) along with starting 37.5 milligrams of Effexor titrated up to three times a day dosing, and continuing 20 milligrams of Abilify per day, 300 milligrams of Lamictal per day, as well as Ativan and Zyprexa as needed. On November 11, 2010, his Effexor was dose was increased to 75 milligrams three times a day and 15 milligrams of Remeron was added to his medication regimen. He had reportedly not received any Zyprexa since October 10, 2010. His Clozaril was increased from 100 to 200 milligrams daily due to worsening aggression and meal refusals. He would go 2 to 3 days without eating at times and would lie in bed and soil his self. By January 11, 2011, Awesome had developed skin breakdown of his buttocks and shoulders. He had lost 20 pounds in a month. He continued to be aggressive to staff, refuse meals, and refuse hygiene measures.

Awesome was evaluated at the Emergency Room on January 13, 2012. He had complaints of abdominal pain and constipation. A urinalysis was done and was normal. A BMP was wnl (within normal limits) except for a slightly decreased potassium of 3.4. An abdominal series demonstrated nonspecific gaseous distention of the small bowel and colon. Incidental mild degenerative changes of both hip joints with mild supraacetabular spurring were noted. He received an enema and his symptoms resolved. He was evaluated again in the ER on January 21, 2011 due to complaints of abdominal pain and discomfort. An ultrasound of the gallbladder showed cholelithiasis with a contracted gallbladder without evidence of acute cholecystitis. A CT scan of the abdomen and pelvis showed a contracted gallbladder containing small stones, a nonobstructing small calculus in the lower pole of the left kidney, trace bilateral pleural effusions and trace nonspecific free pelvic fluid. Awesome was evaluated by a gastroenterologist due to his gallstones and he was put on a mild muscle relaxer to help decrease the gallbladder spasms but he did not experience any relief in his intermittent abdominal pain. Awesome has had significant issues with constipation and had several ER visits where he required enemas because of severe constipation.


On January 27, 2011, Awesome was evaluated at ER for worsening skin breakdown and abdominal skin discomfort. There were also reports where he had been hitting his head during episodes of SIB. His laboratory evaluation was completely normal including a lipase, amylase, CMP, CBC, and urinalysis. A CT scan of the head showed partial opacification of the right sphenoid air cells. The mastoid air cells were clear and there was no evidence of acute intracranial abnormality. He was diagnosed with sphenoid sinusitis and treated with a 10-day course of Augmentin. Due to continued complaints of abdominal pain, which consists mostly of him verbally reporting abdominal discomfort and waving his hand over his sternum, he underwent a laparoscopic cholecystectomy on February 14, 2011 without complications. It was reported in the hospital that he would get up, sit at the table, and eat all of his meals. He had an EGD and colonoscopy scheduled due to his irritable bowel symptoms and history of GERD but it was cancelled prior to his admission. He reportedly had an EGD done about 10 years before which was normal. He had an episode about one week prior to admission where his group home staff was unable to arouse him and EMS was contacted. When EMS arrived, he rolled over on his own. He had low blood sugar in the 60’s and was given oral glucose, which improved his level of alertness.

When he first came to this facility, Awesome was staying in bed most days, all day long. He would refuse breakfast but may ask for snacks. Some days he would get up and go to the bathroom when prompted but about once a week he was still incontinent in the bed. He refused most lunches but would get up to eat supper. Once he was done with supper, he would immediately go back to bed. He used Duoderm on his lower back to avoid skin breakdown and has had to use it on his shoulders in the past. His CBC was monitored weekly because he was receiving Clozaril. Awesome reportedly had a low WBC several weeks before but it was repeatedly being monitored weekly and his WBC improved. He has a history of hyperlipidemia, which was treated in the past with Lopid and Zocor.

MEDICATIONS:

At Admission:Abilify, Clozaril, Effexor, Remeron, Ativan, Lamictal, Propranolol, Flonase, Zyrtec, Prilosec, Amitiza, Robinul, Bentyl, Colace, Lactulose, and Vitamin D daily.

Tylenol, MOM (Milk of Magnesia), and Metamucil as needed.

Currently:Colace, Flonase, MOM, Multiple Vitamin, Zyprexa, Omega-3 Purified Fish Oil, Prilosec, Propranolol, and Zocor daily.

Tylenol and MOM as needed.

ALLERGIES:

Awesome has NKDA (no known drug allergies).He is allergic to tree pollen, dust, and dander.Awesome’s food allergies are eggs (eyes glaze over), and milk or milk products (causes increased secretions and rhinorrhea).

PHYSICAL EXAMINATION:


General Appearance: He is a disheveled 37-year-old white male who leans to the right and seems mildly intoxicated and sedated. He is unkempt with greasy hair and an untrimmed beard.HEENT:Head: Dark brown hair. Scalp clear. Atraumatic normocephalic (AT/NC). Eyes: Gray. PERRL. EOMI. Positive red reflux OU. Fundus exam obscured by squinting and motion. Sclera is nonicteric and conjuctiva is clear.Ears: Both the tympanic membranes are obscured by wax.Nose: Both of the nares are patent without discharge. He has mild mucosal erythema. Throat: The oral pharynx was clear without exudates or lesions. The teeth appear in fair condition with multiple fillings.

Neck: Supple without JVD, lymphadenopathy or bruits. Carotid +2 and equal. No thyromegaly.

Breasts: No gynecomastia. No axillary lymphadenopathy.

Chest & Lungs: The chest wall is grossly symmetric. The lungs are clear to auscultation without rhonchi, rales or wheeze.

Cardiovascular: Regular tachycardia without murmur. Pulses are normal in all extremities. No peripheral cyanosis, clubbing edema or varicosities.

Abdomen: Mildly protuberant. Soft and non-tender with normal bowel sounds in all quadrants. No hepatosplenomegaly or masses.

Genitalia: Normal circumcised male with both testes present in the scrotal sac and benign to palpation. No hernia. No inguinal lymphadenopathy.

Rectal: No hemorrhoids mass or fissure. Stool is heme negative. Prostate is mild to moderately enlarged but smooth without nodularity.

Musculoskeletal: Spinal alignment is grossly normal. Full range of motion in all extremities.

Skin: A 10x4 mm horizontal scar is present in the mid forehead. Multiple small dark brown (<4 mm) nevi are present on the upper back and shoulders. Several are also located on the anterior torso. Two nevi with inch long hair are present on the anterior left shoulder. Four 1.5 cm well healed abdominal surgical incisions are present from recent laparoscopy cholecystectomy. Two are present in the right upper quadrant, one is located just below the umbilicus and one is located below the sternum at the midline. Moist white fungal changes are present between the fourth and fifth toes on both feet.

Neurologic: Awake and alert and oriented to person.Cranial nerves II-XII are grossly physiologically intact.Vision: Appears to fixate and follow without difficulty.Hearing: Grossly normal to verbal request.Speech: Expressive skills- limited to one or two word phrases during the exam. Receptive skills- follow simple requests.Motor: Strength and tone normal in all areas.Sensory: Normal response to light touch and noxious stimuli in all areas.


Coordination: Gross motor control is reduced. Fine motor testing not performed. No tremor.Gait: Leans to the right and veers to the right in an intoxicated manner.DTRs: +2 and equal in upper extremities. None elicited in the lower extremities but cooperation was limited. Babinski: Bilateral plantar flexion.Clonus: None.


Definition

Intellectual disability is now regarded as a more appropriate term for what was previously

referred to as mental retardation. The move toward the new terminology of an intellectual

disability rather than mental retardation is an attempt to move away from labeling individuals

with this diagnosis. Intellectual disability, which is classified as a developmental disability, is

seen as a term that conveys the ability to grow. It doesn’t restrict an individual in the way that

mental retardation negatively brings attention to the disability without even describing the

disability (Harris, 2005). Terminology is important because it can affect how individuals without

the diagnosis think and feel about those with the diagnosis. Naming a diagnosis is important

because it will be associated with a certain group of individuals and this can have negative

effects if done without consideration. The terminology is changing from mental retardation to

intellectual disability because it shows the change in ideas and feelings towards this diagnosis

and is an attempt to be more considerate (Wehmeyer, 2013).

An intellectual disability is defined as having limitations on an individual’s ability to

learn and develop in a way that affects their daily life. An intellectual disability is classified as a

developmental disability so an individual with an intellectual disability may learn and develop

slower than others their own age. Intellectual disabilities can range from moderate to severe. An

intellectual disability can be caused before birth, during birth, or when the child is older

(National Center on Birth Defects and Developmental Disabilities [NCBDDD], 2015). An

intellectual disability is also characterized by being recognized and diagnosed before the age of

18. An intellectual disability may also be shown through slower development, difficulty adapting

to new situations, and a lack of curiosity. These characteristics can range in severity but some


standard ways to identify an intellectual disability are an IQ test score of less than 70 and having

development below that of their same age peers (Kaneshiro, 2013).

Demographic Information

The National Dissemination Center for Children with Disabilities [NICHCY] (2015)

estimates that about 6.5 million individuals in the United States have an intellectual disability.

This makes intellectual disabilities the most common developmental disability. NICHCY also

estimates that about 545,000 school aged children have an intellectual disability and receive

special education services. Furthermore, 1 out of every 10 students who receive special

education services have an intellectual disability. Intellectual disabilities range in severity and so

the services for these individuals vary as well. Some individuals with intellectual disabilities

need less support than others (2015).

1%-3% of the population has an intellectual disability but only about 20% of these

individuals know the cause of their disability. Some of the known causes are infection that can

occur before or after birth, exposure to drugs or alcohol before birth, and other trauma before or

after birth (Kaneshiro, 2013). Some other causes of intellectual disabilities are genetic conditions

that can cause Downs Syndrome, Fragile X Syndrome, and others. Problems during pregnancy or

birth can also cause intellectual disabilities (NICHCY, 2015).

Strengths of the Client

One of Awesome’s strengths are that his family is involved with his treatment. Awesome

is close with his older sister and mother and both visit him often. This will be important to

Awesome’s therapy because both of these women can help to motivate Awesome to participate

in the Recreational Therapist’s activities. According to Saaltink, MacKinnon, Owen, and Tardif-

Williams (2012), people with intellectual disabilities are encouraged to be more independent in


the family context. His family can encourage him to be more independent. His family visits with

him often so they will be able to provide input on progress toward goals outside of therapy.

Awesome is also currently working at a job where he sweeps and helps to make dog biscuits. He

is also good at sewing and folding clothes. Awesome is able to focus through processes like

making dog biscuits which will be helpful to a Recreational Therapist when going out into the

community or working with him on daily life skills. Awesome will be able to focus on tasks

during therapy as well as get around well.

Awesome likes to be dressed nice. This could be used as motivation to get up and out of

bed and take part in therapy. The Recreational Therapist might use Awesome’s preference to be

dressed nice as motivation to complete tasks during therapy and to put him in a better mood

which will make his therapy more beneficial. Staff also report that Awesome has opened up to

them since arriving and wants to help out in any way he can. This type of willingness will also be

beneficial to Awesome during therapy because he may have a willingness to participate and

follow through with tasks he is asked to complete.

Needs of the Client

Awesome has several different needs but only two would be best addressed through

recreational therapy. These two are:

Awesome needs to manage his aggressive behavior. Aggressive behavior can

make integration into society harder for people with intellectual disabilities.

Aggressive behavior can also pose problems for Awesome’s care providers that

can restrict Awesome’s access to residential settings and occupational

opportunities (Crocker et al., 2006).


Awesome’s lack of motivation, to leave his bed and live his daily life, needs to be

addressed. This may be a sign of depression. Individuals with intellectual

disabilities can show depression in ways that are different than normal such as

aggressive behavior as well as usual symptoms. Awesome has aggressive

behavior as well as lack of enthusiasm and motivation for daily life (Davies &

Oliver, 2014).

Environmental Barriers

Inclusion of people with intellectual disabilities may be a barrier to Awesome’s

community participation. Although there has been a move to inclusion for people with

intellectual disabilities in communities, physical presence doesn’t always equate to a true

sense of belonging and inclusion (Amado, Stancliffe, McCarron &, McCallion, 2013).

Awesome lives at a developmental center which is segregated from the community. This

is an environmental barrier because people with intellectual disabilities that live separate

from the community usually have lower community participation than those living in the

community (Verdonschot, de Witte, Reichrath, Buntinx &, Curfs, 2009).

Cultural Information

Awesome is 38 years old.

Awesome is male.

Awesome moved from the Midwest to the Southeastern US in 1993.

He has lived with his mother and in group home settings. Group homes provide a home

like environment for people with intellectual disabilities. They provide specialized care

for at least four but no more than eight individuals (Government of the District of

Columbia Department of Health, 2015)


He has work history of working in a restaurant but now works in the onsite resource

center. His job in the resource center is supported employment. At this job he is able to

receive training and long term support he needs to maintain employment (De Urris,

Verdugo, Jenaro, Crespo & Caballo, 2005).

Efficacy Research

Bazzano, A.T., Zeldin, A.S., Shihady Diab, I.R., Garro, N.M., Allevato, N.A., Lehrer, D.,

LCSW, and WRC Oversight Project Team. (2009). The healthy lifestyle change program:

A pilot of a community-based health promotion intervention for adults with

developmental disabilities. Journal of Preventative Medicine 37(6), 201-208.

1. Summary

Individuals with developmental disabilities have higher rates of obesity and inactivity

than the general population. This could be for reasons like lack of physical activity education,

community segregation, and lack of accessible fitness facilities. Individuals with intellectual

disabilities also have a higher rate of preventable mortality than the general population. There are

few healthy lifestyle programs for adults with developmental disabilities even though there has

been success shown in these programs. Some of the few programs that are available are flawed

because they are too short or aren’t client centered.

Staff in the Health and Medical Department at Westside Regional Center (WRC) noticed

that their clients with developmental disabilities were having difficulty with obesity and

inactivity. This would often result in the clients being moved to more restrictive areas such as

residential facilities or adult day centers. Clients weren’t always in favor of this option and so the

staff decided to intervene to help their clients maintain their independence. The staff at WRC


enlisted the help of individuals with developmental disabilities and their family members, care

providers in their community and academic researchers to create a health promotion group that is

community based. The staff at WRC saw a need for a healthy lifestyle program for their clients

with developmental disabilities and this is why they as well as others in the community and

academic researchers decided to research and create a program to fit their clients’ needs. It was

recorded that clients saw a positive change in their self-efficacy, nutrition, access to healthcare,

physical activity, and maintaining or losing weight after participating in the program that WRC

implemented.

2. Subjects and Methods

Clients at WRC were eligible to participate in the program if they were between the ages

of 18-65, had a developmental disability and were high-functioning, were overweight or obese,

and had another risk factor for diabetes or already had diabetes. There were 431 clients eligible

and of those 85 clients signed up, 68 participated in one class, and 44 completed the program. To

create the program, the team of WRC staff, individuals with developmental disabilities and their

family members, community members, and academic researchers surveyed what the participants

in the program wanted from it. They worked to include these items in the final program.

There were 11 peer mentors hired to be a part of the program. These peer mentors also

had developmental disabilities so that clients could relate to their peer mentors and share similar

experiences. If clients are comfortable with the program, they are more likely to continue with it.

The peer mentors played a large role in the program. They helped with the program planning and

participated in the program by holding physical activities sessions, giving review and evaluation

assessments, and making healthy snacks. Peer mentors also traveled with academic researchers

to present the findings from the study of the program.


The program met twice a week and each session was two hours long. The program lasted

for seven months. During each session there was 50 minutes of health education, a 10 minute

healthy snack break, and then 1 hour of supervised physical activity. Professionals with

experience working with individuals with developmental disabilities led the education portion of

the session. Peer mentors helped the professionals lead these sessions by modeling behaviors and

making sure participants understood the material. Exercise was community-based by using local

parks and other local fitness resources. Participants had support to continue the program from

peer mentors and those involved with creating the program.

Evaluation tools were researched by the academic researchers on the planning team and

were decided on by the team as a whole. Participants were measured for seven things before and

after participating in the program. The participants were measured for weight loss, improved

dietary habits, increased exercise, increased self-efficacy, improved access to health care,

improved life satisfaction, and increased community capacity. Participants completed a variety

of assessments and surveys specific to each measurement. Professionals also completed

assessments of the different things being measured on the clients to collect the before and after

data.

3. Findings and Implications

Participants saw positive changes in their bodies and habits but also their confidence. The

program results showed that two-thirds of participants lost or maintained weight. 74% of

participants also saw a decrease in their abdominal girth measurement. Physical activity

increased for 61% of the participants and the average number of times a week individuals

exercised as well as how long they exercised increased. Contributing to weight loss and healthy

habits, participants reported eating more nutritional foods as well as eating less unhealthy foods.


Along with reporting more exercise and better nutrition participants reported an increase in their

confidence in their own skills. Participants reported an increase in participants’ confidence in

their exercise skills and abilities. They also reported an increase in their ability to choose for

themselves healthy foods when ordering at a restaurant or grocery shopping.

Participants reported that they felt they could better access health care after the program.

After the assessments from professionals before and after the program, for the 44 participants

who completed the program there were 206 referrals for medical care. Nearly half of these were

for primary care and over half were for dental care. After the program there was an increase in

participants who felt they could make their own doctor’s appointment. Although there was no

change in mean life satisfaction, there was an improvement in the individual life satisfaction of

59% of participants.

The program was viewed as successful enough to continue at least two years or more

because it was still in place at the time of publication. The information for the program was

distributed to 20 other centers in California similar to the WRC. 19 of the initial clients and 37

new clients were participating in the program two years later. The staff also see about one person

referred to the program each week.

4. Applications for this Case

Awesome may not have the opportunity to take part in a healthy lifestyle program but

that doesn’t mean he doesn’t have the opportunity to take part in some modified parts of the

program. Awesome needs to work on his lack of motivation to live his daily life. Through a set

schedule of physical activity Awesome may see improvements in his life satisfaction. Staff

reported that Awesome opened up to them and he may enjoy the opportunity to get to know a


peer mentor and work alongside them in learning and implementing ways to live a healthier life.

He may work better with someone who is just there to be a peer mentor.

Awesome is also able to make dog biscuits at his job and could use these skills to take

part in making his own nutritional meals. Having a part in making his own choices may lead to a

positive increase in Awesome’s feelings of self-determination. Staff reported that Awesome

would sometimes refuse breakfast but then later ask for snacks. He would also sometimes refuse

lunch but then eat dinner. He isn’t refusing all meals. Given the opportunity to take part in

preparing his own meals and feeling he has a say in what he eats, Awesome may be more likely

to spend time out of bed preparing and eating meals. Staff also report that Awesome helps out in

any way he can and so this increases the likeliness that he will enjoy being able to prepare meals.

An increase in Awesome’s self-determination about his meals may translate to other areas of his

life as well and this could increase his motivation for daily living tasks.

Top 3 Strengths/Needs

Strengths:

Family Support

Ability to complete simple tasks

Some intrinsic motivation to have nice physical appearance

Needs:

Increase motivation for daily life activities

Increase physical activity

Increase self-determination


Goals

To increase motivation for ADLs through choices in physical activity and meals

To increase physical activity through utilization of exercise resources at the center

Learn to manage aggressive behavior

Facility

Awesome lives at a developmental center. His center provides him with supportive

living. He currently lives in an apartment setting. He has two roommates and there are other

apartments on either side of his and across from it. There are residences that are more like houses

that are more separated and allow for more independent living. He also receives training to

develop skills for independence and community integration. There are a variety of therapies the

developmental center offers as well as other activities that the clients can participate in. Clients

are able to attend religious services, work somewhere on the grounds or in a workshop, and take

part in gardening or crafts. Clients also have access to a gym, walking trails, a pool, and a riding

arena.

Intervention

I am going to have Awesome participating in physical activity as well as taking part in

preparing his own healthy meals. The study showed that participants were able to participate in

physical activity as well as make choices about healthy snacks. Awesome will participate in the

intervention for eight months because his placement will be reevaluated in eight months.

Awesome will participate in physical activity for 30 minutes, once/d 5 days a week. He will take

part in choosing and preparing a snack or meal once/d every day. For physical activity,

Awesome will be encouraged to utilize the center’s walking trails when the weather is nice.


When he is inside, he can walk in the gym, learn how to and use the equipment, or do exercises

in the pool. Awesome will decide which activity he wants to participate in for 30 minutes. For

the nutritional part, Awesome will be encouraged to make healthy decisions but allowed to make

his own decisions about what he wants to prepare and eat. Awesome will then do some of the

same steps he does at work, pouring pre-measured ingredients and mixing ingredients. He can

also roll out dough, cut out the dough using cookie cutters, and count items used in cooking.

These are skills he can use when cooking snacks and meals but he will still need assistance.

Giving Awesome a choice in his activity and meals will help him be more involved in his daily

life so that he will be more motivated to get out of bed and participate in ADLs. Taking part in

physical activity will give him the opportunity to get up and out of his apartment.

Objectives

1. *Skill Acquisition: At the beginning of a cooking session, Awesome will choose one out

of three meal choices, he has been given by CTRS, to prepare once/d to increase self-

determination through meal choices.

2. Functional Use of Skill: Before his cooking session, Awesome will choose one of five

meal choices and stick his choice to the refrigerator to make later once/d to increase self-

determination through meal choices.

Progress Note

S (Subjective Data): After choosing and preparing his first meal, Awesome sat down at the table

in the dining room, took his first bite and said “Good.”

O (Objective Data): During the first meal preparation, Awesome completed all the tasks he was

given with little to no verbal prompts. When I did one of the tasks he needed assistance with,


putting the homemade pizza in the oven, he cocked his head and bent down slightly while

looking in the oven. He insisted on trying to touch the food before it was cool and stayed in the

kitchen through the entire cooking process, including while the food was in the oven and while it

was cooling.

A (Analysis): Awesome seemed to enjoy the cooking activity. He stayed focused and stayed in

the kitchen involved with the food for the entire session. He seemed to enjoy eating his finished

product because he took it into the dining room to eat it. Since the holidays are coming up in a

few weeks, I think I will give Awesome the choice to make a holiday treat for himself and his

roommates. I will give him five treats to choose from. This might give him more confidence in

his abilities to choose and prepare food.

P (Plan): Awesome seems to be enjoying and benefitting from choosing and preparing his own

meals. He seems to find satisfaction in eating something he has helped prepare. This will help to

make him more confident in his decision and increase his self-determination. Awesome still

needs to work on being physically active and finding activities he enjoys participating in. He

may need to work up to some activities in or order to enjoy them. After I get written permission

from Awesome’s mother, I will refer him to the activity’s coordinator at the center’s gym. She

will help Awesome find activities that the center offers that Awesome may be interested in.

Discharge

Awesome is a 38 yo SM living in a developmental center. He has a main dx of an intellectual

disability. His main needs are to improve motivation for ADLs, improve physical activity, and

manage aggressive behavior. Awesome is currently involved in a physical activity and meal


intervention that allows him to make choices about his activities. This intervention has lasted 8

months with Awesome participating in physical activity for 30 minutes once/d 5 days a week and

choosing and preparing a meal once/d every day. Client met objectives regarding cooking during

his time with me. He still needs to find physical activities that he is interested in. His residency is

going to be reevaluated on 12/5/2015 and he may be moved to a different residence, depending

on his needs. He needs to continue being physically active as well as having choices in his daily

life and learning to manage his aggressive behavior. After receiving written permission from his

mother, I am going to refer Awesome to the activity coordinator, Violet James, at the center’s

gym. She will help Awesome find activities the center offers that he may be interested in.

Gretchen Gragg, RT Student

3 December 2015


References

Amado, A.N., Stancliffe, R.J., McCarron, M., & McCallion, P. (2013). Social inclusion and

community participation of individuals with intellectual/developmental disabilities.

Intellectual and Developmental Disabilities, 51(5), 360-361. doi: 10.1352/1934-

9556.5.360.

Bazzano, A.T., Zeldin, A.S., Shihady Diab, I.R., Garro, N.M., Allevato, N.A., Lehrer, D.,

LCSW, and WRC Oversight Project Team. (2009). The healthy lifestyle change program:

A pilot of a community-based health promotion intervention for adults with

developmental disabilities. Journal of Preventative Medicine 37(6), 201-208.

Crocker, A.G., Mercier, C., Lachapelle, Y., Brunet, A., Morin D., & Roy, M.E. (2006).

Prevalence and types of aggressive behaviour among adults with intellectual disabilities.

Journal of Disability Research, 50(9), 652. doi: 10.1111/j.1365-2788.2006.00815.x.

Davies, L.E. & Oliver, C. (2014). The purported association between, depression, aggression,

and self-injury in people with intellectual disability: A critical review of the literature.

American Journal on Intellectual & Developmental Disabilities 119(5), 453. doi:

10.1352/1944-7558-119.5452.

De Urris, F.B.J, Verdugo, M.A., Jenaro, C., Crespo, M., & Caballo, C. (2005). Supported

employment and job outcomes. Typicalness and other related variables. Work 25(3). 221-

222.

National Center on Birth Defects and Developmental Disabilities. (2015). Facts about

intellectual disabilities. Retrieved September 9, 2015 from:

http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/IntellectualDisability.pdf

http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/IntellectualDisability.pdf


Government of the District of Columbia Department of Health. Group homes for people with

intellectual disabilities. (2015). Retrieved September 9, 2015 from:

http://doh.dc.gov/service/group-homes-persons-intellectual-disabilities

Harris, J.C. (2005). Intellectual disability: Understanding its development, causes, classification,

evaluation, and treatment. USA: Oxford University.

Kaneshiro, N.K. (2013). Intellectual Disability. Retrieved September 9, 2015 from:

https://www.nlm.nih.gov/medlineplus/ency/article/001523.htm

Saaltink, R., MacKinnon, G., Owen, F., & Tardif-Williams, C. (2012). Protection, participation,

and protection through participation: Young people with intellectual disabilities and

decision making in the family context. Journal of Intellectual Disability Research 56(11),

1076-1077. doi: 10.1111/j.1365-2788.2012.01649.x.

Verdonschot, M.M.L., de Witte, L.P., Reichrath, E., Buntinx, W.H.E., & Curfs, L.M.G. (2009).

Community participation of people with an intellectual disability: A review of empirical

findings. Journal of Intellectual Disability 53(4), 303. doi: 10.1111/j.1365-

2788.2008.01144.x.

Wehmeyer, M. (2013). Story of intellectual disability: An evolution of meaning, understanding,

and public perception. Baltimore, MD: Brookes.

https://www.nlm.nih.gov/medlineplus/ency/article/001523.htm

rtportfolio.wcu.edu … · web viewintellectual disability treatment plan. gretchen gragg. western...

Documents