TTAP with developmental disabilities

The 10 Steps of Therapeutic Thematic Arts Programming, for Individuals with Developmental Disabilities Theme: Love Colleen Ryan: Therapeutic Recreation Intern, Hudson Valley Developmental Disabilities Services Office.

Developmentally Disabled
Mental retardation is a type of developmental disability.
Approximately four million Americans have a developmental disability, (NACCD, 2007).
Today, two different interpretations of this disability exist.
In general, individuals with a developmental disability may possess: cognitive and physical disabilities, emotional disturbances, behavioral issues, and lack of socialization, self-concept, and motivation . They additionally may have difficulty with activities of daily living and independence.

Definition #1 by DSM-IV-TR
An individual with mental retardation must meet three criteria .
They must have sub average general intellectual functioning (IQ of 70-75 or lower)
Major impairments in adaptive functioning (based on how they compare to individuals of the same age and culture in independence, sociability, and communication)
Number 1 & 2 must onset before age eighteen.
They are categorizes into one of four degrees of severity .
Mild : IQ of 50-55 (majority, usually diagnosed during middle school)
Moderate : IQ of 35-40, to 50-55 (about 10% of the population, usually found early in life due to obvious factors such as delayed walking or talking)
Severe : IQ of 20-25 to 35-40 (small percentage, able to develop functioning skills).
Profound : IQ 20-25 or below (smallest percentage, usually have dual diagnosis, such as seizure disorder)
(Carter, Andel, Robb, 2003).

Definition # 2 by American Association on Mental Retardation (AAMR)
Focuses on the abilities, rather than disabilities.
Agree onset must be before age eighteen.
Must be significant limitations in “personal capabilities”, substantial “subaverage intellectual functioning”, and concurrent “with related disabilities in two or more adaptive skill areas” (Carter, Andel, Robb, 317, 2003).
AAMR only has two functional levels , mild and severe, based on the adaptive skills of the individual, and on the level of support needed at different stages in life. The support services range from as needed and limited, to around the clock support for those who are severely developmentally disabled.

Causes of Mental Retardation
May occur in three different stages of life.
Prenatal includes: drug and alcohol abuse during pregnancy, chromosomal disorders, metabolic errors, brain formation disorders, or maternal disease.
Perinatal occurs anytime from the twenty-eighth week of pregnancy to twenty-eighth days after birth. Possibilities that may occur here are, “head trauma at birth and infections” (Carter, Andel, Robb, 318, 2003).
Postnatal includes: “head injuries, infections, degenerative disorders, seizure disorders, environmental deprivation” such as emotional and physical abuse (Bullock & Mahon, 2000; Sherrill, as cited in Carter, Andel, Robb, 319, 2003).

Participants of Love Themed TTAP method
The group I implemented the TTAP method with was a moderately developmentally disabled couple, Julio and Barbara. They are both middle aged, and have been dating for two years. Julio and Barbara both live in group homes, which are located across the street from one another.
Barbara and Julio are high functioning, and for the most part independent. They wish to get married, but due to a lack and/or limitation of basic survival skills, it is not possible. Julio and Barbara do not possess money managing skills, are unable to provide for themselves, and have limited travel expertise . In addition, Julio has been diagnosed with muscular dystrophy , which results in him utilizing a feeding tube. Therefore, he needs close medical attention, and this would be a deterrent to living independently. Finally, both Julio and Barbara have a past of behavioral issues , and while these are in the past, there is always the possibility that they may regress back to this stage of their lives.
The couple does not seem to mind the current arrangement. They see each other at least once a week. Besides participating in the TTAP program with me weekly, they also go on outings, visit one another at home, and special events.

Environment
Our “love” participants meet once a week at Barbara’s house for about an hour. Each week I pick up Julio at his house, and walk with him across the street to Barbara’s.
Barbara lives in a home with six other women. All are invited, but Barbara and Julio are weekly participants. The other ladies vary from week to week, depending on what we do.
We meet in the dining room, at a large wood table. It is a very open room, where everyone is able to see one another and socialize comfortably. Each week participants sit at the same seats, a form of habit. I found myself doing the same. This is an example of structure and routine. In addition, each week before I get there one of the ladies brings down her radio for me to use. This makes her feel important and helpful.

Theme: Love 
Being in love is a very important part of Barbara and Julio’s lives. They have been dating for over two years, and thoroughly enjoy each others company. Julio and Barbara have both expressed to each other, and I, that they hope to be together forever.
It is through the theme of love and the TTAP method that they are able to deepen their love and grow closer together.

Goals of Love Themed TTAP
1. Social
Increase and strengthen Julio and Barbara’s relationship.
Allow them to identify what they love about one another, and what they may need to work on to improve their relationship.
Maintain and increase friendships with members in the house
Allow opportunities to identify similarities, accept differences, and form and strengthen bonds
Maintain and increase communication, conversational, and active listening skills
Maintain and increase cooperative and competitive skills
Encourage them to speak of their relationship and their love freely, without prompts.
Maintain and increase socialization with others when together in public.
In addition, I reiterate that love is something we all need, can relate to, and is not limited to couples, but is experienced by all.

2. Emotional
Freely express emotions, feelings, and ideas
Understand and be aware of ones emotions
Reflect on life, love, past, present, and future
Understand the importance of recreation therapy and how it may help us be in touch with emotions we may or may not have been aware of.
Control anger and establish emotional control
Experience the catharsis effects of recreation therapy
Promote self-efficacy, intrinsic motivation, and freedom

3. Physical
Maintain and increase fine, gross, and perceptual motor coordination
Increase heart rate and burn calories
Reinforce a healthy diet through discussion
Increase range of motion, coordination, and hand-eye coordination.
Maintain and increase muscle strength, endurance, and energy.

4 . Cognitive
Maintain and increase cognitive stimulation
Promote developmental growth
Increase brain activity
Stimulate left and right brain so that memories can be stimulated, and to rejuvenate and reproduce cell growth in the brain.
Prevent further memory loss
Increase brain cells through visual, auditory, sensory, verbal, and kinesthetic stimulation.
Increase quality of life and wellness through cognitive stimulation
Increase knowledge in all nine creative arts areas of TTAP.
Gain insight into self, develop understanding of what they know, and want to know about one another and the theme.
5 . Spiritual
Promote spirituality and openness to speak of ones spirituality
Understand, explore, and reflect on values
Respect and explore one another's values
Maintain a positive belief of oneself and others
Treat all with respect, and find something positive in everyone.

Step 1: Creating a Theme
Because of the cognitive functioning level of participants, and this being the first time they are doing the TTAP method, I chose the theme to prevent frustration and misunderstanding.
The TTAP method is explained. Once a week I will come over, and we will do a creative art, based on the theme of “love.”
Following the introduction to TTAP, love is discussed using a Graphic Organizer. Using a large piece of paper “LOVE” is written across the top. I cue each participant to tell me what love means to them.
Barbara “Love is being nice and I care about him”
Julio “Barbara makes me feel like a man and a human being! My heart feels like staying with her. It is fun being with her.”
I remind participants that love is not just being IN love, but love is also how we feel towards our friends and family as well. Everyone agreed and stated they all love each other and being together.
A calm and relaxed mood is set with soft music

Step 2: Creating an image
Week two, the participants are asked if they remember what the theme is. They do not recall right away, so the graphic organizer is brought out. I go over what everyone said, and they are reminded.
A short discussion about love takes place.
Soft romantic music is played in the background
Participants each chose a colored sheet of construction paper. They are directed to make an image about why they love the other. Stickers, heart shaped doilies, markers, crayons, glitter, glue and scissors are provided.
The two pictures are combined into a frame for them to keep. It hangs above the fireplace in the house for all to see. It is now the conversation piece of the house.

Step 3: Sensory Stimulation
Progress is seen when participants remember the theme without prompts. The graphic organizer is brought out anyway. When working with an individual who has a developmental disability it is beneficial to use behavioral strategies such as “reinforcement, repetition, and modeling ” (according to Carter, Andel, and Robb, 328, 2003).
Being that it was Valentine’s Day I planned a romantic evening. Lights were dimmed, light up candles were glowing, a red tablecloth was placed on the table, and romantic music was played.
Scented lotions, bubbles, and body sprays were provided. Participants were asked to give one another hand massages, and upon completion to smell their hands and guess the scent. Barbara and Julio became very involved, and were observed gazing into one another’s eyes. They also enjoyed using a hand held back massager on one another.
Julio stepped up as a leader and request me to put on “Love me Tender” by Elvis Presley. He sang this love song, word for word, to Barbara. Following this, they shared a slow dance, where the rest of the ladies in the house watched. This process was independent on their part. I observed them take leadership roles, and turned the process into something more than imagined. My goals for this session went above and beyond expectations.
They agreed this was their most romantic Valentines Day yet, and that they had never experienced anything like this before. They also stated they hoped to do this again.

Sensory Stimulation, cont.

Step 4: Special Event
Each year HV-DDSO has a couples Valentine’s Dance. This served as step four of the TTAP method, Special Event.
Barbara and Julio spent the evening together dancing and dining. It was here I observed how much respect and love they have for one another. Barbara politely asked Julio if it would be okay for her to dance with someone else. Julio showed off his vibrant personality by dominating the dance floor. They shared many slow dances together, exchanged gifts, and danced with me as well. They held hands most of the night and were radiantly glowing in each others presence. They told me this was their favorite event held by the TR department at HV-DDSO.

Step 5: Sculpture
The session is started as usual, asking participants if they remember the theme, which they did, and the “Love” graphic organizer is hung up and reviewed.
Step five is introduced, which is planting. Participants decoupage a “jiffy pot”; a cardboard like pot used for starting off seeds. Dirt and seeds fill the pot, along with a tissue paper flower.
A discussion follows regarding what type of love a plant requires. Julio and Barbara both responded “sunlight and water.” Julio said, “ A plant loves you, and you need to love the plant too. We both put our love into the plant. Barbara and I want to learn to love each other better.” The couple both agreed that doing this activity made them feel calm , and they would be interested in doing it again.

Step 6: Movement
Step 6 is started off with a discussion about the plants. There is no signs of sprouts yet, but they update me with regards to watering the plant everyday and providing them with sunlight.
A Nintendo Wii is used to demonstrate love through movement. Wii involves a hand held controller, which transmits your body image. Games include; tennis, boxing, bowling, golfing, fishing, and many more. Julio and Barbara must work cooperatively to play this game, which puts their love to the test. Will they treat one another with respect if they lose or win? As an added physical bonus, Wii increases ones heart rate, burns calories, improves range of motion, and improves fine and gross motor coordination.
Barbara and Julio play a match of tennis, which Barbara wins . Julio takes it lightly, surprisingly since he is a very competitive and athletic guy. Barbara does not rub it in his face, but only laughs when someone remarks “you got beat by your girlfriend”.
They then played baseball, which brought about memories of “Touching Bases”, a baseball program for adults who are developmentally disabled. Lastly, bowling was played by everyone in the house. It was here when Barbara started to get upset and agitated because she felt as though Julio was more into the game than her. Here is when I changed gears and took the picture frame they made off the mantel and reminded them of how much they love one another.
In closing, they told me “playing Wii is like love because you have to work together.”
This program allowed this couple to strengthen their love and bond. They were able to have a new experience together, which they enjoyed.

Movement

Step 7: Music
Session seven started off on a very positive note. The plants started to bud, which Julio and Barbara were very excited and proud of. This provided them with a sense of self-worth and value . We discussed how the love they gave to the plants made them grow .
Following this we did Karaoke. Julio and Barbara both love to sing and dance, so doing Karaoke was the perfect opportunity for them to combine their two passions.
Julio sang his favorite love song to Barbara, “Love me Tender” by Elvis. He held her hands and looked into her eyes as he sang this song to her. Barbara and Julio did a duet to Grease, and had a great time dancing together. This too was a physical work out for them.
When asked what does music and Karaoke have to do with love, Julio responded “ Barbara is more in love with me then before when I sang that song. When I sing, her heart joins mine.”

Step 8: Food
A pre-made gingerbread house was used to symbolize love through food.
Barbara and Julio were provided with candies to decorate the house together.
Being that it was only a few days before Easter, and both participants are of Catholic faith, they decorated this into an Easter bunny hutch.
Julio placed the two bunny candies next to one another on the house and said that it was Barbara and him.
In closing he stated “this house is from my heart to hers. We worked well together!”
Working on this house helped them to work together cooperatively towards the same goal, increase their emotional connection and speak openly of their love for one another. In addition it strengthened their fine motor coordination .
* Due to Julio’s muscular dystrophy, he is unable to eat. Barbara is aware of this, and I noted out of compassion for him she was snacking on the candies during this activity.

Step 9: Photography
To start off one of our last sessions, we had a closing conversation of how the past eight weeks have been. I explain once more the TTAP method, and went through the ten steps with them.
As I went through each step, I ask participants to tell me what we did for each one. They had some trouble remembering them all, which is when I distributed the pictures I had taken over the past eight weeks. Once they saw the pictures, they immediately recalled each step, and their emotions and feelings during each one.
The couple arranged the photos, in a collage style, into the album. They relied on one another for support, and smiled as each picture brought back memories, one of the many benefits from photo therapy .
The couple truly appreciated being able to save all of their memories into this book. Julio made a touching statement saying, “When we fight, we are going to look at this book together, and make up”.

Step 10: Words
For the final step, the album is brought back out, and with my help, the couple adds thoughts and feelings to the book.
One page is dedicated to TTAP, where we write out the 10 steps, what we did for each, and where it can be found in the album.
The couple also adds a page of love notes to one another. Barbara writes “I love you because you are the only guy I want to be with. I like to bowl and dance with you.” Julio adds a love note that he wrote to her a few weeks ago. He said he can’t wait to see her later and make something with me. He also asked her if she would dance with him.
We add a page of question and answers about one another. They answer what their favorite thing is about one anther, and their favorite thing to do together. Barbara says he looks great in a suit, and is a great dancer. Julio says he loves her eyes, and his heart is hers forever.
Finally I ask the couple what they learned about one another these past ten weeks. They said “we became close more than ever!” “I learned we love each other and care about each other.”

Benefits for the Therapist
As an intern, having the TTAP method was extremely valuable. This method made me feel in control and prepared . Coming up with new ideas and activities can be stressful, but having this method eliminated this stress . Each step is planned out, and a flow is established.
Once a theme is created, thinking of ideas for each step comes simply. As a new intern I wanted to be sure that I made a great impression, and would be remembered. I believe that implementing this method is something I will be remembered for. Not only do the individuals have the actual art pieces we made, but they have a photo album of the TTAP method. The process and each step can be revisited by staff, friends, and family. Therefore, my ideas or work will never be forgotten .
The TTAP method made me feel confident as a therapist. After each session I was not worried about what to do the following week, because the main step was already planned out. I could spend more time focusing on the individuals wants and needs, rather than worrying about what will I do next with them. I was able to focus, and never felt overwhelmed.
Lastly, working for ten weeks with the couple allowed me to get to know and connect with them on a more personal level. I established friendships with these individuals, and truly enjoyed and valued the time I had spent with them. I knew them prior, from Special Olympics, but from doing the TTAP method, I now can say I truly know who they are and what they are about.

Benefits for Participants
The couple who experienced the Love themed TTAP method were able to connect to one another in a new way. Though they see one another often, and exchange words, they have never had the opportunity to participate together in a creative process. I believe this was extremely beneficial, especially for Barbara, who at times has difficulty expressing herself through words .
Julio and Barbara stated that through this method they were able to fall deeper in love, and learn more about one another . This benefited them socially and emotionally. They were able to have new experiences, work with materials they have never worked with before, and learn new ideas , which is beneficial cognitively . Each session was beneficial physically , whether it was dancing, playing Nintendo Wii , walking to one another's houses, or improving their gross and fine motor coordination . Finally, spiritually they increased their self value and worth . There were times when Julio or Barbara would come into the group upset or agitated about something that happened earlier in the day. I can truthfully say that by the time each session was over , they had forgotten about what had upset them , by being able to talk it out with one another , express it through the art , or put it behind them by getting lost in the experience .
Another benefit of the TTAP method is that after each step, participants are able to keep each item they made. This allows them to look back on this from time to time, and revisit their feelings.
In addition, they now have the photo album which allows them to remember the method, and how much they grew and learned together through it.

Happily Ever After 

TTAP with developmental disabilities

by levinemadoriphd on Aug 31, 2011

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TTAP with developmental disabilities — Presentation Transcript