Vol 1 • Issue 4 • Jun 2010
In recent issues of Continuums, I’ve focused on the relevance of residential treatment as a vital component in an integrated system of care. Another critical element in any integrated continuum of care is the availability of an approach known as “wraparound” services. To ensure that the individuals we serve receive the most advanced client-centered treatments, we “wrap” and customize our various service lines and professional disciplines specific to the needs of each client and their family’s needs. Within the context of residential services, this is accomplished through multidisciplinary teams, multimodal treatments and, most importantly, family involvement as an equal partner in the treatment process. The ultimate goal of wraparound is to create a community based system of support designed to keep our clients in their homes and communities. Specifically, these services focus on increasing the independence of the individual, allowing them to live as autonomously as possible.
For Grafton, these services manifest through collaborative, team-based planning. While it is not always simple to provide a client with effective wraparound treatment, even in the most challenging situations, the notion that “they can’t be served in a community based environment” never enters Grafton’s mindset or lexicon.
When Grafton creates a wraparound service plan, strength-based family involvement and other natural support systems are integral components. We ask, listen, respond and learn from both the individual and family. The diminishing need for utilization of paid professional support by replacing them with naturalistic community-based support systems is always our optimal goal.
Many of Grafton’s clients have benefited from this collaborative, team-based planning. “Jake” who you will read about later in this newsletter, is one of my favorite examples. Not only has he excelled during his time at Grafton, but by creating an individualized wraparound services plan for him, Jake will soon be leaving Grafton and heading off to a public high school.
Another example of effective wraparound efforts is Grafton’s recent partnership with the city of Winchester to offer early intervention services for children up to the age of three. This program, entitled Infant & Toddler Connection of Shenandoah Valley, relies upon the joint collaboration between teams of professionals and family members to provide children with the best support possible. Interaction, reaction and feedback are all important markers of a child’s success. The depth of our wraparound experience will be invaluable in providing our early intervention clients with the natural support they need for optimal development so that they may later become proactive contributing members in their community.
Jake*, an 18-year-old male who loves to dance, receives wraparound services from Grafton. He was born alongside a twin brother, who did not have any difficulties at birth. Jake, however, faced numerous complications. He had a significant intestinal disorder and underwent critical surgery at six days of age, which left him in a coma for one week. As he developed, it became clear to his parents that he was not progressing along the same developmental timeline as his twin. He was unable to communicate coherently and engaged in self injurious and aggressive behaviors.
Before he came to Grafton, Jake underwent two psychiatric hospitalizations at the Virginia Treatment Center for Children. He was admitted for his aggressive and self-injurious behaviors. He had trials of a number of different medication trails including Naltrexone, Clonidine, Depakote and Ritalin.
At the time of admission, Jake was diagnosed with Pervasive Developmental Disorder, Attention-Deficit/Hyperactivity Disorder, and Speech Language Impairment in addition to an intellectual disability. Behavioral symptoms included impulsivity, aggression, and an inability to focus on a task. His aggressive behaviors manifested in biting, kicking, hitting, pinching and destroying property. He also frequently engaged in self-injurious behaviors, such as biting his own hand or banging his head against a wall. In addition, his inability to communicate left others unable to understand most of what he said.
When Jake first arrived at Grafton, he had a difficult time staying on task in the classroom, frequently engaging in destructive behaviors directed at himself and those around him. His behavioral difficulties necessitated 1:1 support to maintain his safety and that of others. When Jake entered Grafton as a day student, a positive behavior support plan was immediately implemented with the goal of integrating Jake back into his home school and community.
Jake’s multidisciplinary team members included his teacher, behavior specialist, speech language therapist and occupational therapist. During speech therapy sessions, he was given activities that focused heavily on visual modes of communication, encouraging him to use pictures and devices to communicate. Over time, he was able to improve his use of spoken language, accurately communicating his wants and needs verbally.
It did not take the multidisciplinary team long to understand that many of Jake’s aggressive actions and self injurious behavior were due to sensory overstimulation. As part of his occupational therapy, Jake was prescribed a “sensory diet,” which involved a carefully designed activity schedule that provided Jake with varied sensory input to help him regulate his attention and activity. Weighted blankets, hugs, joint compression, heavy lifting and physical activities were incorporated into his sensory diet.
Jake’s love of dance was also assimilated into his therapy. Listening to music and dancing have been strong motivators for Jake and were integrated into his daily treatment programming. For instance, if Jake was having trouble staying on task, he was offered a “dance break” after he completed his assignment. Due to his response and the success of using his sensory diet, Jake’s occupational therapist recommended that he no longer needed occupational therapy, as he and his family had learned to apply the same strategies in his natural settings. Because of their active involvement as “partners in care”, Jake’s parents are able to recognize when and how to make adjustments to his environment, depending on his sensory needs.
In addition to participating in his various therapies, Jake has also worked closely with his psychiatrist, who successfully titrated his medication regimen down to maximum effectiveness. Family support and additional agency involvement have also been critical in Jake’s development. Chesterfield County Public School’s LEA representative, school social workers and school psychologists have all worked in tandem to help with his transition. Due to an extensive support circle and the combined success of his multi-modal treatment course, Jake has shown remarkable progress.
During his first three months at Grafton, Jake exhibited behaviors including:
- 290 incidents of screaming and yelling
- 148 incidents of biting himself
- 35 incidents of property destruction
Over the course of the last year, Jake has made significant progress as evidenced by ZERO incidents of aggression and property destruction. Occasionally, Jake will let out a nervous squeal when he is excited; however, these vocalizations are not disruptive to the classroom environment. Jake is also now able to communicate verbally at a level where others can understand him 85 to 90 percent of the time. He is better focused in his assigned activities and is better able to modulate his attention and activity as needed. Additionally he has improved in his ability to dress, toilet and feed himself. He has made many friends whom he knows by name and with whom he enjoys socializing and joking around. Jake also displays his extraordinary dancing skills in the Grafton Talent Show each year!
Jake’s family has been very involved in his progress and care. They have maintained ongoing communication with both Grafton’s multidisciplinary team and the referring locality’s public school staff. Family engagement as equal partners in care is essential to achieving optimal outcomes. As an example of his developmental progression, Jake recently sat through a 90 minute triennial meeting, remaining interactive and engaged the entire time.
Jake’s development and stability have allowed him to take part in multiple work and volunteer opportunities, both on and off campus. He participates in Meals on Wheels, works at the Richmond Animal League, affixes labels to Red Cross folders and lends a hand in Grafton’s kitchen. It is anticipated that his training in vocational activities will continue once he enters public school.
Most exciting, Jake’s multidisciplinary team is working with him to transition to a public high school. This fall, Jake will enter the 12th grade. He will once again have 1:1 support both as he prepares to leave Grafton and while he acclimates to his new school environment. This 1:1 support will be provided by a Grafton employee, and it is anticipated that the support will fade within the first nine weeks at the public school. He has already visited and had tours of his new school – the very one his twin graduates from this month.
*Client’s name has been changed to protect his privacy
- “Positive Outcomes for Individuals with Intellectual Disabilities and the Organization Providing Services to them After Minimizing the Use of Physical Restraints”–presented at the 10th annual International Research and Practice conference hosted by the British Institute of Learning Disability (BILD) in Dublin, Ireland on May 6th by CEO, Jim Gaynor and executive director of the Winchester facility, Kim Sanders. http://www.bildservices.org.uk/acatalog/bild_conf2010_behaviour_support.pdf
- “Promising Evidence Based Practices in Autism”–a webinar was presented on April 21st to parents and referral sources for clients placed at Grafton.
- Grafton Teacher, Roger Styron, wins 2010 Margaret Shepherd Teaching award – presented at the Virginia Association of Independent Special Education Facilities (VAISEF) spring conference on April 29th.
- “Mental Health Services Boosted by Healthcare Reform, but Struggle in the Face of Budget Cuts” – an op-ed article by CEO, Jim Gaynor was published in The Winchester Star on May 26th.
- “Mental Health Services Struggle” – an op-ed article by CEO, Jim Gaynor was published in The Richmond Times Dispatch on May 29th.
- Substance Abuse and Mental Health Services Administration (SAMHSA) – recognized Grafton’s clinical best practices in restraint and seclusion reduction in Issue brief #4 of “Promoting Alternatives to the Use of Seclusion and Restraint.” To be published on the SAMHSA web site soon.
- “If Safety is Your Priority, Physical Restraint is Not Your Option” – will be presented at the 41st annual Autism Society conference in Dallas, Texas on July 7th by Allyson Bateman, educational administrator, Jason Craig, assistant educational administrator and Kim Sanders, executive director, Winchester facility.
- “A Good 4-Letter Word: Increasing Goal Mastery through Data-Based Decision-Making” – will be presented by Lisa Marshall, director of clinical services, at Opening Doors—Unlocking Potential 2010—Invigorating Instruction for Students who are Deaf or Hard of Hearing on August 3rd & 4th in Charlottesville, Virginia.
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