Module 3 Environmental Complexity

Initially, "Cindy" demonstrated significant difficulty handling new people and activities in her safe, familiar home environment. Prior to therapy, Cindy was content watching movie videos, fixating on video boxes, and self-stimming by twirling in circles. Very little demands were placed on her, providing for a peaceful home environment. Cindy would spend the day in her diapers because she refused to get dressed and stay dressed. Her hair was generally dirty and tangled due to her refusal to take baths. She grazed on the few food items she would eat, from the coffee table or floor and she demonstrated meltdowns whenever her pacifier was taken away. When therapy was introduced, Cindy avoided it by screaming and running to the other side of the room. Attempts to calm Cindy and redirect her were met with kicking, hitting, scratching, and screaming. Cindy's mother also became very distressed when any attempts were made to increase her child's compliance and on-task behavior. The initial plan was to help Cindy utilize self-calming techniques so she could effectively sit and participate in an activity. Very few strategies were effective however (gentle swinging in a blanket, "hotdog" deep pressure input, reducing distracting lights and sounds, etc.) as Cindy did not tolerate input that was received from others. Instead, we allowed her to acheive homeostasis in her own terms before proceeding. This generally included her pacifier and snuggling in tightly with mom. Once a calm, alert state was achieved, we began to introduce new activities to aid in her development. As suspected, unfamiliar tasks were resisted. Taking a few steps back, we started with familiar actvities and objects that were perceived as "safer". Even familiar, enjoyable tasks were difficult to expand upon however. For example, even though Cindy loves to color with crayons, she would only color on an 8 1/2 x 11 inch piece of paper. Eventually, we were able to move to coloring on paper plates, coloring on paper taped to the door, etc. Use of favored video boxes were also beneficial reinforcers at the completion of short-term tasks.

To add to the challenges of Cindy's rigidity, her home environment was very stimulating. The floor was covered with clothing, food, toys, and other debris. The television was always on and the volume was very high. When the television was on, Cindy was underresponsive to others in her environment. When it was off, the visual complexity of the items on the floor, appeared to significantly increase her activity level. Requests were made to keep the televeision off as much as possible, especially during therapy sessions. Cindy's special intructor purchased a child size table and chair which was beneficial in helping Cindy identify this space as her therapy/work space. The table was placed in a corner of the room to minimize distractions. Cindy made steady gains in her acceptance of new challenges although transitions from preferred activites continued to be difficult. A picture schedule was recently introduced to help Cindy predict what was going to happen and what would be expected of her during the session. Although this new strategy was only implemented a week ago, immediate gains have been observed.

Cindy continues to participate in therapy in her diapers with tangled hair and a pacifier as needed. When looking at our priorities at this point and time, we have found it more important for Cindy to feel "comfortable" while developing her language, cognition, motor skills, etc. We have also worked on increasing her tolerance to various forms of sensory input with the long term goal of increasing her acceptance to clothing, grooming, etc.