Performing Art Therapy in Mental retardation

In the modification of behaviour of Mentally retarded children, performing art therapist should pay specific attention to deficits and deformities in the Murta layer of consciousness through performing art improvisation. Performing art includes specifically music, songs, dance, drama, painting etc having taal, lay, chanda. The last three are important as changes in murta layer of consciousness may affect Raag layer of consciousness that results intrinsic motivation to new or modified behaviour. Intrinsic motivation results sustainable change in the behaviour of children.

Before introducing intervention, case history taking and mental status examination are important. Case history may be collected from the parents or other informants. During taking the history, therapist should check extent of reliability of the statement of informants as there is a scope for hello error. Second, beginning and variation of each complaint must be recorded. If variation is needed, therapist should record the duration of behaviour constancy, possible antecedents or reasons, possible facilitators and inhibitors of the behavior.

Performing art therapist by improvisation of activity can assess child's sensory thresholds, pattern of perception, short, long term memory, working memory, psychomotor co-ordination etc. It must be remembered that aim of performing art therapist is not to teach singing, playing music, drama etc but to facilitate performing arts in order to improve adaptive and to control maladaptive behaviour.

Therapist should identify which adaptive behaviour requires minimum support and which one requires maximum support. For the same, one can prepare behaviour checklist using rating scale. The scale categories will be:

Assign 5 if the behaviour requires least support of others
Assign 4 if the behaviour requires less support of others
Assign 3 if the behaviour requires moderate support of others
Assign 2 if the behaviour requires much support of others
Assign 1 if the behaviour requires maximum support of others

The scaling will help therapist to plot graph of changes and association among different adaptive skills.

ADAPTIVE BEHAVIOUR

Adaptive behaviors are everyday living skills such as walking, talking, getting dressed, going to school, going to work, preparing a meal, cleaning the house, etc. They are skills that a person learns in the process of adapting to his/her surroundings. Since adaptive behaviors are for the most part developmental, it is possible to describe a person's adaptive behavior as an age-equivalent score. An average five-year-old, for example, would be expected to have adaptive behavior similar to that of other five-year-olds.

Performing art therapist will prepare adaptive and mal adaptive behaviour checklist before intervention. Below are the some adaptive and maladaptive behaviour.

MOTOR SKILL

1. Motor Skills
   
2. Gross Motor
   
3. Fine Motor
   
   SOCIAL SKILL
   
4. Social & Communication Skills
   
5. Social Interaction
   
6. Language Comprehension
   
7. Language Expression
   
8. Personal Living Skills
   
   SELF-HELP SKILLS
   
9. Eating & Meal Preparation
   
10. Toileting
    
11. Dressing
    
12. Personal Self-Care
    
13. Domestic Skills
    
14. Community Living Skills
    
    OCCUPATION
    
15. Time & Punctuality
    
16. Money & Value
    
17. Work Skills
    
18. Home/Community Orientation
    

Maladaptive Behavior - General
INTERNALIZED

1. Hurts Self
   
2. Repetitive Habits
   
3. Withdrawn or Inattentive
   
4. Asocial
   
5. Socially Offensive
   
6. Uncooperative
   
   EXTERNALIZED
   
7. Hurts Others
   
8. Destructive to property
   
9. Disruptive
   

Bengali version checklist
Below is the Bengali version checklist to assess abilities to detect source of sound, to pronounce sound and to vary the sound in the ascending and descending orders.

BEHAVIOUR CHECKLIST IN BENGALI LANGUAGE (Click it to make it big)



ACTIVITY ANALYSIS: Activity analysis is most important in modification of one's behaviour.

Activity: First play one rattle lightly and rhythmically in front of the child. Second, observe movement of eye ball, change in facial expression (smile, muscular changes in face), and tertiary activity. Third change the source of sound, observe and score the behaviour. (Click below to make the figure big)

INTERVENTION
Identify deficit > Set target behaviour > Set systematic steps to achieve target behaviour > Activity > Observe > Intervention by activity > Is target behaviour achieved? > yes > Is it sustainable? > Yes > Stop

Here Intervention includes
1. Segmenting behaviour: Target behaviour should be segmented in interlinked parts of behaviour. Each part should be linked with antecedents and consequences so that facilitating and inhibiting factors can be identified.
2. Associating behaviour: Now, arrange the behaviour in such a fashion so that facilitating factors are incorporated
3. Disassociating Behaviour : The inhibitors should be disassociated from each segment of behaviour
4. Shaping behaviour: The existing behaviour can be shaped using reinforcement schedule principles
5. Modeling behaviour: The new behaviour can be modeled using reinforcement schedule principles

MENTAL RETARDATION
Mental retardation (MR) is a generalized disorder appearing before adulthood, characterized by significantly impaired cognitive functioning and deficits inhttp://www.blogger.com/img/blank.gif two or more adaptive behaviors.


MR possesses less than 70 IQ and SQ level. According to the definition by the American Association on Mental Retardation (AAMR), an individual is considered to have mental retardation based on the following three criteria: intellectual functioning level (IQ) is below 70-75; significant limitations exist in two or more adaptive skill areas; and the condition manifests before the age of 18. Adaptive skill areas are those daily living skills needed to live, work, and play in the community. The new definition includes ten adaptive skills: communication, self-care, home living, social skills, leisure, health and safety, self-direction, functional academics, community use, and work.

Cognitive functioning: Any mental process that involves symbolic operations–eg, perception, memory, creation of imagery, and thinking; Cognitive functioning encompasses awareness and capacity for judgment.

Individual fails to put the blocks in the hole according to the size and shape. This suggests impairment in perception.
Adaptive behaviors: It is the individual’s everyday behavior that he/she emits to respond to the demands of his/her cultural, social, and physical environment. Adaptive behaviour includes self-help eating (taking food without other's help), dressing (to wear cloth him/her self, to button the wearing), socialization (to play with others, to visit the neighbour's house), occupational activities (to string the bead, to clean the utensils etc).

Physical demand: "Open the door", "Close the door"
Social demand: "Hello","Go to toilet"

STATISTICS

According to the World Health Organization (1994); approximately 156 million people, or 3 percent of the world's population have mental retardation. Prevalence by continent:

Africa 20,310,000
Australia 5,25,000
Asia 97,710,000
Europe 15,390,000
Latin America 13,800,000
North America 8,610,000

Mental retardation knows no boundaries. It cuts across the lines of racial, ethnic, educational, social and economic backgrounds. It can occur in any family. One out of ten American families is directly affected by mental retardation.

Ref: http://www.disabilityindia.org/MentalRetardation.html

CAUSES:
Problems at birth:Although any birth condition of unusual stress may injure the infant's brain, premature birth, and low birth weight predict serious problems more often than any other conditions.

Problems after birth: Childhood diseases such as whooping cough, chicken pox, and measles can damage the brain, as can accidents such as a blow to the head or near drowning. Mercury and lead poisoning can cause irreparable damage to the brain and nervous system.

Poverty: Children in poor families may suffer mental retardation because of malnutrition, disease-producing conditions, inadequate medical care, and environmental health hazards. Also, children in disadvantaged areas may be deprived of many common cultural and day-to-day experiences provided to other young children. Research suggests that such under-stimulation can result in irreversible damage and can serve as a cause of mental retardation.

CLASSIFICATION:
In ICD-10, there are 6 classifications as

1. (F70–F79) Mental retardation
   
2. (F70.) Mild mental retardation
   
3. (F71.) Moderate mental retardation
   
4. (F72.) Severe mental retardation
   
5. (F73.) Profound mental retardation
   
6. (F78.) Other [[mental retardation
   
7. (F79.) Unspecified mental retardation
   

Mild mental retardation: Approximately 85% of the mentally retarded population is in the mildly retarded category. Their IQ score ranges from 50-75, and they can often acquire academic skills up to the 6th grade level. They can become fairly self-sufficient and in some cases live independently, with community and social support.

Moderate mental retardation: About 10% of the mentally retarded population is considered moderately retarded. Moderately retarded individuals have IQ scores ranging from 35-55. They can carry out work and self-care tasks with moderate supervision. They typically acquire communication skills in childhood and are able to live and function successfully within the community in a supervised environment such as a group home.

Severe mental retardation: About 3-4% of the mentally retarded population is severely retarded. Severely retarded individuals have IQ scores of 20-40. They may master very basic self-care skills and some communication skills. Many severely retarded individuals are able to live in a group home.

Profound mental retardation: Only 1-2% of the mentally retarded population is classified as profoundly retarded. Profoundly retarded individuals have IQ scores under 20-25. They may be able to develop basic self-care and communication skills with appropriate support and training. Their retardation is often caused by an accompanying neurological disorder. The profoundly retarded need a high level of structure and supervision.

The American Association on Mental Retardation (AAMR) has developed another widely accepted diagnostic classification system for mental retardation. The AAMR classification system focuses on the capabilities of the retarded individual rather than on the limitations. The categories describe the level of support required. They are: intermittent support, limited support, extensive support, and pervasive support. To some extent, the AAMR classification mirrors the DSM-IV classification. Intermittent support, for example, is support needed only occasionally, perhaps during times of stress or crisis. It is the type of support typically required for most mildly retarded individuals. At the other end of the spectrum, pervasive support, or life-long, daily support for most adaptive areas, would be required for profoundly retarded individuals.

medical-dictionary

MENTAL STATUS EXAMINATION
Psychiatric mental status examination

1. Observations of Examiner (not in response to questions):
2. Patient's own subjective evaluation of his emotional reaction and mood
3. Content of thought
4. Examination of the Cognitive Functions

THERAPY

Applied Behavior Analysis (ABA):Applied behavior analysis is the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior. Learning principles include classical, operant conditioning and trial and error theory.

Socially significant behaviors" include reading, academics, social skills, communication, and adaptive living skills. Adaptive living skills include gross and fine motor skills, eating and food preparation, toileting, dressing, personal self-care, domestic skills, time and punctuality, money and value, home and community orientation, and work skills.

Components of ABA

1. selection of interfering behavior or behavioral skill deficit;
   


2. identification of goals and objectives;
   


3. establishment of a method of measuring target behaviors;
   


4. evaluation of the current levels of performance (baseline);
   


5. design and implementation of the interventions that teach new skills and/or reduce interfering behaviors;
   


6. continuous measurement of target behaviors to determine the effectiveness of the intervention, and
   


7. ongoing evaluation of the effectiveness of the intervention, with modifications made as necessary to maintain and/or increase both the effectiveness and the efficiency of the intervention.
   

PERFORMING ART THERAPY
Performing art therapist will prepare one case history records and behaviour check list based on possible limitations of children or based on observation of child's behaviour. The check list of behaviour will be graded in such a fashion so that one can measure change in behaviour across periods. Measurement is important as this will give therapist regular feedback about therapy. Therapist should be aware of different developmental stages from birth to childhood and its different principles. I am suggesting Hurlock or Mussen's book on child development. Knowledge about the developmental stages gives idea about extent of development with age. Development includes physical, intellectual, social, moral, emotional and personalty development.To develop adaptive behaviour, it is important to know about gross (total-body movements as playing football) and fine motor skills (delicate movement where in eye-hand coordination is involved as beading string).


DANCE THERAPY: Dance is useful therapy to improve psycho-motor skills. Dance therapy is not movement therapy where in movement is important for adaptive skill development. Dance therapy helps to integrate sensory organs of the children. Physical complaints can be reduced by the dance. Besides, it develops socialization skills. Dance helps therapist to examine the extent of physical and cognitive deficits of the children.Therapist can design the training need oriented dance in order to develop specific adaptive skills. But in this technique, client's consciousness will not be free floating. Therefore, therapist can act as facilitator rather trainer. Therapist can demonstrate phule phule dhole dhole dance of Tagore sangeet. It facilitates both eye-coordination and coordination among different parts of body.



DRAMA THERAPY: To perform drama, therapist can use mask of pet animals, toys, flash cards, sands etc. to develop adaptive behaviour skills.

MUSIC THERAPY: Therapist can improvise theme using instrumental music. Some of the instruments are given below:




The theme should be directed to develop adaptive behaviour of the children.