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Handle.orgThe HANDLE® Institute
7 Mt. Lassen Drive, Suite B110
San Rafael, CA 94903
CASE STUDY ADD, Autism, Central Auditory Processing Disorder, Sensory
Processing Disorder in 14-year-old female Presented by Peg Simon, certified HANDLE® Practitioner, from Judith Bluestone’s client notes These case studies, each submitted by a Certified HANDLE® Practitioner, demonstrate outcomes achieved through implementation of an individualized HANDLE program. The acronym stands for the Holistic Approach to NeuroDevelopment and Learning Efficiency. The HANDLE paradigm for understanding behaviors and their root causes is thoroughly explained in The Fabric of Autism: Weaving the Threads into a Cogent Theory, by Judith Bluestone, the creator of HANDLE and the founder of The HANDLE Institute. For intimate insights into client and family experiences of HANDLE, see The Churkendoose Anthology, with commentary by Judith Bluestone.
For each of the clients in these Case Studies, the practitioner began with a comprehensive assess-
ment, the findings of which led to a Neurodevelopmental Profile, which in turn formed the basis
for a program of activities complex in their neuroscientific premises and very simple to implement.
Thereafter the client’s program was modified about monthly in accord with changes achieved in the
interim. Each client participates in twelve to fifteen activities regularly; the practitioner, in writing
up the case study, names those activities in brief without the full details and explicit information
each client-family receives in why and how to implement the program. Go to www.handle.org for
a fussy eater, does not drink much water, and prefers chocolate and cola. She is under the Client is the only child of well-educated parents. care of a psychiatrist specializing in autism. She She has a history of ADD, autism, and sensory pro- was seen for suspected sleep apnea, but did not cessing disorder; diagnosed with central auditory meet criteria for diagnosis; went to school for processing disorder (CAPD); at time of HANDLE special children for elementary years; had many assessment was taking Depakote, Trileptal, Foc- years of sensory processing disorder therapy; will continue speech therapy in group setting.
Early Health and Developmental History
At time of assessment, client was entering seventh
Mother’s pregnancy and delivery were normal, grade at a public junior high School.
with mild jaundice and some feeding problems at birth. Client suffered numerous ear infections in Participation in HANDLE® Program
early childhood. She had high fevers, with febrile Referral Concerns
seizures and no diagnosed dehydration. All devel- Client’s mother came to a HANDLE informational opmental milestones were reported met; reported presentation, and subsequently set up appoint- difficulty/delay with playing ball sports and with ment for her daughter. The referral concerns were Nutrition and Current Health
Educational concerns: dealing with transitions • It was observed at HANDLE assessment that in junior high; organizational skills; auditory client has pudgy feet and generally tight skin, and cannot tolerate closed shoes—wears flip flops only. Client has nocturnal enuresis. She is Social concerns: social ability is limited in negotiating and compromising in a group; has Other notes: Client has difficulty in modulating no friends. voice and gets easily upset/angry. Mother felt need Specific perceptual and/or processing con- cerns: CAPD, Sensory Integration Disorder, Initial HANDLE Program
Attention, Hyperactivity, Visual Perception, Autism.
Client was given an initial HANDLE program to address the referral concerns by organizing and Findings
strengthening the disorganized/weak systems Initial Assessment: Sept. 7, 2007
Client is hypersensitive to most light touch, with tactile sensitivity limiting food choices; she also Crazy Straw and Blowing activity to enhance blocks pain sensation. Grinds teeth at night, and the visual functions, auditory functions, needs to chew ice or gum, indicating trigemi- interhemispheric functions, and muscle tone; nal nerve is disorganized. Lymph is not flowing in addition, Crazy Straw was given to aid with well, causing tight skin and puffy feet with easy Buzz Snap (hands, face, feet) to enhance Vestibular system disorganized. Client requires muscle tone, proprioception, and to help get stimulation (likes to spin, jump, etc.) to focus, falls asleep in moving car or when overheated; Face Tapping to enhance interhemispheric dizziness is a factor during movement if wearing functions, tactility, differentiation, auditory glasses (for near point vision). Her muscle tone is mildly diminished, and differentiation not com-plete (there is mild overflow to mouth when track- Skull Tapping to enhance interhemispheric ing and startles to unexpected sound). Auditory functions, tactility, auditory functions, and to sequencing challenged by guttural sounds (prob- Proprioception is compromised (requires mother system flow, vestibular system, and auditory beside her in order to fall asleep). She often Chocolate Ears to enhance auditory functions, Visual Systems: Ocular motility is challenging as vestibular system, and to improve digestion; sustained tracking leads to mild nystagmus—cli- Crossed Arm Bounce to enhance interhemis- ent prefers to move head or body instead. Bin- ocularity not fully established as left eye tends to 2-Finger Spinal Massage to aid the autonomic over-converge, and she sometimes closes left eye to focus. There is mild light sensitivity. Ball Back Roll and Side to Side tips to enhance Lateralization: right side dominance with mild the vestibular system, auditory functions, left side weakness and lack of synchronicity seen visual functions, interhemispheric functions, Higher order functions: Receptive language chal- Spinal Twist to aid with vestibular system, au- lenged by auditory sequencing difficulties and by ditory functions, interhemispheric functions, client’s limited ability to read non-verbal com- munication. Written expressive language com-promised; time management and organization challenging; reading comprehension also compro- ception, tactility, and muscle tone along with Observed strengths: visual perceptual constancy; Additional suggestions were made to begin sup- motor planning; oral expressive language (relative plementing with Omega 3 fatty acids to balance the 3-6-9 EFAs, and to increase water intake while decreasing caffeinated food/beverage intake.
Program Review/Reassessment Visits
address long-term organizational needs. Discon- Activity Check: Sept. 11, 2007
tinue Buzz Snap Face, Buzz Snap Hands and Feet, 2-Finger Spinal Massage, Peacemaker Massage, Family report: The activities have been done for the 3 days since seen at assessment.
Clinician’s observations: Feet less puffy.
Program revisions: Further instructions given on Summary:
Ball Back Roll and Side to Side Tips re the number Client is now functioning well in school and ap- of repetitions and what to gauge increases by. In- propriately in social situations. Enuresis stopped crease amount intense sucking with Crazy Straw. Guidance given on more accurately doing several Social concerns of limited social ability and of the activities. Adaptations made in Crossed Arm lack of friends are met. Client has friends and Bounce. Added Jiggle Bridge to further enhance is able to work things out with them normally — can apologize for overreacting, or friends can apologize for hurting feelings. She is able Program Review #1: Oct. 16, 2007
to sleep on own and no longer needs or wants Family report: Has girl friends for first time; enure- sis stopped completely; no longer needs or wants Educational concerns of transitions, writing, mom in bed with her to fall asleep; less need for and CAPD met. Organizational skills improv- chewing. Activities being done regularly. ing but still needs help for long-term projects. Clinician’s observations: Feet not as puffy, less Generally, school is much better. Handwriting bruising; lymph is beginning to flow better. Im- is precise, easy to read and fluent. She now has provements seen in proprioception, interhemi- 4 regular teachers out of 6. New activity given spheric functions, tactility, vestibular system, to accomplish the goal of improved organiza- Program revisions: Side to Side Tips—focus on Perceptual and processing concerns: Visual small object. Crossed Arm Bounce—4 bounces tracking is smooth and convergence is ac- “reading objects.” New activities: Sunrise-Sunset; curate. Hemispheric synchronicity resolved. Reflexology diaphragm stretch. Discontinue Facial expressions are all appropriate, and Chocolate ears and generalized blowing. On hold: she is able to read and respond to non-verbal Peacemaker Massage. Continue the others.
communication. Physical sensations more organ ized and emotional feelings in normal Program Review #2: Feb. 25, 2008
range. Tactility issues mostly resolved, and has Family report: Client has begun to react to pain; begun to react to pain. Feet less puffy, with has friends and normal problems with them; less bruising. Wears closed shoes with ease.
sleep over at friend’s house with 5 others and no need to prep host family; organization skill is Future plans
improved but still somewhat challenging for long Client is enthusiastic participant in therapy and wants to become a therapist and invent activities herself. Client will continue with maintenance Clinician’s observations: Visual tracking smooth; convergence accurate; bimanual circles and triangles synchronous and symmetrical; feet less What Makes This Case Unique
puffy and can wear closed shoes now; handwrit- This client had received many years of therapy ing precise, easy to read, and fluent. Client carries and had been in a special needs school for her on meaningful conversation during session and elementary years, yet when seen was not able to is able to modulate voice appropriately and show function appropriately socially or academically. In addition, nocturnal enuresis was still a nightly Program revisions: Introduced Hula Bounce to problem. This client was seen four times over nearly six months and her HANDLE program was revised three times. At the exit interview she was func- Client’s behaviors/symptoms leveled off for a long tioning appropriately both socially and academically, enough period of time that both her neurologist and and presented as a neurotypical (and very bright) psychiatrist agreed to begin weaning her from her 14-year-old, able to have friends and even sleep over medications. On April 30, 2009, her mother reported without any special arrangements with host family. that in the last six months, with the supervision of Nocturnal enuresis was completely resolved. Aca- client’s neurologist and psychiatrist, she has been demic concerns, including CAPD, were corrected, with weaned off of Depakote and Trileptal with no ill ef-long-term organizational skills still being addressed. fects. Next they hope to wean her off of Seroquel.
Both the length of time the client’s problems had persisted and the relatively short time of the HANDLE program in resolving the majority of the concerns are For further information, Peg Simon can be contacted at notable. Also notable is the very full recovery made.
firstname.lastname@example.org. She lives in Seattle, Washington.
The HANDLE Institute presents these case studies to demonstrate the successes of the HANDLE approach and
pique the interest of researchers and funders in engaging in clinical studies to further examine the efficacy of
these interventions. For more information about The HANDLE Institute, go to www.handle.org or email us at
email@example.com. You can download case studies from the website or email us to obtain pdf files.
The HANDLE® Institute
7 Mt. Lassen Drive, Suite B110
San Rafael, CA 94903
O rganization to S trategies in Acute I schemic S yndromes Overall Efficacy of Fondaparinux vs Enoxaparin in VTE Prevention: Meta-analysis Fondaparinux better Enoxaparin better P = 0.000000000000000001 % odds reduction Overall odds reduction for proximal DVT = 57.4% [CI: 72.3 - 35.6]; p = 10-6Turpie et. al. Arch Intern Med 2002: 162: 1833-40 Baseli