A Demonstration of Helping Adolescents With Mild Intellectual Disability Climb Ladders

A Demonstration of Helping Adolescents With MildIntellectual Disability Climb Laddersjppi_322 283..289

Kok Hoe Anthony Chan, Jayashree Lakshmi Varahan, Peng Loong Daniel Loh, and Sey Ing TanAssociation for Persons with Special Needs, Delta Senior School, Singapore

Abstract A research team at a vocational school in Singapore, catering mainly to students between the ages of 17–21 with mildintellectual disability, studied how to best address the challenge of enabling students to learn how to climb ladders (a skill necessaryat many job placements). They documented the approach used and suggested extrapolations and scalability for similar problems. Anexploratory approach was adopted for tackling the training program. The students in the study with motor or anxiety issues requiredshorter periods of intervention, and prognosis of success in intervention was higher compared with students with a history of fear orphobic experiences. Mapping the process helped enhance the understanding of the support and intervention modality needed byoccupational therapists and psychologists to provide information to the staff in the vocational disciplines with the means to enablesuch motor and dexterity skills. Future studies should involve determining if the process is applicable to difficulties in other vocationaltask issues or with other phobic activities that involve both psychomotor and psychological issues.

Keywords: climbing ladders, intellectual disabilities, mobility, multidisciplinary approach, occupational skills

INTRODUCTION

Being able to climb a ladder is a skill useful in many vocationsand certainly one necessary for successful job placement in manytrades. The problem encountered at the Delta Senior School inSingapore, an educational facility catering to youth between theages of 17 and 21 who have mild intellectual disability, is that anumber of the students enrolled in the hospitality trainingprogram were unable to demonstrate this skill. This posed aproblem as these students were being prepared for working in oneof many of the settings where they may have been required toclimb a ladder (e.g., in a hotel where they have to climb up on aladder to clear ceiling air vents). The reasons why someone maybe unable to perform this task vary (inexperience, fear of heights,uncertainty with balance, poor coordination, etc.). Thus, to helpovercome this deficiency in a set of students with intellectualdisabilities in the Delta Senior School, the authors undertook aprogram to enable those students who were unable to demon-strate this skill to overcome their reticence or fear and becomeproficient in it.

To begin, a literature review was conducted to find out aboutcurrent practices of how to resolve students’ difficulties and fearof climbing ladders. The review was structured so as to search forinformation related to the problem (e.g., theoretical informationon related topics, such as fears and phobias, and frameworks for

assessment and intervention strategies). The results of the reviewand our approaches are organized by topics and are discussedbelow.

PHOBIA OF CLIMBING LADDERS

We first explored the notion of phobias. A phobia is a type ofdisorder in which the affected individual displays a marked andenduring fear of specific situations or objects. Individuals withspecific phobias experience extreme fear as soon as they encoun-ter a defined situation or object (i.e., a phobic stimulus). Forexample, an individual with a phobia of dogs will become anxiouswhen confronted by a dog. The specific phobia triggers distress orsignificantly impairs an affected individual. The fear of climbingladders is related to acrophobia, or a fear of heights, where thefear is exacerbated by being off the ground and in the air (as withclimbing up the rungs of a ladder).

Researchers have found that the development of a specificphobia may be determined by a variety of factors, includingbehavioral or cognitive, and can be explained by social theories oflearning and conditioning. A major determinant of specificphobias is conditioning. Association and avoidance are types ofconditioning. In association conditioning, a stimulus that wasinitially neutral begins to trigger an anxiety response. Forexample, if an individual was climbing a ladder one day andexperienced a strong anxiety response, an association may formbetween climbing and anxiety. Individuals are not classifiedphobic until they begin to avoid. In avoidance conditioning, indi-viduals learn to avoid a stimulus that triggers anxiety. Every time

Received April 13, 2010; accepted October 9, 2011Correspondence: Kok Hoe Anthony Chan, Association for Persons withSpecial Needs, Delta Senior School, 20 Delta Ave, Singapore 169832,Singapore. Tel: +65 62763818; E-mail: [email protected]

Journal of Policy and Practice in Intellectual DisabilitiesVolume 8 Number 4 pp 283–289 December 2011

© 2011 DELTA SENIOR SCHOOL

individuals avoid the phobic stimulus—using a ladder, forexample—they are rewarded by the sense of relief from anxiety.

THEORETICAL BASIS FOR THE INTERVENTIONS

Cognitive–Behavioral Therapy (CBT)

In order for our students to overcome anxiety about climbingladders, we explored recommended therapeutic practices. Basedon what is available in the literature, we opted to use a combinationof relaxation and CBT with interactive imagery. CBT is a maintreatment of choice for specific phobias. It consists of two parts:changes in thoughts and behavior. Behavioral techniques thatexpose the client to the feared situation either gradually (system-atic desensitization) or rapidly (flooding) are frequently used. Inaddition, the client is taught ways of stopping the panic reactionand regaining emotional control. CBT is a short-term problem-focused psychosocial approach that can treat phobias effectivelywith direct exposure where treatment can be completed in onesession. The underlying principle of CBT is that what people thinkof in a given situation affects how they feel emotionally andphysically, and also alters what they do. Thinking (or ruminating)often becomes unhelpful and, in the extreme, puts a negative slantto their actions by dwelling on past or current problems. Behavioris altered with reduced or avoided activity that in fact may oftenworsen the problem. When people feel anxious, they experiencedifficulty in doing activities. Negative thoughts lead to avoidanceof activities and this causes anxiety, thus resulting in a viciouscircle. As noted by Marks (1987), there is a dynamic relationshipbetween age and specific phobias. Research has indicated someconnections between the age of individuals with specific phobiasand insight into the extreme aspect of their fears. Insight tends toincrease with age, and adults and adolescents can report feelings ofdistress about having a phobia.

Various relaxation exercises have been useful in reducinganxiety. As the mind affects the body, relaxation exercises relaxthe body in an attempt to induce relaxation in the mind. Thus,it was important to teach our students a way to relax that is likelyto reduce negative emotions of fear or anxiety. Students weretrained to carry out diaphragmatic breathing exercises with thehelp of abdominal instead of chest muscles. The physiologicalsymptoms of anxiety were thus lowered by this behavioraltherapy. Relaxation was then followed by guided imagery of aquiet and tranquil place. Guided imagery was followed bythought prompts or cues that facilitated helpful thoughts ofbeing “OK” or “I can handle this,” as well as positive reinforce-ment given by the psychologist as the student progressed. Thestudent’s thinking patterns were gradually changed by exposureto ladder climbing (i.e., practice effects) as well as because of theCBT (i.e., calming imagery). The CBT thus integrated bothbehavior modification and changing thoughts to enable the stu-dents to overcome fears. The distorted thinking and irrationalfears of the students were thus redirected to helpful thoughts byconverging on the interactive imagery that the psychologist used.Interactive imagery was thus initiated with the student as asource of guidance and mobilization of inner strength of thestudent to adapt and overcome fears.

The Model of Human Occupation and How Its “Factors” Relate toThis Study

The model of human occupation (MOHO; Forsyth & Kiel-hofner, 2006) provides a theory for delivery of occupational-focused practice. It explains aspects of engaging in occupationand problems that arise because of illness and disability. Its con-cepts address (1) the motivation of occupation; (2) the routine ofpatterning of occupational performance; (3) the nature of skilledperformance; and (4) the influence of environment on occupa-tion. In the MOHO, behavior is dynamic and dependent oncontext. What a person does in work, play, and self-care is afunction of motivational factors, life patterns, performancecapacity, and environmental influences. When people performtasks, they shape who they are. Hence, the model allows cliniciansto understand how people with a disability perform.

The concept of MOHO is that people are made up of threeinterconnected components: volition, habituation, and perfor-mance capacity. Volition refers to the person’s motivation toperform tasks and to choose what they do. This involves theperson’s values, interests, and personal causation. Hence, thecapacity for participating in occupations means little if a personchooses not to use that capacity. Habituation refers to a processwhere the activities frequently performed are organized into pat-terns and routines. This allows the person to do regular tasksefficiently and automatically. Performance capacity refers to themental, musculoskeletal, neurological, cardiopulmonary, andother bodily systems that are required to do things. Environmentis also inseparable from the above components of the person.Environment may consist of several types. The physical environ-ment refers to the natural- and human-made spaces and theobjects within them. The social environment refers to groups ofpersons and the occupational forms that persons belonging tothose groups perform. The environment can have positive ornegative impacts, or be a barrier and or an enabler for people withdisabilities.

Doing a task can be reviewed at different levels: skills, occu-pational performance, occupational participation, occupationalidentity or competence, and occupational adaptation. Based onthis model, the occupational therapist can use an intervention,such as altering the physical environment to remove constraints,or to facilitate function, or in providing or changing social groupssuch as families or work colleagues.

Intervention by Occupational Therapists

Occupational therapists are interested in performance in thecontext of actual daily life activity (Brentnall & Bundy, 2009).They provide intervention with the aim of helping people learn orrelearn the activities that they are not able to perform or masterbecause of illness or disability, and that prevent them from livingindependently. The activities include self-care, work, or leisure(Neistadt, 1998). At the Delta Senior School, the area of focus ison activities at work. In this case study, the ability to climb aladder to clean the ceiling is specifically salient. Interventions canbe targeted at one or more of the following areas: (1) occupa-tional performance areas (i.e., the task itself, in the domains ofwork, leisure, or self care); (2) performance components (i.e., the

Journal of Policy and Practice in Intellectual Disabilities Volume 8 Number 4 December 2011

K. H. A. Chan et al. • Teaching Ladder Climbing

284

students’ skills such as physical capabilities, cognitive capabilities,and mental well-being); and (3) performance contexts (i.e., thephysical environment and social environment or support)(Neistadt, 1998).

The length and frequency of intervention depends on the typeof intervention done and the degree of a student’s impairment.Interventions in performance components involve using theapproach of remediation. The remediation approach aims torestore or establish the deficit skills, which are needed for the task.Some examples include strengthening for weak muscle strength,balance training, and sensory integration therapy for gravita-tional insecurity. Intervention strategies are carefully structuredand graded to make it progressively more difficult to get thestudent to achieve to the ultimate goal in a step-by-step manner.While the occupational therapist provides the intervention strat-egies for the student, the student participates by being informedand educated on how the strategies will lead to improved taskperformance (Early, 2001; Holm, Rogers, & James, 1998).

Interventions in occupational performance areas and perfor-mance contexts mainly use the approach of compensatory tech-niques. That means the task, equipment or object used, and/orthe environment are adapted to suit the client’s needs and physi-cal capabilities. For example, when parsing adaptation of the taskof ladder climbing, one needs to include the way hand and footplacement occurs on the ladder and how it can be adjusted, anduse of prescriptive assistive devices or modifications to the ladder.Another aspect of compensatory techniques is giving physical orverbal supports, such as supporting an elbow on the wall so onefeels more secure, or verbal prompting to guide the studentthrough the steps of the task (Early, 2001; Holm et al., 1998).

On top of that, education to involved parties is also required.In the school setting, this includes but is not limited to thestudent, the instructor, employer, and parents. Education involveseducating on the student’s capabilities and weaknesses, the inter-vention done, and how to further support the student to enablethe student to perform the task at other settings, or without thetherapist’s presence (Early, 2001; Holm et al., 1998).

METHODOLOGY

The study used a combination of case study, qualitative, andexploratory approaches to look at the various possible issues thatwere faced by the students with difficulties in ladder climbing.According to Stake (1995), a case study works well when it uses anexplanatory approach. The authors used this type of approachas they also investigated the effects of a multidisciplinary effortamong the psychologist, occupational therapist, and vocationaltrainers who worked together to assist different students withdifferent levels of fears and needs to overcome in ladder climbing.This research process we employed also closely resembles “a sim-plified model of research processes,” as noted by Punch (1998).

Our subjects were four students (see Table 1), all of whom hadsome difficulty with ladder climbing. They were late adolescentswith mild intellectual disability. Three students (A, B, and C) werenot phobic. Student D was phobic with respect to climbingladders. All four students (three females, one male) involved inthe study were 19 years old and had no physical disabilities,mental illnesses, visual spatial deficiencies or recorded history of

anxiety disorders, developmental trauma, or brain damage. Thestudy period encompassed 3 months. The interventions werecarried out by a psychologist and occupational therapist whowere assisted by other faculty at the school.

Protocol for Intervention

Students were referred to the allied health group at the schoolby faculty of the Department of Hospitality Services who wereresponsible for preparing and training the students for positionsin Singapore’s hospitality industry. All students referred haddemonstrated difficulties or impairment when tasked with climb-ing a ladder during their vocational training in vertical cleaning.After the students were referred, a protocol was drafted and put inplace in terms of assessment and equal periods of intervention,such that each case study went through the same protocol forconsistency in analyzing the generated results. For the purpose ofrecording results and gathering evidence, the authors used directobservation supplemented with photos of students’ performance(see Figure 1). Subsequently, the authors triangulated the evi-dence from different disciplinary perspectives to increase the reli-ability of the data. They adopted an explanation building trend tounderstand different needs of intervention based on the variousstudents’ assessment gathering of the type of fear and assistancein ladder climbing. The description of how each case study(support, assessment, and observation) was conducted and whatprocess data were collected over the 3 months of the study arepresented in Table 1.

DISCUSSION

In general, students with motor ability or anxiety issues (e.g.,cases A and B) required shorter periods of intervention, and weestimate that the prognosis of success due to the interventionswill be higher, compared with the students with history of fear orphobic experience. Given our experiences with enabling the stu-dents to overcome their difficulties, we expect that the school’sDepartment of Hospitality Services will collaborate further withthe staff of the allied health group (the occupational therapist andpsychologist) in performing screening evaluations of students’motor abilities with respect to ladder climbing suitability, beforeplacing them in the class for cleaning vertical surfaces, glass areas,and ceilings.

Mapping the process enhanced the understanding of thesupport and intervention modality that the staff from the alliedhealth group (i.e., the occupational therapist and psychologist)could provide to staff from the vocational disciplines. Thismapping showed the potential benefits of the multidisciplinaryapproach, based on our experience with the four students, assuitable for use at the Delta Senior School. The transferability andscalability of this map to other settings is possible, but withcaution, because of possible limitations such as availability of staffand resources.

With respect to limitations, we were only able to use anexploratory approach rather than a quantitative approach as onlyfour students were identified with such a difficulty and as the case



285

TABLE 1Intervention case process

Psychological state Motor abilities Analysis for intervention areaResults after 10 weeks of

intervention

Student A No history of phobicexperience or behaviortoward climbing ofladder.

Student was able to trythe first two steps, but inattempting third step,she appeared fearful andhesitant to persist incompleting the task andexpressed fear of fallingdown.

She tends to place herright foot at an angle asher left foot would nothave space for placementon the ladder steps.

She would have issueswhen reaching the laststep of the ladder as herleft foot would not havespace for placement ifher right foot placementtook up more space.

In order to lower heranxiety as she attempts toreach for third and fourthsteps, therapist would haveto provide environmentalmodification by placementof ladder near the wall andgetting her to use her elbowto support against the wall.

Another main area fortherapist to work with willbe to correct her motorabilities in terms of footplacement when shereaches the top of ladder.Intervention strategies willinclude forward chainingpractice with physicalprompts to adjust the footwhen she reaches last step.

Student able to reach thetop of the ladder with goodplacement of right foot andusing the wall as adaptationto gain confidence in thestep-by-step climbing.

She at the same time gainedfurther confidence tosupport herself with onehand and raise herdominant hand to simulatecleaning.

According to literatureresearch of the works ofMOHO model of routinepatterning of occupationalperformance, therapist alsoapplied graduationtechnique and graduallymoves the ladder awayfrom the wall and gets herto practice ladder climbingand cleaning of the ceiling.

She was successful andindependent in achievingher goals.

Student B No history of phobicexperience or behaviortoward climbing ofladder.

He is able to attempt theladder and climb up tothe fourth step.However, he lacks theconfidence to climb thelast step, as he toldtherapist “He cannot ashe is scared.”

He is able to self-adjusthis foot placement whileclimbing up the ladder,and in terms of bilateralhand coordinationmoving up the ladder,he had no issues in handplacement on side ofladder.

With the Reading FreeVocational InterestInventory 2 on vocationalassessment, he was rated ashaving above average tohigh interest inhousekeeping. That meanshe has the volition toattempt the task.

He will need psychologicalsupports such as musicrelaxation to adjust hisanxiety level and boost hisconfidence for the last stepby providing guided imagethrough his thinkingprocess to mentally preparehim for the last step.

Positive reinforcementinitially by playing hisfavorite music andsubsequently progressing tointrinsic reinforcementassisted student inintervention, such assharing with him positivestatement: “Others can do it,I can do it.” This becamemorale booster for himduring psychologicalintervention. Subsequently,the student developed hisown confidence boosterstatement every time heattempted to climb up theladder by saying “I am verygood with the ladder.”



286

TABLE 1 Continued

Psychological state Motor abilities Analysis for intervention areaResults after 10 weeks of

intervention

Student C No history of phobicexperience orbehavior towardclimbing of ladder.

However, student isfearful in climbingup the fifth step ofladder, which is thelast step of ladderand highest point.

She is able toself-adjust her footplacement whileclimbing up theladder, and in termsof bilateral handcoordination inmoving up theladder, she had noissues in handplacement on side ofladder.

Using the shorterladder, student foundit difficult to climbup all the way to thefourth step and thento the top as thesupport bar is shortercompared with thetaller ladder.

Janitorial department providedtask adaptation, as advised byMOHO model, for her by lettingher use the taller ladder thatprovides more arm support inorder for her to build on herlevel of confidence.

She needs to climb on the fifthstep of the tall ladder which willbe sufficient and equivalent tothe last step of short ladder.

For the fifth step, she will needmaximum environmental supportfrom therapist as she will need tohold on the window grill toprovide her with confidence andsteadiness to climb up.

A cue card to encourage thestudent that “She is OK” and tolook straight while climbing.

By holding on the window grillwith her right hand forenvironment support, she wasable to progress to the fifth stepwhile receiving psychologicalencouragement (according to theliterature review of MOHO,altering the environment canchange one’s volition andmotivation in task participation).

In the end, the student was ableto climb to the fifth step of theadapted ladder with both herhands on the ladder itself.

The next step of progression forstudent C is to gradually train herto hold the ladder with one handwhile the other hand will reachup to perform cleaning tasks.

Student D Student had historyof phobic experienceor behavior towardclimbing of ladderand resists evenattempting to try theladder or standanywhere near it.

Therapist at theinitial stage could notestablish any findingsof motor abilities asshe did not attemptthe ladder.

After the discussion bypsychologist and therapist, it wasdecided to try the approach ofengaging a peer who is close tostudent D.

The multi-team approach consistsof her close peer and psychologistproviding emotional support andoccupational therapist providingphysical assistance to help her bemotivated and attempt the ladderwith proper motor coordination.

Psychologist used the gradedexposure or systematicdesensitization to reduce heranxiety about climbing ladders ina gradual manner. She was firsttaken to a playground to accessthe ladder attached to a child’sslide. Next, she was exposed to ascenario using the three-steppodium where a simulation ofprize giving was enacted.Subsequently, the real ladder wasexposed.

Emotional support and guidancewas provided by a peer who isstudent D’s close friend in class,and at the same time, elbowsupport was given to her to helpher to overcome initial fears.

Subsequently, with verbalprompts to “look up,” she is ableto look up in front, whichovercame her visual fear as she isable to climb up to the third stepof the short ladder.

However, for the fourth step ofladder, she still has difficulty thatcan be due to her initialpsychological state of phobia.

The next step will be to continueusing peer support, introducecue cards, and environmentalsupports in holding window grillsor use the adapted ladder (usedby student C) to help her progressto last step.

MOHO, model of human occupation.



287

studies were applications of research to practice. Therefore, thesample size was small. Moreover, the intent was also to codify theprocess involved in administrating therapy for such issues formodeling and scalability. Time was also a factor as students whomight have required longer periods of intervention due to thecomplexity of different needs (such as student D) were restricted

to the period of time available for the intervention due to thevocational certification process (i.e., the course term).

Future studies should involve looking into students’ difficul-ties in other vocational task issues or where other phobic activitiesinvolve psychomotor and psychological issues, like bicycle riding,and determine if such a process model is applicable.

FIGURE 1

Demonstrations of ladder climbing of students.



288

REFERENCES

Brentnall, J., & Bundy, A. C. (2009). The concept of reliability in thecontext of observational assessments. OTJR: Occupation, Participa-tion and Health, 29, 63–71.

Early, M. B. (2001). Occupational performance. In L. W. Pedretti & M. B.Early (Eds.), Occupational therapy practice skills for physical dysfunc-tion (5th ed., pp. 226–236). St. Louis, MO: Mosby Inc.

Forsyth, K., & Kielhofner, G. (2006). The model of human occupation.In E. A. S. Duncan (Ed.), Foundations for practice in occupationaltherapy (4th ed., pp. 69–107). Edinburgh: Elsevier ChurchillLivingstone.

Holm, M. B., Rogers, J. C., & James, A. B. (1998). Treatment of occupa-tional performance areas. In M. E. Neistadt & E. B. Crepeau (Eds.),Willard & Spackman’s occupational therapy (9th ed., pp. 323–390).Philadelphia: Lippincott Williams & Wilkins.

Marks, I. M. (1987). Fears, phobias, and rituals. New York: Oxford Uni-versity Press.

Neistadt, M. E. (1998). Overview of treatment. In M. E. Neistadt & E. B.Crepeau (Eds.), Willard & Spackman’s occupational therapy (9th ed.,pp. 315–322). Philadelphia: Lippincott, Williams & Wilkins.

Punch, K. F. (1998). Introduction to social research: Quantitative andqualitative approaches. Thousand Oaks, CA: Sage Publications.

Stake, R. (1995). The art of case research. Newbury Park, CA: SagePublications.



289

Documents

A Demonstration of Helping Adolescents With Mild Intellectual Disability Climb Ladders