Anxiety

REI for Adult Autism, Sleep and Bipolar – A Case Study

Even though the REI Custom Program is implemented at the listener’s home and we create the recordings based on a comprehensive intake questionnaire, I still occasionally get to play live for a client before they start their program.

In this case study, I met with the subject, Russell, in the group home where he was living and played for him twice before making the REI recordings. Russell was 38 years old and had been at this facility since its inception 11 years previously. Prior to then, he was cared for at home by his family.

According to records, Russell was diagnosed with autism and bipolar disorder. He had very limited communication skills and was functionally non-verbal. The facility staff described that his communication consisted of mostly pointing, directing and vocalizing (mostly with grunts and other non-language cues). He also exhibited severe often self-injurious, self-stimulatory behaviors, the most significant of which were head-banging, anal-digging, and forehead-scratching.

The issues they were most concerned about, and the reason for wanting to do the REI Custom Program, were his self-injurious behaviors and his bipolar symptoms including, poor sleep and a starvation/binge-eating cycle (where he often gained and lost up to 10 pounds through his cycles).

The severity and frequency of his self- injurious behaviors increased when he was on the depressed side of his bipolar cycle. The staff reported that when he was depressed he needed near-constant redirection to keep him from engaging in these self-abusive behaviors. He was also difficult to engage in activities such as doing chores and interacting with the animals. Instead, the staff described him as lethargic and moody.
 
He, they stated, preferred to sleep during the day or to sit by himself and self-stimulate until asked to stop. He would generally stop when asked to but approximately 30% of the time the staff noted that they needed to physically stop these behaviors. This was done by gently pulling his hand away from either his face or anus or by moving him from the wall that he was banging his head-on. He rarely put up much resistance and seldom expressed any agitation to this redirection.
 
The staff described that Russell hadn’t eaten yet the first day I met with him and had eaten very little in the past 2 weeks since his depressed cycle began. The staff noted that he had lost 7 pounds already since the end of his last manic period.
 
I met Russell in the main group living area where he was sitting by himself. He made no response when I said hello to him and simply sat in his chair with his hand to his forehead. He wore a bandage and was lightly scratching at it as I talked to him.  A staff member pulled his hand away and he fidgeted with it in his lap for a short while before returning it to his forehead where he started scratching again.
 
I began playing the drum. Nothing in his behavior changed for a few minutes until which time he was noticed to be scratching less on his forehead. After approximately 10 minutes he was no longer scratching his head and his hands were clasped in his lap while he sat nearly motionless. His gaze was fixed in front of him and it didn’t appear that he was looking at anything in particular. The staff mentioned that he seemed much calmer, referencing his voluntarily stopping his self-stimulation.
 
He continued to sit quietly with his hands in his lap for about 15 minutes after I stopped playing. At that point, one of the staff came to get him to take a walk outside, which he did without resistance.
 
I met with Russell a second time before making his REI recording so that I could observe him when he was in a manic state. The director called me about 2 weeks after my first visit informing me that he was now manic. When I arrived at the facility he was agitated – evidenced by his pacing back and forth while wringing his hands. I was informed that he hadn’t slept well the last few days and had, in fact, had been under constant supervision for the past 2 days for fear of him hurting himself with his self-abusive behavior.
 
I quickly got out my drum and began playing. His reaction was immediate – he stopped pacing and turned to me, frozen. He stood nearly still for the duration of my playing (approximately 12 minutes). When I stopped he turned and quietly left the room. One of the staff members remarked on how calm he seemed at that moment.
 
The director related that his bipolar cycles were pretty regular – the manic period lasted about 2 weeks and the depressed period lasted between 2 and 3 weeks. He currently wasn’t taking any medication for this because they had tried various ones that had not been successful. They were currently taking a break from medications of any kind.
 
Russell received his REI recording three days after my last visit while he was still in a manic period. Because he was having trouble sleeping it was recommended that he listen at bedtime. Upon my follow-up visit after four weeks, the staff noted that his daily REI tracking log reflected that he fell asleep while the recording played the first night and, aside from 3 nights the first 2 weeks, he fell asleep before the REI recording ended (this is within 20 minutes, a much shorter time than was typical for his manic periods).
 
When his cycle shifted to a depressed mood, the staff continued to play the REI recording at bedtime because it was the easiest time of day for them to play it. He continued to fall asleep while the recording played, though it wasn’t unusual for him to fall asleep within this timeframe when he was depressed before using the REI recording.
 
The staff instructed Russell on how to turn on the recording himself at bedtime and, except for a few days during his depressed cycle, he did so without prompting.
 
The staff had also taken to playing his REI recording during the day during his depressed period (in addition to playing it at night) and they noted that his mood seemed to elevate and he became more active throughout the day. The staff also noted that his self-abusive behavior had lessened. This change in self-abusive behaviors began being noticeable after just over 4 weeks after beginning REI.
 
For the next few months, Russell continued listening to his REI recording at bedtime and during the day during his depressed cycle. Staff tracking revealed that his frequency and intensity of self-abusive behaviors were progressively lessening. When I went to see him at the twelve-week point, he had no sores or scabs on his forehead, at a state that the staff describe as unheard of before starting REI.
 
The staff also described that his manic and depressed cycles were noticeably less severe. When he was most recently manic he was much calmer and was sleeping every night. The staff also described that when he was depressed he was less lethargic and easier to engage in activities. He was also eating three good meals a day.
 
After 6 months, the staff noted that Russell demonstrated an improvement in his symptoms of bipolar disorder – his cycles weren’t as deep, the lows weren’t as long, and he was better able to handle the depressed side when it did occur. The director said that he was no longer listening to the REI recording every day but when he did listen before bedtime he would sleep deeper and wake more rested. After talking with the staff, they agreed to try to be more consistent with playing his recording and in helping him remember to turn it on before going to bed.
 
You can learn more about the REI Custom Program by clicking the Custom Program tab above.

REI Improves Trantrums And Transitions

Note: This article is an excerpt from Strong Institute Director Jeff Strong’s book, Different Drummer: One Man’s Music and Its Impact on ADD, Anxiety, and Autism.

This case study includes Jeff playing live for a client, Timmy. These results don’t require a live performance, however. Timmy’s improvement in tantrums and transitioning from one activity to another was due to listening everyday to his REI Custom Program.

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Many of the people I work with who experience anxiety manifest it through other types of behaviors. Ten-year-old Timmy tantrummed when he became anxious. This anxiety was most prominent when he was asked to change what he was doing. Transitions always elicited an emotional outburst: He would scream and lash out at whoever was close.

“This is our special needs room,” described Sara as we walked into a classroom ringed by cubicle dividers. Each cubicle area was furnished with a small table and a couple of chairs. Some also contained a beanbag chair or a carpet on the linoleum floor. There was a large table in the center of the room with a dozen small chairs and two couches in the cubicle space directly across from the door.

“Why the cubicles?” I asked.

“We work with each student one-on-one for most of the day,” she explained as she led me to the couches where we sat down.

I unpacked my drum, threw it on my lap and give it a quick tune as Sara explained, “Timmy will be coming back to the classroom any minute. He’s usually pretty agitated.”

She paused, then said, “There, you can hear him now.”

Hearing a commotion coming from the hall, I started playing my drum. I jumped into a series of calming rhythms at a pretty high volume, not feeling a need to start quietly because Timmy wasn’t in the room. Instead, I wanted Timmy to hear it from the hallway.

I was playing loud enough that I could no longer hear what was going on outside the classroom. I watched the door for him, ready to adjust my rhythms based on how he acted as he came into the room.

It took less than two minutes for Timmy to peek into the room. He did this by standing across the hall from the door. He seemed to look everywhere but at me. I ignored him as I played, waiting for him to get the courage to enter the room.

Timmy stayed in the hallway for a while, alternately standing where he could see me and moving out of range. I ran through a series of calming rhythms, hoping that he would come into the room. Eventually he did, slowly migrating from the doorway and around the perimeter of the room until he came to the couch. As he navigated closer to me, I dropped my volume until I was playing at barely a whisper as he stood before me.

I continued playing for another minute or two without looking his way. He remained planted a couple of feet from me.

I stopped.

Timmy surprised me by approaching me and touching the drum. He very gently put one hand on each side and looked past me. I tapped the head with my index fingers, creating a syncopated patter, still not looking at him.

His hands moved to the edge of the drum, then onto my hands while not disturbing my playing. I kept playing with just my index fingers, but edged-up the rhythms a little, increasing in speed and complexity. Timmy’s hands gripped my two last fingers, which were hanging off the sides of drum.

As I morphed my rhythms over the next few minutes, Timmy’s grip changed with each permutation. Harder, then softer. Back and forth in different intensities as the rhythms rose and fell. We were dancing the rhythms. This dance lasted several minutes until he abruptly let go and sat down on the floor. The connection was gone.

I dropped my volume and faded out. Timmy was playing with legos, his back to me. I packed up and left the room.

Sara followed me out and said, “That was cool. He doesn’t like physical contact and here he initiated it with you.”

“Yeah, it was cool,” I replied. This connection, no matter how fleeting, was one of the reasons I loved playing live for kids and was something I never really got tired of. It was also something that didn’t happen that often. However, as gratifying as it was, I didn’t allow myself to spend much time on it. I was focused on what I needed to do in order for Timmy to become less emotionally reactive.

“Did he settle down quicker today than usual?” I asked, trying to get a sense of whether the rhythms I had chosen had contributed to his calming after the change in rooms and activities.

“Yes. He is usually pretty agitated for a while. But he seemed to connect with you. That calmed him.”

“That was fun,” I said as I wondered if this connection could be helpful in reducing his anxiety overall. Other kids I had played with seemed to carry that connection to their relationship with their REI recording. My work with past clients showed that this connection wasn’t necessary, but I felt it always helped.

Sara and I talked more about Timmy’s anxiety and she assured me that his parents were on board with him listening to an REI recording.

Sara felt comfortable using our online system, saying she preferred to play the track through her phone. I entered Timmy’s intake data into our system and Sara was able to begin playing his recording in school the next day. She would enter Timmy’s progress into her account and I would only lightly monitor it, letting our software take the lead in creating the tracks for Timmy.

The goal was for Timmy to become less emotional during the many transitions he experienced throughout the day.

Over the course of sixteen weeks, Timmy listened to eight progressively-created, custom-made REI recordings, each used once a day for two weeks during the school week. Making the recordings one after another, based on Timmy’s responses, was the key to making overall changes to his ability to handle change.

Timmy responded immediately with his first REI recording. Sara chose to play Timmy’s recording first thing in the morning because this was generally one of his most difficult times. The transition to school nearly always caused a meltdown. She also hoped that listening first thing would make the rest of the day easier.

The first day it took about five minutes for Timmy to settle in. Ordinarily he could be agitated for up to an hour. His calm lasted until lunchtime, when he had a meltdown in the cafeteria. I asked that Sara not play Timmy’s recording more than once a day because I wanted to ensure that he didn’t get overstimulated from the drumming.

Timmy’s first two weeks continued with him listening first thing in the morning, calming quickly and remaining calm until lunchtime. At the two-week point, Sara called me to ask whether another time of day would be better from Timmy. She described that he seemed to adjust to the day easier and he was arriving at school less agitated. We decided that playing his recording right before lunch might be worth a try.

Timmy again responded immediately with this new schedule. Sara turned on his recording about ten minutes before it was time to go to the cafeteria and let it play as he got his food and began eating. She described from the first day that he stayed calm as he went through the transition from classroom activities to lunchtime.

It was obvious from the outset that Timmy would calm when the REI recording played. At the beginning of the Program, he would remain calm until another transition took place. Then he would get anxious. This pattern changed over the course of about six weeks. At first Timmy had the occasional time when he handled a change without issues, but after six weeks he would tolerate most transitions without a problem.

“Timmy is now self-regulating,” described Sara at our eight-week check-in. “You can see him begin to get stuck in his pattern and almost have a meltdown, but then he collects himself. He never used to be able to do that.”

Given that he was calmer and beginning to learn to calm himself and tolerate change, we had Timmy return to listening first thing in the morning. This was an easier time for Sara to play his track and we wanted to see how well he could navigate the day’s changes without using the track during a transition.

The goal of reducing anxiety with REI is to get to the point where the listener is able to learn to self-regulate. As with Timmy, it can be helpful to use the REI recording when the anxiety is at its worst, but eventually it can become a crutch. The switch back to listening when a client isn’t having an emotional reaction to change removes this crutch.

Timmy handled this change well. For the first few days, Timmy was agitated when transitioning to lunch; but by the end of the first week he was able to transition as smoothly as he did when he listened during this transition.

The last seven weeks of the Program were designed to integrate his self-regulation skills solidly enough that he would not need to listen to his REI recording everyday. He did this successfully. I talked with Sara a couple of weeks after he stopped listening to his last REI recording.

“Timmy is a new kid. He no longer tantrums when asked to move on to a new activity. His resistance has melted over the last couple of months and now all I need to do is let him know a minute or so before we make a change that he needs to get ready to do something else. You can see him preparing himself. He stops what he’s doing for a few seconds and gets quiet. Then, when we ask him to switch activities, he does it without hesitation. He hasn’t had a meltdown in several weeks.”

Timmy illustrates the REI Custom Program path that many clients struggling with anxiety follow. The first track provides an immediate, temporary calm. Each progressive track extends the amount of time the listener remains calm after listening until we see some level of self-calming in situations that caused anxiety before beginning the Program.