THE Bi SOCIAL THEORY OF = BIRLECTICAL BEHAV oe crore BEMAVIOR THERAPY [DBF.RU seems | BIOLOGY Some people are born more emotionally vulnerable than others. They experience emotions Thajr intense emotions iast more frequently. = . longer. INTENSITY + FREGUENCY + DURATION EMOTIONAL VULNERABILITY ULNERABILITY ICAN FEEL LIKE AN MOTIONAL ROLLER COASTER THE GOOD NEWS THE NOT-SO GOOD NEWS The upside is, you may be more sensitive to | The downside is, you Subtle emotions in your environment so that | may feel distressing @\ you can be more responsive to others. You | emotions more may also feel fove, strongly. People are connection, passion, often uncomfortable C> and joy more around strong strongly. emotions. They may try to get you to stop having emotions for their own comfort.THE BIGSCCIAL THEORY OF DIALECTICAL BEHAVIOR THERAPY (OR WHY I HAVE TROUBLE WITH EMOTIONS) An invalidating environment can be PAINFUL for someone emotionally vulnerable. People in your life may be uncomfortable with emotions that are: 1. Intense 2. Frequent 3. Long-iasting They may (unknowingly) invalidate you by asking you to stop having emotional reactions. They may say that your emotional reactions are: WEIRD | 7 ~ WRONG @ @) crazy | +73 © You may hear things like: What's wrong with youl Stop being so dramatic. Calm down! Don't be such a baby! Quit your ‘complaining Why can't Other people you just get eo don't act so emotional over it?1THE BlosociaL THEORY OF DIALECTicAL BEHAVIOR THERAPY (OR WHY | HAVE TROUBLE wrTH EMOTIONS) oo essa TRANSACTION Everyone experiences invalidation. Big problems arise when there is repeated confiict between emotional vuinerability and the environment, and each affects the other over time. This can be very hard when you're young and just learning about emotions. (— EMOTIONAL )_ VULNERABILITY | ~ The transaction between a person with emotional vulnerability and an invalidating environment can look like this: Im feeling sick. You're fine. “m feel Stop being such a Um, Tim feeling 9 really sick. baby. You're fine. OVER TIME, THE TRANSACTION MAY LOOK LIKE EITHER: * gues Tm no sick - xy am T such a Good job! Om yebeby”) HELP! I'm dying. Bring Oh, noll Let me get me to the hospital! ‘the cor!THE BICSOCIAL THEORY OF BIALECTICAL BEHAVIOR THERAPY (OR WHY | HAVE TROUBLE WiTH EMOTIONS) You may start to believe that you're not sick at all OR that you're dying. You may not be able to find any middle ground. | You may learn to mask or hide what you're reallly thinking or fet 9. Over time, intense emotions and “innacurate” expression make people in your environ- ment more likely to invalidate you, because they don't understand or can’t tolerate your emotions. Environmental invalidation makes you more likely to invalidaie yourself and/or overstate the situation to get help. This in turn makes the environment even more likely to invalidate you. INTENSE EMOTION FEAR/SHAME RANSACTION EMOTIONAL VULNERABILITY LONG TERM CONSEQUENCES You may feel shame and/or _| You may believe you You may feel a different fear when you experience should avoid intense emotion like anger to intense emotions. emotions entirely. block the first distressing emotion. You may distrust your own | You may rely on others to | You may become desperate reactions, because you're | help you understand how | and do ANYTHING to get told they're crazy or you feel, so that being rid of an emotion inappropriate. alone can feel very scary.Extract from ACT Made Simple, 2nd e: The Six Core Pathological Processes of Psychological Rigidity The core pathological processes of ACT, as shown in the figure below, are fusion, experiential avoid- ance, inflexible attention, remoteness from values, unworkable action, and fusion with self concept. Any ot all of these processes can give rise to psychological rigidity. CONTACT WITH THE PRESENT MOMENT Inflexible Attent istractability, Disengagement, Disconnection ACCEPTANCE Experiential Avoidance PSYCHOLOGICAL FLEXIBILITY Psychological Rigidity DEFUSION Fusion: Past, Future, Reasons, Rules, Judgments SELF-AS-CONTEXT Fusion with Self-Concept ‘An ACT Model of PsychopathologyCi 4 Ore Pathological Processes i This worksheet isto exacerbate them. ify the issue, problem of in ACT: A Worksheet lp You conceptualise client problems in terms of core ACT processes that create, maintain, oF [oU're trying to figure out how to use ACT with any clinical issue or DSM diagnosis, frst “unpack” * label in terms of these processes. (Note: fusion with self-concept is included in the fusion box.) What d es the client describe as the main problem(s? relevant, what OSM dlsorder has she been given? EXTERNAL BARRIERS: Are there any external balers (as opposed to psychological barriers) toa rich and fllife-e-., Social legal, medical, financial, or occupational problems? (These will need to be addressed through values and committed ‘ction, including problem-solving, sil-training, goal-setting, and action planning.) FUSION: (Include specific thoughts, as well as cognitive processes such as “worrying”, and core beliefs/narratives/schemas) PAST & FUTURE: (rumination, worrying, fantasizing, blaming, predicting the worst, reliving old hurts, idealizing the past or the future, flashbacks, “if only...” “why did it happen?,” catastrophizing, resentment, regrets, etc.) SSELF- DESCRIPTION: (self- judgments, self-limiting ideas about “who I am” or “what I can and can’t do,” self- labels) REASONS: (reasons the client gives for why she can’t, won't, or shouldn’t change, or why her life can't be improved) RULES: (about how I, others, and life should be: look for key words such as should, have to, must, ought, right, wrong, always, never, can’t because, won't until, shouldn't unless, perfectionist ideals etc.) JUDGMENTS: (mostly these will be negative, but sometimes positive; may be about anyone or anything: other people, ‘oneself, one’s job, one’s body, one’s thoughts and feelings, the past, the future, or even life itself) OTHER: (e.g. traumatic memories, core beliefs, schemas, emotional reasoning) EXPERIENTIAL AVOIDANCE: ‘What private experiences the client is trying to avoid or get rid of, or is unwilling to have? THOUGHTS, IMAGES, MEMORIES, EMOTIONS, FEELINGS, SENSATIONS, URGES, IMPULSES, DESIRES, CRAVINGS, WITHDRAWAL SYMPTOMS: LOSS OF CONTACT WITH THE PRESENT MOMENT: ‘The 3 Ds: Distractbilty, Disengagement, Disconnection from thoughts and feelings? Deficits in ability to narrow focus, broaden focus, sustain focus, or shift focus? “Splitting off” from important aspects of the present moment, as in dissociative states? Who or what does the client find it hard to focus on, be attentive to, engage in, be present with?a, UNWORKABLE ACTION: 2 ‘What is the client doing that makes life worse, keeps her stuck, worsens Problems, inhibits growth, prevents healthy solutions, impairs health, damages relationships, etc.? Focus mainly on overt behaviors ie physical actions. (Put covert behaviors — psychological actions such as worrying, ruminating, obsessing, disen avoidance, and loss of contact with the Present moment.) \gaging - in the previous sections on fusion, What IMPORTANT people, places, events, activities, situations, goals, problems, and challenges is the cient avoiding or escaping ~ i.e. withdrawing from, quitting, procrastinating, giving up on, or staying away from? SKILLS DEFICITS: Does this client have significant deficits in skill, that maintain or exacerbate patterns of unworkable action? E.g. are there deficits in social sills, assertiveness, parenting, communication, time management, self-care, self-compassion, ‘mindfulness, empathy and perspective-taking, goal-setting, action-planning, problem-solving? REMOTENESS FROM VALUES: What values does this client seem to have lost touch with or disconnected from? What values may be underlying some of the fusion identified above; buried beneath rules, reasons, perfectionism etc? ‘What values is this client moving away from when fused, avoidant, distracted or disengaged? ‘What kind of fusion/avoidance/unworkable action happens when you attempt to identify or clarify or connect with values? BRAINSTORM: What ideas does this give you about how to intervene and what core ACT therapeutic processes could be helpful? ‘Are you stil using vague terms such as “perfectionism, “low self-esteem’, “complex trauma”, “attachment issues” to conceptualise your client's problems? If yes, go back and unpack these terms, using the sections above.WHAT Do} ES THE CLIENT DESCRIBE AS THE MAIN PROBLEM(S)? (Use the client’s own words.) wi HAT DOES THE CLIENT WANT FROM THERAPY/COACHING/COUNSELLING? Emotional Goals (How you want to feel differently): What thoughts, images, feelings, emotions, sensations, ‘memories, urges, would they like to avoid, reduce or get rid of? (Note: To convert emotional goals to behavioral goals, we may say: “So part of our work here is learning new skills to handle these difficult thoughts and feelings ‘more effectively, so they have less impact and influence over you.”) Bel Is (What you ;ntly}: What would the client like to stop/start; do ‘more/less? How would they like to treat themself, others, the world, differently? What activities/skills would they lke to start or develop? What people, places, activities, challenges, would they like to approach rather than avoid? What relationships do they want to improve, and how? Goals (What you want to have, get or achieve): What outcomes would the client like to achieve = e.g. get a job, find a partner, go on a holiday, buy a house, recover from an illness, heal an injury, have a child, start a new career, buy a book, make new friends, build a better relationship? (Note: To convert outcome goals 0 behavioral goals, we may say: “So part of our work here is to explore what you can start doing differently, to increase your chances of achieving these goals.") RELEVANT PAST HISTORY Was there any trauma, neglect, attachment issue, or other significant childhood problem, directly relevant to current issues? What traumatic events have played a significant role in current issues? Have other major life events—not necessarily traumatic, but disruptive and stressful precipitated the current presentation? PHYSICAL BARRIERS TO QUALITY OF LIFE ‘What physical barriers are there as opposed to psychological barriers) to arch and full life? For example, are there legal, social, medical, financial, or occupational problems? Are there systemic problems like racism, sexism, prejudice, rmination, poverty? Are they living in a hostile environment (e.. prison, domestic violence]? Is the client's occupation playing a role, (e.g. exposure to trauma in the armed forces or emergency services)? (These issues require values-guided committed action: problem-solving, action-planning, accessing resources, and skills- training.)REEXPERIENCING TRAUMA and/or ABNORMAL AROUSAL How isthe client reexperiencing traumatic events (e.g. flashbacks, nightmares)? Are there symptoms of extreme hyperarousal (e.g. hypervigilance, palpitations) or hypoarousal (e.g, dissociation, numbness)? UNWORKABLE ACTION ‘Whats the client doing that makes life worse, or keeps her stuck, worsens problems, inhibits growth, prevents healthy solutions, impairs health, damages relationships etc? (What would we see and/or hear ona video?) ‘What IMPORTANT or MEANINGFUL people, places, events, activities, situations, goals, problems and challengesis the client avoiding or escaping (e.g. withdrawing from, quitting, procrastinating, giving up on, or staying away from)? EXPERIENTIAL AVOIDANCE: What private experiences is the client trying to avoid, reduce or get rid of? May include: thoughts, images, memories, emotions, feelings, sensations, urges, cravings, withdrawal symptoms, FUSION: (Include examples of specific thoughts, as well as cognitive processes such as worrying or ruminating) PAST & FUTURE: (rumination, worrying, fantasizing, blaming, predicting the worst, reliving old hurts, idealizing the past or the future, flashbacks, ‘ifonly why did it happen?, catastrophizing, resentment, regrets etc.) SELF-DESCRIPTION: (self-judgments, self-limiting ideas about ‘who | am’ or ‘what I can and can’t do’, self-labels) REASONS: (reasons the client gives for why they can’t, won't or shouldn't change, or why their life can’t be improved) RULES: (about how myself, others, life should be: look for key words such as: ‘should’, ‘have to’, ‘right’, ‘wrong’, ‘always’, ‘never’, ‘can't because’, ‘won't until’, ‘shouldn’tunless’ -etc.) JUDGMENTS: (mostly these will be negative, but sometimes positive; may be about anyone or anything: other eople,oneself, one’s job, one’s body, one’s thoughts and feelings, the past, the future, or even life itself) OTHER - INCLUDING NARRATIVES, SCHEMAS & CORE BELIEFS: LOSS OF CONTACT WITH THE PRESENT MOMENT: To what extent are the “3 Ds” -Distractibilty; Disengagement; Disconnection from thoughts & feelings - a problem? What activities would the client lke to more focused on or ‘engaged in? (©) Russ Haris, 2021 ww.imLeamingACT.com 2faa REMOTENESS FROM VALUES: What ite domains and what other intimate rel: and what people does the client care about: e.g. work, study, health, parenting, marriage or Values in at least lationship, friends, family, spirituality, community, environment? Is the client in touch with their Some of these domains? If yes, which values, in which domains? ‘What values does the client seem to have lost touch with, or be disconnected from? What values seem to be buried beneath fusion with rigid rules? What values does the client seem to be avoiding because they are too painful to connect with? SKILLS DEFICITS: ‘What important skills does the client either lack or fail to apply effectively - e.g. problem-solving, goal-setting, action-planning, self-soothing, assertiveness, communication, conflict resolution, empathy, time management? ‘CLIENT RESOURCES STRENGTHS & SKILLS: What useful strengths, skills and other personal resources does the client have? What external resources can the client potentially access? \VALUES-CONGRUENT GOALS & ACTIVITIES: What values-congruent goals and activities does the clier a) already have; and b) want to pursue? MY PERSONAL BARRIERS: What difficult thoughts and feelings show up for me, regarding this client? How can | apply ACT to myself to help with this? (Note: Complete this section on a sheet that doesn’t go into the client's notes.) ‘BRAINSTORM: What core ACT processes may help? What questions, exercises, worksheets, metaphors, tools, techniques and strategies might be useful? What skill-tralning may be required? Is values-based problem-solving and action-planning required for addressing physical barriers? C1 Passe Hare, 2021 wwetleienminnACT eresee DISSECTING THE PROBLEM bed form is to help gather information about the nature ofthe main challenge, issue, or problem facing you. Please imarize, in one or two sentences, what the main issue or problem is: Please describe, in one or two sentences, how it affects your life, and what it stops you from doing or being: Regardless of what your problem is—whether it is a physical illness, a dificult relationship, a work situation, a financial crisis, a performance issue, the loss of a loved one, a severe injury, or a dlinical disorder such as depression_-when we dissect the problem, we usualy find four major elements that contribute significantly to the issue. These are represented in the boxes below. Please write as much as you can in each box about the thoughts, feelings, and actions that contribute to or worsen the challenge, problem, or issue facing you: "Hooked" by Thoughts What memories, worries, fears, self-riticisms, or ther unhelpful thoughts do you get "hooked" by or “caught up" in? What thoughts hold you back or jerk you around or bring you down? Life-draining Actions: What are you currenty doing that makes your life ‘worse in the long run: keeps you stuck; wastes your time or money; drains your energy; restricts your life; impacts negatively on your health, work, or relationships; maintains or worsens the problems you are dealing with? Struggle with Feelings ‘Avoiding Challenging Situations: What emotions, feelings, urges, impulses, or What situations, activities, people, or places are you sensations do you tend to fight with, avoid, avoiding or staying away from? What have you quit, ‘suppress, try to get rd of, or otherwise struggle withdrawn from, dropped out of? What do you keep with? “putting of? unt later? (© Russ Harris 2011 wwwactmindfillycomau _russharris@actmindfilly.comauYOUR JES. others, VALUES Deep in your heart, how do you want to Behave? How do you want to treat yourself ‘orld? What sort of person do you want to be? What strengths or qualities do you want o develop? LWork/Education: includes workplace, career, education, skills development, etc. 2. Relationships: includes your partner, children, parents, relatives, fiends, co-workers, and other social contacts 3. Bersonal Growth/Health: may ince religion, spirituality, creativity, life skills, meditation, yoga, nature; exereise nutrition, and/or addressing health risk factors like smoking, ‘ohol, drugs or overeating cte A. Leisure: how you play. relax, stimulate, or enjoy yourself, activities for rest, recreation, fun and creativity. THE BULL'S EYE: make an X in each area of the dart board, to represent where you stand today. Tam behaving like the person I waXt to be My behaviour is Work’ Leisure Education Personal growth/ Health RelationshipsVITALITY VS. SUFFERING DIARY fe e ae now and next session, keep a record of what you do when painful thoughts and clings arise, and notice if these actions lead to increased vitality or increased suffering Painful Thoughts/ Feelings/ Urges/ Sensations! Memories that showed up today Things | did - when those thoughts and feelings showed up - that lead to VITALITY (i.e. enriched my life, or improved my health, wellbeing, or relationships in the ong term) Things I did - when those thoughts and feelings showed up - that lead to SUFFERING (i.e. restricted or worsened my life, drained my health and wellbeing, or hurt my relationships in the long term) © Russ Harris 2009 wwww.actmadesimple.com reprinted by permission of New Harbinger: wirw.newhasbinger.comThe Problems and Values Worksheet Acceptance & Commitment Therapy aims to reduce suffering and enrich life, as shown inthe diagram below To help inthis process, there are four lts of information that are particularly important. These are represented in ‘the four columns below. Between now and the next session, see what you can write in or add to each column. (STRUGGLE & SUFFERING RICH & MEANINGFUL LIFE | Problematic Thoughts Problematic Actions: | And Feetings: ‘What are you doing that | What memories worries, | makes your lif wore inthe fears, self-ericisms, or Jong nin: that keeps you ‘other thoughts do you get | stuck; wastes your time or caught up" in? What ‘money; drains your energy: emotions feelings, urges, or | impacts negatively on your | sensations do you struggle | health or your relationships: with? or leads to you “missing out” on life? ‘Values: What matters fo you | Goals & Actions: What are inthe “big picture”? What | you currently doing that ddo you want to stand for? | improves your life im the ‘What personal qualities and | long un? What do you want strengths do you want to | to start or do more of? What develop? How do you want | life-enrching goals do you {o-enrich or improve your | want to achieve? What life- relationships? How would | enhancing actions do you you like to “grow” or want to take? What life develop. through addressing | improving skills would you ‘your issue(s) oF problenys)? | lke to develop? (© Russ Haris 2009 www.actmadesimple.com reprinted by permission of New Harbinger: wwrw.newharbinger.comVITALITY VS. SUFFERING DIARY Retween now and next session keep a record of what you do when painful thoughts and feelings arise, and notice if these actions lead to increased vitality or increased sufferin [Pamfult | Painful Thoughts/ Feelings/ Urges/ Sensations/ Memories that showed up today Things I did - when those thoughts and feelings showed up - that lead to VITALITY (i.e. enriched my life, or improved my health, wellbeing, or relationships in the Jong term) Things I did - when those thoughts and feelings showed up - that lead to SUFFERING (i.e. restricted or worsened my life, drained my health and wellbeing, or hurt my relationships in the long term) © Russ Haris 2009 www actmadesimpe.com reprinted by permission of New Harbinger: www newhatbinger. 7Soin ¢ the DOTS. - Part 1: What have you tried? Weal try to avoid or get nd Methods you use ‘bad’. ‘right’ a {difficult thoughts & feelings. The ainvs of this exercise are a) to find out which and by how they work in the long term, NR. Please damat start judging these methads as ‘good’ or wrong ‘positive er ‘negative’ The ain is simply to find out if these methods are workable — i.c. do they work in the lone term to sive you a rich and memingfl Fife? (Obviously. if any of these methods de improve ‘Your Iife i the fone term, keop deine them!) What are the main thoughts, feelings, sensations, memories, emotions, urges that you do not want? D-Distract ovnes. TV an 1 do vondo to distract yourself from. or ‘take your mind off” painfil thoughts & feelings? (ee nc\ hooks, computer games, exercise. gardening. gambling. food. drugs, alcohol) © - Opting out: what important, meaningful or life-enhancing activities, events, tasks, challenges. or people. do you vo%6, gut, escape, procrastinate, or withdraw from? (Ifthey’re not important, meaningful ot life-enhancing. then opting ots no problem!) 1 Think strategies: how do youtry (consciously or not) to think your way out of pain? Tickany of the following have ever done, and write in any others that aren’t included: \ onving, Dwelling on the past; Fantasizing about the future; Imagining escape scenarios (c.g. leaving vour job or ur partner) or revenge scenarios; Thinking to yourself “It’s not fair ..." or “If only ...."; Blaming yourset, ‘tuers. orthe world: Talking logically and rationally to yourself; Positive thinking, Positive affirmations; Juxtyyne ‘weizing yourself: Giving yourself a hard time; Analyzing yourself (trying to figure out “Why am I like v7), Anulyzing the situation (trying to figure out why this happened); Analyzing others(trying to figure out '» they are like this); Planning; Strategizing: Constructive problem- solving; Making To Do lists; Repeatime ‘oplTatvonil sayings oF proverbs; Challenging or disputing negative thoughts, Telling yourselt “This too shall pass) oF Ht may never happen Other thinking strategies S= Suty wer AF uther Strategies. what Substances do you use put uy your badly to avid ae yet Ha af pain: foods, Ui cigaretten, recreational drugs, naturopathic & herbal remedies, over-the-counter & prescription mieheations ‘Ver une An Feaponse fo unwanted Hhougbls aril sedation, having altars, aggreanivences, Tat hi, massage, exctcine, picking fights, dancing, musi, suicWe attempts self-harming, prayer, smashing thins, saying 18 bed, sI-help books, secing a therapist or dactor or other health Professional. petting angry at life or other peopl? 1 vcr tod “olerting HW, “putting up with He sucking Mt up and getting on wit it”? Ever tried giving up? ngs? For example, have you tned yoga,Join the D.O.T.S. - Part 2: How has it worked? What has it cost? Most of these strategies give you short term relief from painful thoughts and feelings. But do they PerMmaneny 94 ‘those unwanted thoughts and feelings, so they never come hack? Most ofthe time, with most ofthese strategies, how long does your pain go away for before it returns? Now clearly, some of these methods are helpful, you use them flexibly, moderatels, sensibly ~ in which case, keep using them! However, when we overuse or over-rehvon these methods— when we use them excessively, rigidly, or inappropriately. ~ they have significant costs. When you have over-used them, what have these methods cost you in terms of health, money, wasted time, relationships, missed opportunities, work, increased pain, tiredness, wasted energy, frustration, disappointment, ete? How many of these methods give you relief from pain in the short term, but keep you stuck or make your life worse ‘or have significant costs in the long term? ‘none’ ‘afew’... sees about hall... secu Most. seo tall” ‘You're Not Lazy or Stupid You've tried very hard for a long time to get rid of these thoughts & feelings. No one can call you lazy! And ‘you're not stupid! These are methods that everyone uses to some extent, to avoid or get rid of pain. We all try to distract ourselves: we all opt out of things that are difficult; we all try to think our way out of our pain; and we all put substances of one form or another into our bodies. And our friends, family, and health professionals often actively encourage us to do all these things! However ... no matter how hard we try o avoid or get rid ofthese thoughts and feelings... in the long term, they keep coming back! Are You Stuck In A Vicious Cycle? Unfortunately, often what we do to get short term relief from painful thoughts and feelings, tends to make our life worse in the long term. In other words, we get stuck in a vicious cycle. And most people find it painful when they realise this. What difficult thoughts and feelings does this bring up for you? Can you take a moment to acknowledge just how painful and difficult itis to be caught in this vicious cycle? (s there something kind you can say to yourself or do for yourself?) Given that: ) no matter what youdo, your painful thoughts and feelings keep coming back, and +b) many of the ways you respond to themare making yourlife worse in the long term ‘would you be open to something new? Would you be interested in learning. brand new way of responding to them; a ‘method that is radically different to everything else you've tried? © Russ Harris 2018 www.ImLearningACT.comOnline Figure A. Florida Obsessive-Compulsive Inventory General instructions: The questions below ate designed to wentify some of the common symptoms of obsessive-compulsive disorder (OCD). Keep in mind that a high score on this questionnaire does not necessarily mean you have OCD. Only an| evaluation by 2 health professional can make this determination. Answer these questions as accurately 2s you can. Part A instructions: Please check YES oF NO for the following questions, based on your experiences in the past month - ves No. Have you been bothered by unpleasant thoughts or imag such as: 1. Concems about contamination (ditt, germs, chemicals, radiation) of acquiring a serious illness uch 35 AIDS? 2. Overconcezn with keeping objects (clothing, tools, et.) in perfect order or arranged exactly? 3. Images of death or other horrible events? 4. Personally unacceptable religious o sexual thoughts? Have you worried a lot about terrible 5. Fire, burglary, or flooding of your house? 5, Accidentally hitting a pedestrian with your car or letting it roll down a hil? 7. Spreading an illness (giving someone AIDS)? 8 Losing something valuable? 5 that repeatedly enter your mind, woo w ooe o Jings happening, such as: eooee cosoo 9. Harm coming to 2 loved one because you weren't careful enough? Have you worried about acting on an unwanted and senseless urge or impulse, such as: 10. Physically harming a loved one, pushing a stranger infront of a bus, steering your car into oncoming trafic, inappropriate sexual contact, or poisoning dinner quests? Have you felt driven to perform certain acts over and over again, such as 11 Excessive or ritualized washing, cleaning, or grooming? 12. Checking light switches, water faucets, the stove, door locks, or the emergency brake? 13, Counting, arranging, evening-up behaviors (making sure socks are atthe same height)? 14, Collecting useless objects or inspecting the garbage before itis thrown out? 15. Repeating routine actions (in/out of chair, oing through doorways, rlightng cigarettes) 2 certain numberof times unt it fees just ight? 16. Needing to touch objects or people? 17, Unnecessary rereading or rewriting; opening envelopes before they are mailed? 18. Examining your body for signs of illness? 19, Avoiding colors ("red means blood"), numbers ("13 is unlucky"), or names (“those that start with signify death”) that are associated with dreaded events or unpleasant thoughts? 20. Needing to “confess” or repeatedly asking for reassurance that you said r did something correctly? © O68 Beeoe ® ®ooo coooO I you answered YES to three or more of these questions, please continue with part B. “August 1, 2009 + Volume 80, Number 3 wwwaafporglafp American Family Physician ©Obsessive-Compulsive Disorder ee ee Et Online Figure A. Florida Obsessive-Compulsive Inventory (continued) rt B instructions: The following questions refer to the repeated thoughts, images, urges, or behaviors identified in part A Consider your experience in the past 30 days when selecting an answer. CCheck the box next to the most appropriate number from 0 to 4 [inte ast mnt 1 1. On average, how much time is ou 1a 28 30 aa | ‘occupied by these thoughts or None Mild (less than Moderate Severe Extreme (more behaviors each day? | thou) | toa hous) | @toshous) | than Bhours) 2.How much distress dothey = | 0) 10 2a 38 au | ‘cause you? | None Mig Moderate sere | extreme 1 | (isabling) 3. How hardisit for you to contro | OQ. 10 20 4a them? ‘Complete ‘Much control ‘Moderate ‘No control control contol 4 How much do they cause you oO 12 28 30 i 40 to avoid doing anything, going No avoidance Occasional Moderate Frequent Extreme, anyplace, or being with anyone? avoidance avoidance and extensive avoidance avoidance | (housebound) 5, How much do they interfere oa 1a 20 38 40 with school, work, of your social None Slight Definitely Much extreme or family fe? interference | interferes with | interference | interference functioning (disabling) ‘Sum on part B (add items 1 to 5): ‘After answering the questions in part B, total your score. It should range from 0 to a maximum of 20. If you Scored 8 or more, it is recommended that you consider consultation with a mental health professional Reprinted with permission from Wayne Goodman, MO, ISerer ir INDIAN SCALE FOR booing Perera nern Scale for Assessment of Autism Description Of The Tool ISA is an objective assessment tool for persons with autism which uses observation, clinical evaluation of behaviour, testing by interaction with the subject and also information supplemented by parents or caretakers in order to diagnose autism. ISAA consists of 40 items rated on a 5-point scale ranging from 1 (never) to 5 (always). The 40 items of ISAA are divided under six domains as given below. Domain-I Social Relationship and Reciprocity Individual with autism do not interact with other people. They remain socially unresponsive, aloof and may have difficulty in understanding another person's feelings, such as pain or sorrow. The have significant problems in use of body language and nonverbal communication, such as eye contact, facial expressions, and gestures and establishing friendships with children of the same age. Domain-H Emotional Responsiveness Individuals with autism do not show the expected feelings in a social situation. Emotional reactions are unrelated to the situation and may show anxiety or fear which is excessive in nature without apparent reason. They may engage in self-talk that is inappropriate for their age and may lack fear of danger. Domain-III Speech - Language and Communication Individuals with Autism will have problems in speech development. They find it difficult to express their needs verbally and nonverbally and may also have difficulty in understanding the non verbal language of others. People with autism often, have echolalia and may repeat a word, phrase or sentence outof context. Domain-IV Behaviour Patterns Individuals with autism may engage in self —stimulatory behaviour in the form of flapping of hands or using an object for this purpose. They insist on following routines, sameness and may resist change. Some autistic children may be restless and exhibit aggressive behaviour. Domain-V Sensory Aspects A majority of autistic people are either hyper or hypo sensitive to light, sound, smell and other external stimulation, They may ignore objects or become obsessed by them or they may watch those objects very intently or actas if they are not even there. Some autistic children explore their environment by smelling, touching or tasting objects. MannualDomain-IV Cognitive Component Individuals with autism may lack attention and concentration. They do not respond to instructions Promptly or respond after a considerable delay. On the other hand individuals with autism may also have sae or unusual ability known as, savant ability in some areas like: reading, music, memory and artistic abilities. Guidelines for Test Administration Advance preparation of the examiner The examiner should have a through familiarity with the test items, test materials, recording and scoring. Guidelines for rating ISAA should be adhered. Itis advisable to practice test administration using CD to understand subtle cues and observing examinee behaviout. Each item of ISAA is to be assessed and a rating is to be given based on the intensity, duration and frequency of the characteristics. a) Testing Conditions ISAA must be administered under standard testing conditions and testing methods as given below. > Person's physiological condition (fatigue, sleep and state changes) > Comfort level of the person being tested > Periods of fear or oppositionality in the person being tested > Quality ofinformant's verbalizations > Consideration of environmental and cultural influences > Congenial environment and rapport while interviewing informants . Understanding individual differences Thorough familiarity with the test content and procedures v . Flexibility of the examiner b) Method of Assessment i) Observation ii) Inforinantinterview iii) Testing Observation ‘The tester should focus on the individual being tested for the following aspects. > Interaction with the caregiver and othersComfort level or distress in relation to others > Quality of social responsiveness in terms of duration, reciprocity. > Interest in people and objects > Communication > Useof'sensory modalities > > Inappropriate behaviours For example, testing for “Poor eye contact” should be assessed by observing the individual to see how frequently she/he makes eye contact, how long eye contact is maintained and its appropriateness to the age of the person as well as cultural norms. This information should be supplemented by seeking information from the informants through interview. Interview Reliable information from the informant, across different settings, is crucial for proper evaluation, For example, while testing for delayed response time, use Picture Books/Blocks and ask the child to show some object/thing/fruit in a picture book or natural surrounding, Observe if the child is responding after a delay or repeated instructions or prompts are required to elicit a response. Ask for the names oruses of objects or differences between objects depending on the age of the child, b) Testing Time Assessment of persons with autism may take 20-30 minutes d) Materials The assessment kit should comprise the following items. 1 Car 13 Watch 2 Ball (different sizes) 14 Hand bell 3 Doll (different types) 15 Paper and crayons 4 Rattle 16 Blocks 5 Picture book 17 Squeezer — Cat / Dog 6 Peg board with rings 18 Fruits/Vegetable toys 7 Sorting board 19 Box 8. Cup 20 Bottle and pellets 9 Spoon 21 Mirror 10 Beads with a string 22 Shape sorter 11 Colour card/Board 23 Slide with a rolling ball 12Key 24 Musical toysScoring System ISAA shouldbe scored as per the scoring system given below. Each of the 40 test items is to be rated on 5 categories, out of which one is to be checked. These are further quantified by providing percentages to indicate the frequency, degree and intensity of behavioural characteristics that are observed. The categories along with the percentages assigned are as follows: Rarely (Up to 20%) indicates that the person exhibits this behaviour pattern for up to 20% of the time. This score is normal for their age and socio-educational background - Score 1. Sometimes (21 — 40 %) indicates that the person exhibits this behaviour pattern for 21%-40 % of the time. Some of these behaviours may be a cause for attention and concern, but by and large they may be considered within normal limits for their age and socio-educational background, Person is completely independent in activities of daily life-Score 2. Frequently (41 — 60%) indicates that the person exhibits this behaviour pattern for 41% - 60% of the time, These behaviours occur with such frequency and regularity that they interfere with the persons’ functioning in daily life. Behaviour at this level wil be definitely disabling. Person may be able to perform activities of daily life with minimum assistance - Score 3. Mostly (61-80%) indicates that the person exhibits this behaviour pattern for 61% - 80 % of the time. The given behaviour may occur without any discernible stimulus. The behaviour under consideration occurs so regularly that it significantly hampers the person in performing daily activities. Person needs assistance in activities of daily life-Score 4. Always (81% - 100 %) indicates that the person exhibits this behaviour pattern almost all the time, so ‘much so that it would be considered a major handicap. The behaviour shown is seldom appropriate to the given situation. Person is completely dependent on activities of daily life-Score 5. The minimum score that can be obtained is 40. The maximum score that can be obtained is 200.Indian Scale for Assessment of Autism I SOCIAL RELATIONSHIPAND RECIPROCITY 1. Poor eye contact Individuals with autism avoid looking people in the eye. They are unable to maintain eye contact as expected fora given age or required of social norms. Eye contact may be unusual such as gazing for too long on one spot or looking sideways. 2.Lack social smile Individuals with autism do not smile when meeting people or in reciprocation. A smile that reflects social response and recognition cannotbe elicited from such persons. When the child enters see how he/she reacts to strangers. Whether smiles or not. How he responds to friendly overtures such as asmile ora handshake, 3.Remain aloof Individuals with autism may remain aloof, self-absorbed, withdrawn, and not responsive to people or environment. They seem to be preoccupied with their self and be away from the social world around. They hardly respond to, or initiate contact with others. There is lack of age appropriate pretend play. ‘Ask the child if he has friends, whom he likes at home or what he likes to eat etc. Observe how responsive the child is to you when you interact. 4.Do not reach out to other persons Individuals with autism do not interact with other people and remain socially unresponsive, They do not initiate, seek, or respond to social interactions. They may not respond to their name, and even if they do, it may not be appropriate. Check if the child/individual takes any initiative to elicit a response or reaction from others. ‘Does he respond to his name or not and how he reacts when you try to engage him in a social interaction. 5, Inability to relate to people Individuals with autism do not initiate contact with others and may not relate to people as expected of their age. Reminders are required to attune the individuals with autism to the presence of people and social situations. Persistent effort is required to get their attention. They seem to be indifferent and impersonal in their interactions with others, if at all contact is established.6. Inability to respond to social / environmental cues Individuals with autism are not responsive to social and environmental demands or expectations, They show behavior which is not synchronous with the demands/ requirements of the social environment. Ask if the child behaves appropriately or not in keeping with what is expected in a given social situation and also find out whether the child behaves appropriately when parents take him/her to visit friends or relatives, or behaves properly ina market. 7.Engage in solitary and repetitive play activities Individuals with autism play alone most of the time or prefer solitary activities. They avoid playing with others and may not engage in group oriented activities or tasks at all, ‘Ask if the child plays in a group with other children or he plays alone with some object or material repetitively. 8. Inability to take turns in social interaction Individuals with autism do not comprehend the significance of taking tums in reciprocal interaction with others. They do not wait until their tum comes or the others’ turn ends. Check if the child can play with a ball by taking tums with someone or can he play bat and ball with someoné which requires tum taking and whether he waits for his turns when talking to others. 9.Do not maintain peer relationships Individuals with autism do not develop age appropriate friendships. They may not engage in age appropriate peer interactions or maintain peer relationships as is socially expected. Autistic persons appear to find it difficult to understand social rules and to conform to social boundaries. Ask ifthe child plays with children of his age, what he plays with them, and how well he mixes with them orbonds with them. II EMOTIONAL RESPONSIVENESS 10. Inappropriate emotional response Persons with autism do not show the expected feeling in a social situation. They express inappropriate emotional responses like laughing when scolded or spanked and inappropriate degree of response like excessive crying or laughing that is unwarranted. Emotional reactions are unrelated to the event or situation around the individual. They may show unpredictable shift in emotions, thatis, they may become excited, agitated or distressed for no apparent reason. 11. Show exaggerated emotions Persons with autism may show anxiety or fear which is excessive in nature and which may betriggered off without an apparent reason. At times, it may be exaggerated or atypical. The autistic individual may show extreme fear of innocuous objects or events leading to uncontrolled behavior. 12. Engage in self-stimulating emotions Individuals with autism may engage in self talk that is inappropriate for their age. The autistic individual may smile to self without any apparent reason. Check if the child talks to self or laughs or smiles or whines for no apparent reason, 13. Lack fear of danger Persons with autism may not show fear of hazards or dangers which others of the same age would show or know. Persons with autism may show excitement, over activity or agitation that is both excessive and unwarranted, The autistic child moves around with brisk energy and may be difficult to control. Ill SPEECH-LANGUAGE AND COMMUNICATION 15. Acquired speech and lostit Speech development is not age-appropriate. The autistic individual may have developed speech, but lost it subsequently. 50% of autistic may be mute. 16. Difficulty in using non-verbal language or gestures to communicate Persons with, autism find it difficult to express their needs non-verbally and may also have difficulty in understanding the non-verbal language of others. Instead of gesturing or pointing, they may lead others to the desired object by dragging or pulling the latter's hand. Arrange Cup, Doll, Car, Spoon, and Key in a row and ask the child to point to one of the objects. Keep two or three objects at a time to check if the child can point to objects. 17. Engage in stereotyped and repetitive use of language Persons with autism may repeat a word, phrase or sentence out of context. They repeat the same statement many times. 18. Engage in echolalic speech Persons with autism may repeat or echo questions or statements made by other people. They may notunderstand that they have to answer the questions. Observe if the child is repeating what you said either the whole or a part of what you said. ] ASAE}Vv 19. Produce infantile squeals or unusual noises Persons with autism may squeal, make bizarre noises and produce unintelligible speech like sounds. They may produce speech like sounds which lack meaning. 20. Unable to initiate or sustain conversation with others Persons with autism may not be able to initiate or sustain conversation with others. Check if the child can meaningfully respond to a series of questions or maintain a dialogue for adequate time. 21. Use jargon or meaningless words Persons with autism may use strange or meaningless words which convey no meaning. 22. Uses pronoun reversals Persons with autism may show difficulty in the use of pronouns. They frequently reverse pronouns suchas “I” for “You”. 23. Unable to grasp pragmatics of communication (real meaning) Persons with autism have difficulty in understanding the true intent of speech of others. They may not understand the pragmatics of speech communication. For example, When somebody asks them “Can you tell the time?, they may say 'Yes” and stop. Check if the person understands humor and sarcasm. BEHAVIOUR PATTERNS 24, Engage in stereotyped and repetitive motor manners Persons with autism may engage in self-stimulatory behavior in the form of flapping of hands or fingers, body rocking or using an object for this purpose. 25. Show attachment to inanimate objects Individuals with autism may be staunchly attached to certain inanimate objects which they insist onkeeping with themselves such as string, rock, pen, stick, toy, bottle and the like. Keep all the objects and check if the child shows attachment to inanimate object/s. This can be seen ifhe likes to play with one object consistently and seems very much attached to it and shows resistance and temper tantrums when that object is taken away. 26. Show hyperactivity / restlessnessIndividuals with autism may be restless with boundless energy which makes it difficult for others to control them. The hyperactivity interferes with their learning and performance of tasks. 27, Exhibit aggressive behaviour Persons with autism may show unprovoked aggression and socially inappropriate behavior such ashitting, kicking and pinching. 28. Throw temper tantrums Individuals with autism may show temper tantrums in the form of head banging, screaming, and yelling etc. Such behaviors are emitted when frustrated 29. Engage in self-injurious behaviour Persons with’autism may indulge in self-injurious behaviors like biting, hitting or mutilating self. Such individuals have to be constantly supervised to prevent them injuring themselves. 30. Insist on sameness Persons with autism may resist change in their routine and insist that things be the same as they were. Such individuals may insist on continuing the same activity and it would be very difficult to distract them from such repetitive activities. Any change in the schedule leads to frustration and temper tantrums. Thus, persons with autism show a degree of rigidity in their adherence to routineand accustomed ways. Check if the child wants to sit at the same place, reads the same stories, prefers the same route, wants things to be kept in the same place, and wants the same schedule of activities in a prescribed sequence always. SENSORYASPECTS 31. Unusually sensitive to sensory stimuli Persons with autism may react strongly to certain sounds, light, touch or tastes by closing their cars, eyes or refusing to eat food of certain consistency. They may actively avoid certain sensory stimuli. Ring the bell or any sound making object to see how the child reacts. Check if he is finding the sound aversive or distressing or if he closes his ears. This is for auditory stimuli. Check how the child reacts to your touch. Observe how the child reacts to bright illumination or darkness. 32. Stare into space for long periods of time Persons with autism may stare at some distant spot or space for long periods of ime. They seem it ManualVE tobe unaware of surroundings when thus occupied. 33. Difficulty in tracking objects Persons with autism may have difficulty in tracking objects or persons in motion. They are unable to follow or fix their gaze on moving objects or persons for the required period of time. Throw the ball or rattle and see if the child tracks it or not. Veer a car and move it around or spin the top and check ifthe child is looking at itas it twirls and moves away or not. 34. Has unusual vision Persons with autism may be able to observe tiny details which may not be apparent to others. Such individuals focus their attention on some insignificant part of an object that is generally ignored by others. Check if the child is looking at some miniscule part of the object or toy or watching from the corners of his eyes or brings objects very close to the eyes and stares. 35. Insensitive to pain Persons with autism may hardly react to pain. They seem not to be distressed or cry when hurt. They seem to have high thresholds for pain. 36. Respond to objects unusually by smelling, touching or tasting Individuals with autism may go around exploring their environment by smelling, touching or tasting objects. Some of them may not show appropriate use of objects or toys. Keep all the objects and observe if the child is smelling, touching or tasting the objects orifhe is, using the objects appropriately. COGNITIVE COMPONENT 37. Inconsistent attention and concentration Itis difficult to arouse the attention of individuals with autism. They do not concentrate, and if they do, then it may not be on relevant aspects of the object or event. Asa result of this, they may be inconsistent in their response. ‘Ask the child to put the pegs on the board or sortthe _piecesand put them in their right places on the sorting board or fill he bottle with the beads or string the beads in a twine, Check if'the child can attend and concentrate on the task. 38. Delayed response time Persons with autism do not respond to instructions promptly or respond after a considerabledelay. Quick response to instructions is hardly everto be expected. Show picture books/blocks and ask the child to show some object in a picture book. Observe if the child is responding after a delay or with repeated instructions, Ask for the name of things or objects or ts uses or differences between objects depending on the age ofthe child. 39, Unusual memory Persons with autism may show memory for things which most of the individuals would have Jong forgotten. Some of them have exceptional ability to remember things from the distant past. Check if the child recognizes people he met long time back or remembers the routines taken or places visited or dates or time or locations or names of things to an extraordinary extent, 40. Savant ability Persons with autism may have special or unusual ability in some areas like reading early, mathematical feats or artistic talent. Some of them may show superior ability, but ina restricted field of interest. Standardization of the Tool Validity: Validity of ISAA test items was determined by correlating the individual item scores with the total scores, all the items of the scale were significantly correlated with total scores at 0,001 level, except one item (A40), namely ‘savant ability' which was significant at 0.5 level. Internal consistency reliability: Internal consistency reliability of SAA was computed using Cronbach alpha. The alpha coefficient obtained was 0.93 (p<0.001) for autism group indicating high degree of internal consistency. Anter-rater reliability : Inter rater reliability of ISAA was obtained using Pearson Product Moment Correlation between two raters who independently administered and scored ISAA on 67 randomly selected children (about 17% of the sample). Correlations between raters varied from 0.62 to 0.81 in different domains which are equivalent to those found in standard tool, namely, CARS. Test-Retest Reliability: In order to assess the Test retest reliability of ISAA, 120 subjects (30% of sample) from autism group were retested after three months. Correlations ranged from 0.60 to 0.85 in various domains and for the total score it was 0.83 (p<0.001). These results indicate that test-retest reliability of ISAA is good. Sensitivity and Specificity: Sensitivity and Specificity of ISAA was computed for investigating its effectiveness in discriminating autistic and non autistic children as compared to CARS. Further, st MannualReceiver Operating Characteristic (ROC) curve analysis was carried out to assess the discriminant power of ISAA, using these sensitivity and specificity levels at different cut off. The ROC analysis also confirmed the discriminant ability of SAA, AUC=0.931 with SE=0.009 at cut off 70. Based on the ROC cut off score of 70, a diagnostic categorization of ISAA has been established which aids in the interpretation of total ISAA scores. Using this cut off level, individuals falling below the score of 70 are categorized as non autistic while those with score of 70 and above are categorized as autistic. Norms To arrive at the taxonomy of ISAA, the scores of 376 children who scored 70 and above from autism group were analyzed. The mean score was found to be 106.09, range being 70.0'to 181.0.as given below. Scores ranging from cut off score to mean score (70 to 106) has been classified as mild autism, scores N Minimum Maximum Mean sD ISAA Total 376 70.0 181.0 106.09 23.5 from mean to Meant 2SD (106 to 153) as moderate autism and scores above mean + 2SD (> 153) as severe autism, as indicated below. Norms of ISAA for Diagnosis of Autism ISAA Scores Degree of Autism <70 Normal 70 to 106 Mild Autism 107 to 153 ‘Moderate Autism > 153 Severe AutismPercentage of Disability as per the score Score Percentage (%) 70 40 71-88 50 89-105 60 106-123 70 124-140 80 141-158 90 Above 158 100 Conclusion: Indian Scale for Identification of Autism (ISAA) is a standardized tool with good psychometric properties. Itisa reliable and valid tool for making diagnosis of persons with Autism.INDIAN SCALE FOR ASSESSMENT OF AUTISM | Gender Date:.. a National Insitute for the Mentally Handicapped (Ministry of Social Justice & Empowerment, Govt. of India) Below are given 40 statements which are divided under six domains, please tick ("| ‘An ISO 9001:2000 Institution | mark the appropriate rating for each item of the scale by observing the child and by ‘Manovikes Nogar ewing the parents in order to assess Autism Secunderabad — 500 009 Examiner: ... Rarely | Sometimes | Frequently | Mostly | Always Items Upto 20% | 21-40% | 41-60% Seoret | Score2 | Scores. | Scored | Scores 1 | Has poor eye contact Tacks social smile Remains aloof Does not reach out to others z 3 a 5 | Unable to relate to people © | Unable to respond to social/ environmental cues 7 8 9 ‘Engages in solitary and repetitive play activities ‘Unable to take turns in social interaction ‘Does not maintain peer relationships Penns 10 | ‘Shows inappropriate emotional response 11 | Shows exaggerated emotions 12 | Engages in self-stimulating emotions 13 | Lacks fear of danger 14 | Excited or agitated for no apparent reason [. SPEECH-LANGUAGE AND COMMUNICATION 15 | Acquired speech and lost it 16 | Has difficulty in using non-verbal language or ‘gestures to communicate 17 | Engages in stereotyped and repetitive use of language 18 | Engages in echolalic speech 19 | Produces infantile squeals/ unusual noises 20 | Unable to initiate or sustain conversation with othersUnable to grasp pragmatics of communication Rarely | Sometimes | Frequently | Mostly | ° Atways Items upto 20% | 21-40% | 41-60% | 61-80% | 81-10% Scorel | Score2 | Score3 | Scored | Scores 21 | Uses jargon or meaningless words 22 | Uses pronoun reversals B 24 | Engages in stereotyped and repetitive motor ‘mannerisms 25 | Shows attachment to inanimate objects 26 | Shows hyperactivity/ restlessness 27 | Exhibits aggressive behavior 28 | Throws temper tantrums 29 | Engages in self-injurious behavior Insists on sameness ‘Unusually sensitive to sensory stimuli Oe ae hy 32. ‘Stares into space for long periods of time 33 Has difficulty in tracking objects Has unusual vision 35 Insensitive to pain Responds to objects/people unusually by smelling, touching or tasting Inconsistent attention and concentration 38 | Shows delay in responding 39 | Has unusual memory of some kind 40 | Has ‘savant’ ability Classification [No Autism | Mild Autism <70 70 to 106 ‘Moderate Autism 107 to 153 Severe Autism >153 Total score Test ManualNTo anita) of The National Trust Disha — Early Intervention & School Readiness Scheme Description Day care facility for children with NT disabilities in the age group of 0-10 years for at least 4-6 hours per day fora batch size 20 Training and counseling to children and the parents to enable mainstreaming of children Professional services by special educators, therapists and counselors Availability of optional transport facility Continuous evaluation of children and mapping of development chart Assistance and guidance for admission to schools KPls monitored shall be - PwD strength, LIG:Non LIG ratio, PwD development, PwD mainstreaming, Parent Counselling ens Monthly for 3 months (min, PwD is Sustenance | 4,500 per Differential PwD per month] 2594 of batch size, Le. 4) Monthly 4,500 per eligible PwD per month Monthly on 1:1 ratio for LIG:Non Recurring (+1000 Transport allowance) LIG and All BPL Vikaas - Day Care Scheme Description Day care facility for PwD above 10 years of age for at least 6 hours in a day (between 8 am — 6 pm) fora batch size 30 Training and counseling to PwDs in the age group of 10+ years for enhancing interpersonal and vocational skills, besides mainstreaming Professional services by special educators, therapists and counselors Availability of optional transport facility Enable family members to fulfill other responsibilities Provision for setting up Work Centers KPIs monitored shall be - PwD strength, LIG:Non LIG ratio, PwD development, Gainful employment ofPwD Sustenance | 3,850 per Differential PwD per month| Monthy fr 3 months Monthly 3,850 per eligible PwD per month | Monthly on 1:1 ratio for LIG:Non ng | (+1000 Transport allowance) LIG and All BPL Work Centre | Rs. 25,000 to Rs. 1,00,000/- Case to case basisSamarth — Respite Care Residential Scheme Scheme Description: Residential facilities including meals for orphans/abandoned, families in crises, destitute, BPL and LIG PwDs inall age groups fora batch size 30. Provision to shift an adult resident to GHARAUNDA if stay in Samarth exceeds 5 years and PwDisanadult Professional services by special educators, therapists and counsellors for age-specific vocational and pre-vocational activities ROshould own the location or its should be on a lease of minimum 5 years with renewable clause KPIs monitored shall be ~ PwD strength, LIG:Non LIG ratio, PwD registration with Niramaya scheme, PwD development, Gainful employment of PwD, Inclusion events organized is ‘Monthly for 3 months (min. PwD is Sustenanee | 7,000 per Differential PwD per month) 9697 SF patch size Le, 6) ‘Monthly a Monthly on 1:1 ratio for LIG:Non Tiiivteg 7,000 per eligible PwD per month | Mentily on Work Centre | p. 95,000 to Rs. 1,00,000/- Case to case basis GHARAUNDA - Group Home for Adults Scheme Description Residential facilities including meals and all other facilities for life long stay of adult PwDs (>18 years of age) fora batch size 20, Professional services by special educators, therapists and counsellors for age-specific vocational and pre-vocational activities RO should own the location or its should be on a lease of minimum 10 years with renewable clause Provision of crisis fund per Gharaunda Centre to be maintained with the National Trust — INR 10,00,000/- KPls monitored shall be ~ PwD strength, LIG:Non LIG ratio, PwD registration with Niramaya scheme, PwD development, Gainful employment of PwD, Inclusion events organized for LIG:Nc 10,000 per eligible PwD per month | Monthly on 1: ratio for L1G:Non Crisis Fund 10,00,000/- On need basis Work Centre _| Rs. 25,000 to Rs. 1,00,000/- ‘Case to case basisNiramaya — Health Insurance Scheme Description Health Insurance for PwDs under NT Act Full premium tobe paid by the National Trust, Benefits include surgery, hospitalization, OPD, medicines, dentistry, medical tests, therapies ete. up toRs.1 Lakh ‘No requirement of health check-up or age proof No bar for government or private hospitals/practitioners Enrollment on monthly basis through Registered Organizations (RO) Facilitation through 34 regional claim centers Annual enrolment fee for BPL Rs. 250/-, Non BPL Rs. 500/- and PwD with Legal Guardian (Other than natural parents) FREE. KPIs monitored shall be: turnaround time for the application, Niramaya status report Health Insurance’ |1,00,000 per PwD per year As and when PwD will claim Gyan Prabha — Education Support ‘Scheme Description Encourage PwDs to pursue vocational training/higher education/ professional courses Wide range of courses like medical, engineering, law, management and regular graduation and post graduation covered Noageorincome limit for eligibility Recurring fixed amount for the specified courses covering course fees, transportation, books, OPEs (max 10%) ete. on presenting proofs except OPE Funding shall be provided for maximum duration of course or till when course is completed by PwDasapplicable KPlsmonitored shall be: turnaround time for the application, Gyan Prabha status report ‘Sustenance 5,200 per PwD per month | Depending on course structure: ; ; Monthly, semester wise, trimester Graduation/ Post Graduation | 2,000 per PwD permonth | Went semann’ Vocational Course 1,600 per PwD per month Transporiation allowance | 20,000/- per PwD per annum (for any course) or actuals, whichever is lessSahyogi — Care Associate Training Scheme Description: Creating a pool of skilled care associates through theoretical and on-the-job training to support PwDs and their families Two types of courses ~ Primary (3 months), Advanced (6 months) having both theory and internship Parents and guardians are also eligible to apply for the courses. However, they shall not be involved in internship period of course Meeting(s) for placement amongst families, institutions and trained care associates on a quarterly basis KPIs monitored shall be ~ trainee strength, trainee attendance, internship opportunities, placement, RO visitstatus report : On time on acceptance Set up Cost 1,00,000/- for both primary and advanced et propa s Primary — 4,200 per trainee per batch On completion of Trainee Cost | ‘Advanced — 8,000 per trainee per batch training Primary — upto 5,000 per trainee per batch Trainee Stipend | Advanced — upto 10,000 per trainee per batch *Stipend for all, including parents/ guardians of PwD On completion of training Prerna — Marketing Assistance Scheme Description Funding for participation in fairs and/or exhibitions a district, state, regional and national level NT to sponsor up to four events ina financial year Minimum participation of 51% PwDs in production of saleable items/articles An incentive of 10% for RO on sales turnover verified by Office of DC/DM/LLC/Social Welfare NT shall also reimburse the expenses that ROs incurred in designing and publishing brochures marketing the products prepared by PwDs KPls monitored shall be: Event participation and Growth rate of PwD supported Support for participation | National Level INR 30,000 50% on approval of event | in events Regional Level ( participation of proposal min 5 states) - INR 25,000/- State Level - INR 20,000/- 50% on completion of event! District Level - INR Incentive on Sales ernie 10,000/- 10% of total sales Annually eoaaenent for 10,000 per RO per year AnnuallySambhav — Aids and Assistive Devices Scheme Description ~*~ Additional centres to be set up in cities of India with population of more than 5 million (as pet 2011 Census) Demonstration of aids, assistive devices, software & an accessible model of Kitchen, Living Room & Bathroom etc. for enabling and empowering the PwDs Management coordinator at these Sambhavy centres shall be deployed by NT_ ROs to provide one demonstrator/facilitator and one maintenance staff Sambhav centre can procure new aids/ assistive devices and same shall be reimbursed by NT within maximum limit allowed KPls monitored shall be: increased no. of visitors, organizing visits to the centre (for ROs, educational institute and Medical institute) Set up Cost 10,00,000/- (Stage I 5,00,000 | Stage I— on approval of application and Stage II —5,00,000) Stage Il - On completion of setup period ee Recurring | 40,000/- per month To be paid bi-annually Reimbursement for | On actuals with maximum limit of ie chen INR 3,20,000/- per annum ia Badhte Kadam — Awareness & Community Scheme Description Awareness generation for general public and community stakeholders through various activities for example exhibition, rallies, workshops, media outreach etc. Innovative/special proposals to be sanctioned separately Create platforms for collaborative initiatives between govt. officials, medical fraternity, legal professionals & educational institutes for the betterment of PwDs Outreach activities in areas where NT is under represented Maximize benefits of NT schemes KPIs monitored shall be: activities completed, enabling changes in society and gathering feedback Distributing Handouts, posters etc.| 20,000/- | Workshops with govt officials, | 17,000/- at Educational/ financial/ medical legal/ medical/ bank/educational institutes professionals Sessions with voluntary 15,000/- Social inclusion event like cricket | 16,000/- organizations like CRY or MAD match : 13,000/- per | Sessions in schools/ colleges/ | 8,000/- Rrannize Readiiows day other educational institute aia