Case Study - Bob
Bob is 14 years old and attends a community special school. Bob has septo-optic dysplasia, moderate learning difficulties, and autism.
Despite having visual impairment, Bob does not appear to be very disabled by his poor sight. He navigates around familiar environments independently; he has no significant difficulties with daily life skills; he reads print quite well, preferring N print size 32, but sometimes coping with much smaller print; he has some basic numeracy skills, enabling him to handle small sums of money; and he uses a computer well.
However, Bob's autism is considerably more disabling. It very significantly affects every aspect of his life.
In the past, Bob has often become overloaded with sensory information, sometimes very rapidly. Amongst the difficulties he reports are humming computers and laptops, fluorescent lights flickering and peers crossing their legs.
Bob is unable to tolerate crowded places. For example, he cannot cope with the noise and bustle of the dining hall or of the school entrance hall when the young people arrive. The noise, movement and unpredictability of a crowded space are simply overwhelming for him. In addition, he becomes very distressed if someone bumps into him.
Arrangements have now been made for him to avoid crowded spaces, so he arrives at school a little earlier than his peers and leaves earlier too. As the dining hall is over-arousing for Bob, he now has his dinner in one of the rooms he uses during lesson times. These are aspects of the low arousal approach provided for him. The member of staff supporting Bob constantly monitors the environment to ensure it does not become crowded or over-arousing in any other way.
Initially, staff believed they were providing Bob with a clear boundary for acceptable behaviour by insisting that he attend every lesson in the classroom with his peers. In fact, Bob was unable to do so. He is now taught in a room by himself, with no other young people, and with only one member of staff. Bob uses several rooms in the course of a week; each one contains a work station which is a feature of the TEACCH approach.
As well as being unable to cope if someone bumps into him, Bob cannot tolerate light touch that is intended to be communicative (e.g. to obtain his attention). However, Bob quite often asks someone to rub the top of his back, and seems to need this rubbing to be very firm. It is possible that he finds this sensory integration activity calms him.
Bob's expressive language can appear to be quite sophisticated, resulting in staff over-estimating his level of understanding. In fact, he has significant difficulties understanding spoken language. Staff now understand the need to greatly reduce the amount of spoken language and to simplify it.
Staff augment their spoken language with the printed word (in N print size 32, using the Arial font). This is particularly important when giving Bob instructions; this includes instructions concerning educational tasks and tasks around school (e.g. taking the register to the office). In effect Bob has a mini schedule for all tasks.
Because Bob interprets language very literally, it is essential to give him explicit instructions.
Bob finds it difficult to respond appropriately to questions. Therefore, staff generally avoid asking him questions, presenting Bob instead with a statement to complete. However, if he is calm, he does respond to simple clear questions such as "Do you want a drink?" If he answers "Yes," but does not spontaneously say what he wants to drink, staff offer him a choice.
Bob needs additional processing time, so often responds after a very obvious pause. Staff now follow the "wait for eight" rule.
He is sociable – on his terms. For example, when he has something to say, especially when he wishes to make a request, he approaches a member of staff and initiates contact; he is almost always polite and often charming. Sometimes, when Bob makes a request, it is not appropriate for the member of staff to grant it. For example, Bob likes to use the stapler in the school office, but cannot always do so. On such occasions, the member of staff responds to his request in a positive manner, using the 'now / next' approach.
If someone else initiates contact with him, Bob"s responses vary widely. When he is calm and relaxed, he typically responds positively and politely. However, when he is engaged in a task or a favourite activity, he is unable to respond. This is because he is single-channelled and cannot attend to more than one thing at a time. When he is anxious or stressed, he sometimes responds in a way that most people regard as very rude: he may ignore the other person or swear aggressively. When he is in crisis, he may hit the other person.
It is essential that staff understand when it is not appropriate to initiate communication with Bob. Staff no longer speak to him when he is engaged in a task or a favourite activity, very anxious or stressed, and certainly not when he is in crisis: in the latter situation, they leave to calm down alone. Thus staff provide Bob with a responsive environment.
The practitioners supporting Bob are very aware of his sensory difficulties. They understand the need to:
- control the sensory stimulation in his environment
- provide a calm environment in which he feels safe and secure and which enables him to access educational activities.
They therefore consciously provide a low arousal environment. This is used alongside work stations, schedules and spoken language which is greatly reduced and simplified. Bob also understands that he can leave any situation at any time and go to a safe haven if he becomes too stressed, anxious or overloaded to cope.
The strategies described here have been very effective. They key ones are:
- providing a low arousal environment
- providing a room where he works alone
- using work stations
- providing printed / written schedules
- greatly reducing and simplifying spoken language.
Since their introduction, Bob has been considerably calmer and more content, and has engaged more frequently and for longer periods in educational activities.