Visual Impairment and Autism Guidance Material Strategy

Strategies - Promoting emotional wellbeing

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Introduction – proactively promoting emotional wellbeing

It is important to emphasise that promoting emotional wellbeing in young people with visual impairment and autism is essential. This is because anxiety and stress are more serious issues for these individuals than for typically developing young people. Having a proper focus on promoting emotional wellbeing means permanently employing strategies which minimise the risk of the young person becoming:

overloaded with sensory information

overwhelmed by anxiety and stress.

Being proactive with regard to emotional wellbeing is far more effective than Waitingfor the young person to become overloaded or overwhelmed and thus go into crisis. Once the young person is in crisis, it can be very difficult to react effectively, and it can be very harmful to the individual's emotional wellbeing. It can also be very distressing for the young person's peers and the staff team. Thus, being proactive with regard to emotional wellbeing is better ethically for the young person, for his / her peers and for the staff team.

Monitoring the environment and responding appropriately

In order to promote the young person's emotional wellbeing, it is important to monitor the environment. Doing so enables practitioners to judge whether the environment is becoming difficult for the young person. Having identified a difficulty with the environment, it is, of course, important to respond appropriately.

Depending on the needs of the individual, a wide variety of environmental features should be monitored. These relate to aspects of the sensory environment and may include:

the nature and level of environmental sounds

the nature and level of visual stimulation in the environment; e.g.

the presence of wall-displays which may be very arousing for a young person who has some vision
whether any colour(s) the young person finds aversive are prominent (some sighted autistic young people find red particularly difficult)
the nature and level of movement in the environment
the temperature
the nature and strength of smells.

Monitoring the young person's behaviour and moods and responding appropriately

In order to proactively promote emotional wellbeing, it is important to constantly monitor the young person's behaviour and moods in order to identify raised levels of stress and anxiety and to predict and avert major difficulties. Having identified raised levels of stress and anxiety, it is essential, of course, to respond appropriately. In other words, it is essential to provide a responsive environment.

Both monitoring the young person and responding appropriately require the practitioner to know the young person really well, in order to view the world from his / her perspective.

Practitioners need to view all the young person's behaviours and changes in mood as potentially communicative; they need to be continuously asking themselves the questions

"What is that behaviour / change in mood telling me about the young person?"

"What do I need to do to promote emotional wellbeing?"

This can be illustrated with reference to Charles. Staff supporting him know it is important to monitor his nystagmus, particularly when he arrives at school in the morning. This is because if his nystagmus is very pronounced at this time, it indicates that he is likely to have a disturbed day, with rapid, unpredictable swings of mood. When staff expect Charles to have a disturbed day, they promote his emotional wellbeing by

reducing demands on him

supporting him to stay calm by:

Although Winnie attends to educational activities for no more than 5 minutes at most, it is essential for the teaching assistant (TA) to monitor her closely during a work session for signs of stress / anxiety. The TA sometimes sings to Winnie to enhance her engagement in educational activities. If the TA feels Winnie is becoming stressed or anxious, and she is not already singing to her, she tries to calm her by singing; this sometimes prevents Winnie's stress / anxiety level rising any further. However, if it is clear that Winnie's stress / anxiety level cannot be reduced, the TA brings the session to a close. If she does not do so, there is a risk that Winnie will go into crisis, which can result in self-injurious behaviour: she bites her left hand and hits her head with her fists; occasionally, she hits another person who happens to be close to her. Winnie finds it aversive when her peers make a lot of noise; it can make her very stressed / anxious. As well as monitoring Winnie, therefore, the TA also monitors the environment.

It is essential that staff working with Bob monitor his levels of stress and anxiety. His behaviour provides a reliable way of doing this:

when standing, he bounces up and down if anxious or stressed; as his anxiety or stress increases, so does the speed of his movements

when sitting, he sits with his feet apart and, as he becomes anxious or stressed, moves his legs together and apart again; as his anxiety or stress increases, so does the speed of his movements

when anxious or stressed Bob whines when he speaks; as his anxiety or stress increases, his speech becomes increasingly whiney.

If it is clear Bob is becoming anxious or stressed, the member of staff supporting him tries to decide the cause. In some cases, it is possible to remove the cause. This is the case when Bob is finding it difficult to cope with sensory stimulation. For example,

if fluorescent lights are on, he may be finding it hard to cope with them flickering; turning them off will remove that difficulty

if there is a lot of noise coming from an adjacent room, it may be possible to reduce or eliminate that noise

if there are a lot of people near by, it may be possible to ask them to leave.

If it is not possible to remove a sensory cause for Bob becoming anxious or stressed, it is sometimes possible to take Bob away from the cause. However, before taking Bob anywhere when he is anxious or stressed, the member of staff must be confident that taking him away from the cause will not further increase his level of anxiety or stress; this could occur if Bob failed to understand the reason for being taken somewhere else. The member of staff therefore tells Bob "going somewhere quiet"; if he responds positively to this, the member of staff goes ahead with escorting Bob to a quieter location.

The member of staff must also be confident of finding somewhere quieter and less stimulating before escorting Bob from the current room. This is to minimise the risk of increasing his anxiety or stress level even further by taking him somewhere else which proves to be unsuitable. Unfortunately, the member of staff cannot always be sure of finding a quieter location, and sometimes adopting this strategy is a gamble.

If Bob's level of anxiety or stress cannot be lowered by removing the cause or by taking him somewhere more suitable, it may be necessary to prompt Bob to go to his safe haven.

Bob sometimes becomes stressed when he struggles with an educational task. But, even if it is clear that this is the case, it is important that the member of staff supporting him does and says nothing, unless Bob requests help. This is because he cannot attend to the task and to someone speaking to him. If he struggles with the task but fails to request help, it is important for the member of staff to continue to monitor Bob's behaviour to judge just how stressed he is becoming.

Unfortunately, there is nothing that the practitioner can actively do to reduce Bob's stress in this situation; leaving him alone is the only option. The practitioner needs to monitor Bob in case he becomes so stressed that he goes into crisis. This is because Bob's behaviour is unpredictable at such times. It is advisable for the practitioner to ensure that Bob has a clear route to the door in case he needs to go to his safe haven.

It is also important to respond to the young person's emotions, and to do so positively. This means accepting that the young person is really experiencing the emotion indicated by his / her outward behaviour. Practitioners sometimes try to "jolly" a young person along when his / her behaviour indicates some distress or anxiety. In effect, this is communicating to the young person that his / her behaviour and emotional status are not respected, and will not receive a positive response. This is counter-productive, and will not support building the young person's trust in his / her practitioners.

Members of staff who support Ali respond positively to his emotional status: they accept his feelings, and do not attempt to minimise them in any way. For example, when he bangs his head on the table, the teaching assistant (TA) attempts to convey to him that she knows he is upset and / or hurt. When Ali becomes upset for no observable reason, the TA says "Ali sad", acknowledging his emotion and reflecting it in her voice. She also gives him a firm hug. This provides an example of a coping mechanism: in time, Ali may come to request a hug when he feels upset. Over time, responding positively to Ali's emotions will, hopefully, make a contribution to his understanding of his own emotions, and possibly even to those of other people. However, because he cannot see facial expressions, Ali's ability to read other people's emotions is likely to remain seriously compromised.

Responding to Ali's emotions in this way is, in effect, an aspect of providing a responsive environment.

Reducing the demands on the young person at difficult times

Staff supporting Charles monitor his behaviour and moods. In particular, they monitor his nystagmus when he arrives at school in the morning. This is because if his nystagmus is very pronounced at this time, it indicates that he is likely to have a disturbed day, with rapid, unpredictable swings of mood. When staff expect Charles to have a disturbed day, they promote his emotional wellbeing by reducing the demands on him. They always provide numerous short periods of work with "space" between them.

In order to reduce the demands on Charles, staff provide activities which are even shorter than normal, with longer spaces in between. During the spaces, they support him to stay calm by:

providing opportunities to use a lot of energy

providing access to the sensory environment.

When Amanda is menstruating, she becomes very lethargic and anxious. Amanda's staff team are particularly keen to provide an empathic approach at these times, so reduce the demands placed on her: she is not expected to engage in educational activities. Making normal demands on her would be insensitive and uncaring. It would also be unethical and counter-productive, as it would result in Amanda's difficulties escalating and causing her to go into crisis.

The staff also support Amanda emotionally in other ways when she is menstruating.

The members of Amanda's staff team sometimes reduce their demands on her in another context. On returning to school at the start of a new academic year, Amanda initially appeared to cope well, but gradually presented with some difficulties as she settled back into the school routine. Of relevance here is that she found some transitions of activity extremely difficult. Strategies were already in place to support Amanda to cope with transitions of location. However, these strategies were sometimes insufficient to enable Amanda to transition to another location for a new activity; the activities concerned included swimming and those using TacPac®. At other times, Amanda coped well with the transitions to these activities; indeed, Amanda sometimes finds activities using Tacpac® calming. When Amanda presents as very anxious or upset, staff reduce the demands on her by removing from her programme activities which require a transition of location.

Supporting adolescent girls emotionally when menstruating

It is generally accepted that adolescence is a difficult time for neuro-typical young people. It is important to recognise that many autistic young people find it even more difficult to cope with adolescence than their neuro-typical peers. For girls with visual impairment and autism, the menstrual cycle may have a major impact on emotional wellbeing. These girls may need additional support at these times. This can be illustrated with reference to Amanda.

There is a pattern in Amanda's emotional wellbeing: at times, she is lethargic and anxious; at others, she is relaxed. It is felt that her menstrual cycle may underlie this pattern. When Amanda is menstruating, she becomes very lethargic and anxious. Staff monitor her behaviour and moods, looking for the signs which indicate lethargy and anxiety; these include:

crying

engaging in hair pulling

showing anxiety in her facial expression

failing to go the toilet and therefore experiencing urinary incontinence

lack of interest in work

clinging to members of staff

frequently retreating to the quiet area in the classroom

much reduced expressive communication.

When she is very lethargic and anxious during her menstrual periods, Amanda's staff team are particularly keen to provide an empathic approach they:

reduce demands on her

offer her additional opportunities to relax

offer her additional opportunities to engage in sensory activities.

The occupational therapist has recommended the use of some sensory integration activities to calm Amanda. Several other activities also enable Amanda to calm down and relax:

activities which Amanda finds motivating

using the sensory environment,

singing.

Accepting behaviour that may serve a calming, self-regulatory function

There are situations in which behaviour that appears inappropriate should be accepted in order to promote emotional wellbeing. This applies to behaviour that serves a calming, self-regulatory function.

For example, Archie often rocks when standing on the spot, which some staff feel is inappropriate. Rocking is associated both with visual impairment and with autism. It is therefore tempting to speculate as to the origin of Archie's rocking: does it arise from his visual impairment or from his autism? However, such speculation is fruitless, as this question cannot be answered. What is more important is to understand why Archie rocks. The Advisory Teacher for Autism believes that his rocking serves a useful self-regulatory function for him: it probably enables him to regulate the information he receives from his environment, calming him if he is over excited or anxious, and stimulating him when he is feeling lethargic. The Advisory Teacher has advised that no attempt should be made to stop Archie rocking until an alternative activity can be found which serves the same function for him. For the present, then, staff accept Archie's rocking.

Leaving the young person to calm down alone

Young people with visual impairment and autism need to be left alone to calm down. This can be difficult for practitioners to accept, as it is counter-intuitive. However, these individuals do not respond in the same way as typically developing young people to spoken language that is intended to comfort and re-assure; nor do they respond in a typical way to touch that is intended as comforting.

Indeed, speaking to or touching a young person with visual impairment and autism who is very anxious or stressed is likely to increase the anxiety or stress and may result in the individual going into crisis. If the young person is already in crisis, speaking to or touching him / her is likely to make it much more difficult for the individual to calm down. This issue is also discussed in understanding when it is not appropriate to communicate with the young person.

Sarah sometimes becomes very stressed. When in crisis, she shouts, screams and hits her own head. Initially, Sarah is left to calm down alone in the classroom. On these occasions, staff do not interact with her at all as speaking to her or touching her has the opposite of the desired effect: it further deepens Sarah's crisis. However, if she does not calm spontaneously in three minutes, she is taken out of the situation and taken for a walk.

Jivan is regarded as a "sensory seeker". He engages in a lot of self-stimulatory activity including rocking, hand flapping, twirling and jumping. He often taps items on his head, mouth and chest. These behaviours indicate Jivan's stress level: the more he engages in them, the greater his stress. The teaching assistant (TA) therefore monitors Jivan's behaviour. If he is becoming stressed, she takes him somewhere quiet to calm down alone. The TA takes Jivan to a part of the school where he has some space to himself and there is little or no noise from other young people. Being outside is most effective, but this is not always possible if the weather is bad, or if a class is having a lesson in the grounds. When he is calming, the TA observes Jivan carefully from a distance to ensure he remains safe, but does not interact with him. Any attempt to soothe him with physical contact, reassuring spoken language, singing or by directing him to an activity serves to increase, not decrease, his stress. Other staff also ignore Jivan at these times. When the TA judges Jivan to be calm, she approaches carefully so that Jivan can see her, using his peripheral vision. If he is sufficiently calm he holds out his hand for the TA to take. If Jivan fails to seek contact, the TA backs away and tries again a few minutes later. Once he is calm, the TA takes him back to the classroom.

When Bob is very anxious or stressed, speaking to him is likely to further raise his level of anxiety or stress, tipping him over into crisis. Staff have become expert at monitoring Bob's behaviour to determine when he is becoming very anxious or stressed. At such times, it is essential to leave him well alone and to say nothing. If necessary, anyone else in Bob's vicinity is removed, and aversive sensory stimulation is removed (e.g. lights are turned off, and the laptop / computer is shut down).

Some young people have a safe haven (see the next item) where they can go to calm down alone.

Providing a safe haven

Some young people with visual impairment and autism require a safe haven. This is a place they can retreat to in times of crisis or when overloaded. Most young people who need a safe haven require a space where there are no other people and few sensory stimuli. However, some individuals (for example, Dominic, below) benefit from a familiar space in which no demands are ever placed on them, despite the fact that the space is stimulating and that there may be other people present.

It is essential that a safe haven must always be immediately available to the young person. For most individuals (that is those who require a space where there are no other people), this means the space must never be used by anyone else: it will not be a safe haven if the young person finds other people there on arrival. Practitioners should not normally enter a young person's safe haven until it is clear that the individual has calmed down and can cope with another person. The only exception is when a practitioner has concerns about the young person's physical safety. It is therefore important that staff can monitor the individual without having to enter or speak to him / her. A young person who is at risk of harming him- / herself by banging or kicking the wall, for example, will need a room fitted with soft-play equipment. Such a room can also be useful for an individual who finds physical exercise calming. Some young people calm down most effectively with the help of a particular item, such as, perhaps, a massager or other vibrating item, or a weighted blanket. Any such item must always be available in the safe haven. See also:

calming the young person by providing sensory integration activities

calming the young person by using an atom massager

A safe haven is provided for Bob to use when in crisis or seriously overloaded. His safe haven is a small room which he knows he can always access and which is for his use only. Because there is a window in the door from the corridor, staff can occasionally check that he is safe.

If Dominic becomes very stressed, he is allowed to leave the situation and go to his safe haven (the visual impairment resource base). This is safe because it is a familiar environment he uses everyday and he can always find somewhere within the base to be alone. This safe haven works for Dominic despite the fact that the space is stimulating and that there is always at least one other person present.

Sometimes there are other young people in the resource base, and always at least one member of staff. Dominic cannot enter the resource base without a member of staff seeing him. Although it is usually advisable to say nothing to a young person in his / her safe haven, the practitioner who sees Dominic enter typically asks him, in a low-key way, "Are you OK?" He is not put under any pressure to respond, and only ever nods. Because he is stressed at these times, he is not able to express his concern. However, once he is calm, Dominic sometimes initiates a discussion with a trusted member of staff. This is usually after an interval of several days. In fact, Dominic very rarely accesses his safe haven; it is likely that he is better able to manage his stress as a result of knowing that there is somewhere safe to go when necessary.

Winnie does not cope well when her peers make a lot of noise; it can make her very stressed / anxious. The teaching assistant (TA) therefore monitors the environment, specifically, the level of noise in the classroom. If the level of noise rises and Winnie becomes stressed / anxious, the TA calms her by taking her for a walk. However, if Winnie has recently had a walk, she is not always motivated to go for another one. On these occasions, the TA calms Winnie by providing a sensory integration activities recommended by the occupational therapist. These activities are provided in the classroom. Occasionally, these activities are ineffective, usually because the noise level in the classroom remains high. Therefore, Winnie continues to be stressed / anxious. It may then be appropriate for the TA to take Winnie for a walk. However, if the TA judges that Winnie is very close to crisis / overload, she takes her to her safe haven. Sometimes, Winnie remains stressed following a walk; the TA then takes Winnie to her safe haven to avoid her going into crisis or becoming overloaded. The TA will also do this if, on returning to the classroom following a walk, the level of noise remains high. Winnie's safe haven is a small room very close to her classroom. It is equipped with a CD player which always has a CD ready in it; the CD is of music Winnie finds calming. The TA remains in the room with Winnie, but does not interact with her at all for several minutes. She constantly monitors Winnie's behaviour and mood; if, having waited for several minutes, the TA judges Winnie to be calm, she approaches her and says "Winnie". If Winnie becomes still and turns towards the TA, she regards this as confirming that Winnie is calm, and takes her back to the classroom. If Winnie does not become still and turn towards her, the TA waits for a few more minutes before again approaching her and saying "Winnie".

Cecily also has a safe haven.

Calming the young person by providing an activity incompatible with the one he / she is currently using

In the past, Cecily often flapped her hands when not engaged in any other activity. The purpose of this behaviour was not clear; it is possible Cecily was seeking sensory stimulation; it is also possible she used this behaviour as a calming strategy when stressed or anxious. Staff now support Cecily to regulate this behaviour and to calm down by providing her with an activity incompatible with the hand flapping: they ensure she always has two small balls of Blu-Tack on her table. Cecily often spontaneously locates these and manipulates them. If she fails to use the Blu-Tack and starts to flap her hands, the teaching assistant prompts her to locate it. Manipulating the Blu-Tack enables Cecily to calm down and is regarded as more appropriate than hand flapping. It supports Cecily's inclusion, as it does not attract the attention (or the teasing) of her peers.

This strategy is very similar to reducing a negative behaviour by promoting an incompatible positive behaviour.

Calming the anxious young person by redirecting him / her

Because Dominic has difficulty understanding the behaviour of his peers, he becomes anxious when there is disruption in class. The teaching assistant re-directs him to the task set by the teacher. This strategy is, in effect, a variation of calming the young person by providing an activity incompatible with the one he / she is currently using; in this case, the incompatible activity is focussing on the task, distracting Dominic from focussing on the disruption, which is the source of his anxiety.

Calming the young person who is becoming overloaded by redirecting him / her

Dominic sometimes becomes overloaded during lessons. The reasons for this are not always clear. However, if Dominic starts to fidget a lot and to lose focus, the teaching assistant (TA) assumes he is becoming overloaded. Dominic usually calms in these situations if he draws or writes down the thoughts that are in his head at the time. Thus the TA always has spare paper and pencils for him and uses them to redirect Dominic.

Calming the young person by providing an activity he / she finds motivating

Some young people with visual impairment and autism are calmed by activities they find very motivating. For example, Amanda finds the following activities motivating and calming:

1:1 pottery lessons

petting rabbits

having a story read to her.

Members of Amanda's staff team sometimes provide one of these activities to calm her. At other times, staff use sensory integration activities and singing to calm Amanda.

Calming the young person by supporting him / her to use relaxation techniques

Cecily does not react well to stress or to completely new situations. She can become very defiant and very agitated and sometimes hits and bites herself. In these situations, the teaching assistant prompts Cecily to use her relaxation techniques. These involve breathing deeply and slowly and counting the breaths: she takes 10. Cecily then tenses and releases the muscles in her hands 10 times. Occasionally, a situation becomes so stressful that these relaxation techniques are not effective. Cecily then withdraws to her safe haven.

Calming the young person by providing access to the sensory environment

Because Charles is subject to rapid swings of mood, staff closely monitor his behaviour and mood. If they expect him to have a disturbed day, staff make fewer demands on him than usual; they also help him to stay calm. They do so in one of two ways; they provide:

access to the sensory environment

an opportunity to use a lot of energy.

The sensory environment is used because Charles is calmed by the bubble tube there. In addition to its use for calming Charles, the sensory environment is used to promote his attention to stimuli.

Calming the young person by providing sensory integration activities

All the young people referred to in this section, with the exception of Bob, have been assessed by an occupational therapist. In each case, the occupational therapist has recommended the sensory integration activities described to address the needs of the individual young person. They would not necessarily be appropriate for any other young person, and sensory integration activities should only be used under the direction of a practitioner who is trained in sensory integration.

Sarah becomes anxious when another young person in her class cries. In this situation, the teaching assistant uses deep pressure to calm Sarah: she hugs Sarah very firmly.

When Ali becomes stressed, staff calm him with one of several sensory integration activities contained in advice from the occupational therapist: using an electric toothbrush, having his back and the back of his hands rubbed, his hands and knees squeezed, and his shoulders tapped rapidly. Staff also employ these strategies when he becomes overactive and it is not appropriate to take him outside for an additional opportunity to use a lot of energy.

Winnie has a range of sensory needs. Perhaps the most difficult to manage is that she finds other people's noise aversive; it can make her very stressed / anxious. The teaching assistant (TA) therefore monitors the environment, specifically, the level of noise in the classroom. If the level of noise rises and Winnie becomes stressed / anxious, the TA calms her by taking her for a walk. However, if Winnie has recently had a walk, she is not always motivated to go for another one. On these occasions, the TA calms Winnie using a sensory integration activity recommended by the occupational therapist: vigorously rubbing the back of her head, her neck and the top of her back, along her shoulders. As well as finding this calming, Winnie usually seems to enjoy it. Winnie also finds a weighted blanket calming. She occasionally uses this spontaneously, usually when the classroom becomes noisy. In addition, the TA prompts Winnie to use the weighted blanket if the rubbing fails to calm her. Occasionally, neither the rubbing nor the weighted blanket is effective, and Winnie continues to be stressed / anxious. This is usually because the noise level in the classroom remains high for more than just a few minutes. It may then be appropriate for the TA to calm Winnie by taking her for a walk. However, if the TA judges that Winnie is very close to going into crisis or becoming overloaded she takes her to her safe haven.

Bob quite often asks someone to rub the top of his back, and seems to need this rubbing to be very firm. He appears to find this calming.

Amanda has been assessed by the occupational therapist (OT) who is a member of her staff team. The OT has recommended the use of several sensory integration techniques and items to calm Amanda when she presents as very anxious or stressed:

rollers

brushing

a weighted blanket

a weighted vest during transitions of location

deep pressure stimulation

rocking her body in a side to side motion

giving her arm / shoulder massages.

Members of Amanda's staff team also use motivating activities and singing to calm Amanda.

Other sensory integration activities are used to prepare Amanda to participate in educational activities and sometimes to enhance her engagement in educational activities.

Calming the young person by taking him / her for a walk

Physical exercise is regarded as having several positive effects, apart from contributing to physical fitness. Exercise

is calming

helps to reduce depression, anxieties and stress

contributes to a good sleep pattern

contributes to self-esteem

contributes to a general sense of wellbeing

Therefore, for a young person who is stressed / anxious / overloaded, having a walk is often calming. Apart from the positive impact of the walk itself, the fresh air can be beneficial. An additional very important feature of this strategy is that the young person is removed from the cause(s) of the stress / anxiety / overload.

Sarah sometimes becomes very stressed. When in crisis, she shouts, screams and hits her own head. Initially, Sarah is left to calm down alone. However, if she does not calm spontaneously in three minutes, she is taken out of the situation and taken for a walk around the school campus to calm down.

In fact, Winnie is frequently taken for a walk as part of providing sensory integration activities to address her sensory needs. On some occasions, this involves walking up a slope; on others, Winnie carries a back-pack.

As well as calming Winnie, taking her for a walk also removes her from the cause of her raised stress / anxiety. However, if Winnie has recently had a walk, she is not always motivated to go for another one. On these occasions, the TA calms Winnie by providing sensory integration activities recommended by the occupational therapist. Occasionally, Winnie remains stressed following a walk; the TA then takes Winnie to her safe haven to avoid her going into crisis or becoming overloaded.

Calming the young person by providing an opportunity to use a lot of energy

Physical exercise is regarded as having several positive effects, apart from contributing to physical fitness. Exercise

is calming

helps to reduce depression, anxieties and stress

contributes to a good sleep pattern

contributes to self-esteem

contributes to a general sense of wellbeing.

Therefore, for a young person who is stressed / anxious / overloaded, using a lot of energy is often calming. If this involves being outside, the fresh air can also be beneficial. An additional very important feature of this strategy is that the young person is removed from the cause(s) of the stress / anxiety / overload.

Because Charles is subject to rapid swings of mood, staff monitor his behaviour and moods closely. If they expect him to have a disturbed day, staff reduce demands on him; they also help him to stay calm. They do so in one of two ways; they

enable him to use a lot of energy

provide access to the sensory environment.

If staff believe Charles would be calmer after using a lot of energy, they usually take him to the playground. Because he has so much energy, he typically runs around on his own. When there are no other young people in the playground, this is regarded as safe, though the teaching assistant uses heading-off and gentle guiding as necessary.

However, if the weather is poor, or the playground is being used for a lesson, Charles is taken to the soft-play room. Although some young people relax and are physically inactive in a soft-play environment, Charles uses the soft-play room very energetically. Thus he gets a good deal of physical exercise there. Following a spell of about 20 minutes in the soft-play room, Charles is usually calm. However, it is essential to inform Charles when to expect the end of using the soft-play environment.

Calming the young person by using an atom massager

Jivan has no major challenging behaviours although he sometimes scratches and bites himself. These behaviours are thought to be related to his level of stress and tiredness. If she believes Jivan is becoming stressed, the teaching assistant first tries to calm him with an atom massager; if this fails to reduce his stress, she calms Jivan by taking him for a walk.

Calming the young person by singing

Cecily is very sensitive to sounds and covers her ears and expresses dislike when loud noises occur. The teaching assistant (TA) sometimes helps her to calm down afterwards by singing quietly to her. Cecily enjoys music, has a pleasant singing voice and can reproduce previously heard songs and tunes very accurately. The TA calms Cecily by quietly singing a song she knows. Cecily usually joins in after a few seconds, and the TA then stops singing. Once she appears to be sufficiently calm, the TA directs Cecily back to her planned task.

Winnie attends to educational activities for no more than 5 minutes at most. Although this is just a short period, it is nevertheless essential during a work session for the teaching assistant (TA) to monitor her for signs of stress / anxiety. The TA sometimes sings to Winnie to enhance her engagement in educational activities. If the TA feels Winnie is becoming stressed or anxious, and she has not already singing to her, she tries doing so: this can have a calming effect on Winnie, sometimes preventing her stress / anxiety level rising any further. However, if it is clear that Winnie's stress / anxiety level cannot be reduced, the TA brings the session to a close. If she does not do so, there is a risk that Winnie will go into crisis or become overloaded.

Providing counselling

Archie has unrealistic expectations about being able to drive and to live an independent life in the future, and refuses to accept loss of sight as a possibility. Although it is not unusual for young people to find it hard to come to terms with losing their sight, Archie's difficulties are compounded by his autism. This is because he does not readily understand that another person may have a different perspective on the situation, and he tends to reject any view put forward by someone else. He has weekly counselling sessions to talk through the future and his prospects.

Providing desensitisation

Some young people with visual impairment and autism have very marked fears / anxieties / aversions in relation to certain experiences or objects. Gradual desensitisation or exposure to the object or experience helps some young people to overcome their difficulty.

However, it is important to understand that this approach is unlikely to address fears / anxieties / aversions that have a basis in the young person's sensory difficulties. Many young people with visual impairment and autism have much more sensitive sensory systems than their typically developing peers. It is essential that their sensory difficulties are addressed.

Sebastian finds messy activities very difficult. These include modelling with Play-doh, and handling ingredients when preparing food. He is supported to engage in messy tactile activities with a counting strategy that informs him when to expect the end of the activity. This is, in effect, a desensitisation programme.

When the programme was first introduced, Sebastian was required to engage in handling Play-doh to the count of 4. At this stage, he was told to "Roll the Play-doh while I count to 4." Sebastian was judged to have sufficient receptive language to understand this. At the count of 4, the activity was terminated and Sebastian washed his hands. Gradually, the count was increased to 10. In addition, as the count increased, the rate was slowed, until he was engaging for about 1 minute. On every occasion, as soon as counting reached the target, the activity was ended, and Sebastian immediately washed his hands. At this stage, the procedure was modified; Sebastian was told to "Roll the Play-doh while I count to 10. I'll count to 10 twice." Again, Sebastian was judged to have sufficient receptive language to understand this. Counting was accelerated again; as soon as 10 was reached, the teaching assistant (TA) said "Once. Counting to 10 again." As soon as 10 was reached the second time, the TA said "Twice. Finished." Again, as soon as counting reached the target, the activity was ended, and Sebastian immediately washed his hands.

At present, this strategy is still being used with Sebastian. The TA now counts slowly to 10 three times and then ends the activity. He is thus engaged with the activity for 3 – 4 minutes. Generalisation is now being addressed by using the same approach in food technology lessons when Sebastian handles messy food items.

It is not clear what this strategy is achieving. Sebastian certainly engages for longer in rolling Play-doh when the strategy is used. However, it is not known whether he would do so if the strategy were removed. Nor is it clear whether the strategy is actually addressing his tactile defensiveness; it is possible that he would still find new messy activities aversive.

In the long term, it is possible that directly addressing sensory needs with a variety of strategies might be more effective than desensitisation programmes in helping young people with visual impairment and autism to cope more easily with sensory difficulties. However, if a young person finds light touch, flickering lights, loud sounds or any other sensory experience painful, it may be that this will continue regardless of any strategies put in place to address it. Practitioners manage Cecily's difficulty with light touch and Bob's difficulty with flickering lights by avoiding these triggers. This is likely to be the most empathic, supportive and effective strategy for many, if not all, young people.

Desensitisation might assist in addressing fears. One that seems to be quite common amongst sighted autistic young people is that of dogs. This fear can be used to illustrate how desensitisation could be approached.

A desensitisation programme to address a fear of dogs could start by exposing the young person to recordings of dogs barking. These recordings could be placed onto a device such as a 'BIGmack'. This would result in the young person having control of the sounds. If the individual has sufficient vision to see pictures, this might offer another strand. The young person could start by looking jointly with a trusted adult at cartoons of dogs. Once the young person copes with this, line drawings, then pictures that are gradually more life like, then photographs and finally videos could be used. It would be important to ensure at each stage that the individual was coping before moving on. The next stage might be to let the young person see a trustworthy, quiet dog. The dog could be walked past the individual. Gradually, the dog could be brought in closer. The young person could be invited to hold the dog's lead, or to stroke the dog.

It may be possible to support this process with a Social Story™. See also using stories to support social understanding .

Cognitive behaviour therapy (Stallard, 2002) may help some young people with visual impairment and autism.

A possible difficulty when addressing fears is that many young people with visual impairment and autism have excellent memories for events in the distant past, perhaps especially for events that provoked fear or some other negative response. An individual who is afraid of dogs could have a vivid memory of the event that caused that fear. Anything that reminds the young person of that event might again cause fear: it could be hearing the word "dog" or seeing a picture of a dog, or touching a piece of material similar to fur. The response could be so strong that it would be insensitive to put a desensitisation programme in place.