Strategies - Promoting physical wellbeing
Using heading-off and gentle guiding to ensure physical safety
Seeking professional advice for achieving a good sleep pattern
Monitoring the young person's health
Some young people with visual impairment and autism have a diagnosed medical condition, such as septo-optic dysplasia. An individual who has a diagnosed medical condition may have several medical needs; for example, in septo-optic dysplasia it is important to stabilise hormone levels.
Sarah, who has septo-optic dysplasia, is therefore monitored closely by her consultant paediatrician. School staff, in conjunction with her parents, monitor Sarah's health and provide information as appropriate to the paediatrician.
Providing opportunities for physical exercise
Several of the young people featured in the case studies in this guidance material are very active / have a lot of energy. Most of these individuals are regarded as needing and benefiting from more opportunities for physical exercise than their peers.
Physical exercise is regarded as having several positive effects, apart from contributing to physical fitness. Exercise
See also calming the young person by taking him / her for a walk and calming the young person by providing an opportunity to use a lot of energy.
Jasper is very active; he frequently uses a mini trampoline. Because he so active, he is provided with many opportunities for this and for other forms of physical exercise.
Stacey has unstructured independent times, which provide "space" between educational activities. However, because these periods are unstructured, Stacey does not understand what she should do, and lacks the ability to select a functional activity for herself. Consideration is now being given to making the periods between educational activities more supportive for Stacey. As she has a high level of energy and presents as restless, it is likely she will have physical exercise and opportunities to fulfil a sensory need appropriately.
Charles is physically very active. He is interested in football and plays alongside other pupils in the playground. Thus Charles uses a great deal of energy during breaks in the playground, and it is thought this may help to reduce restlessness during educational activities. If staff expect Charles to have a disturbed day, they take him to the playground at times other than designated breaks; thus they calm Charles by providing an opportunity to use a lot of energy.
As Jivan is very active, he is provided with several short periods of exercise each day.
Ali has a lot of energy and is physically very active during the breaks in the school day. If he becomes restless towards the end of the school morning, the teaching assistant takes him outside again so he can have additional physical exercise and use up more of his energy climbing the mounds and crossing the wobbly bridge. Occasionally, it is not appropriate to take him outside (e.g. when the weather is poor or other young people are being taught in the outside play area). The staff then address Ali's restlessness and calm him by providing sensory integration activities.
Winnie learns most effectively when she has short periods of work rather than fewer, longer sessions. She is also provided with "space" between educational activities during which she either has her favourite activity (listening to music) or a walk. Winnie is frequently taken for a walk. On some occasions, this involves walking up a slope; on others, Winnie carries a back-pack. These activities are described in greater detail in providing sensory integration activities. 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 most effective way to support her is to take 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 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.
Using heading-off and gentle guiding to ensure physical safety
Staff believe it is important to allow Ali the freedom to move around the outside play area alone, in order to
However, because Ali is unable to see, there are clearly risks with this approach, particularly when he is running: for example, he might
Therefore Ali's physical safety is ensured with the use of heading-off and gentle guiding: this requires a member of staff to shadow Ali at all times in the outside play area. Whenever there is a risk that Ali will collide with a peer (all of whom are sighted and have autism), the shadowing member of staff heads-off the other individual if there is time to do so; if not, she gently guides Ali to change direction. Whenever there is a risk that Ali will move into the path of a peer using a swing, the shadowing member of staff gently guides Ali to change direction. If Ali is running and there is a risk that he will collide with a fence or a building or trip over a kerb or on an uneven surface, the shadowing member of staff gently guides Ali to change direction. Ali walks with his arms stretched out in front; therefore, when Ali is walking, staff do not usually guide him away from a fence or building, but let him find it for himself. Ali's independence in the outside play area (and elsewhere) is further supported by waiting and providing time.
Using foam padding to reduce the risk of injury
Stacey appears to gain a great deal of satisfaction from independent movement around the playground during break times. Staff do not want to curtail this, as physical exercise at breaks helps her to remain calm during teaching periods. However, there was concern that she might collide with the legs of the playground pagoda. Following a risk assessment, staff arranged for these legs to be wrapped in bright yellow foam. Although Stacey has only light perception, and it is thought she is very unlikely to see the padding, yellow was selected as it is the colour most likely to be seen by a young person with visual impairment and indeed by all the young people. The pagoda legs are very well padded to reduce the risk of injury if she ran or fell into them when playing.
Seeking professional advice for achieving a good sleep pattern
Poor sleep patterns are common amongst sighted autistic young people and young people with visual impairment without autism. Clearly, this can have serious implications for the individual, the parents, and, indeed, the whole family. Achieving a good sleep pattern can be very difficult. If a young person does not sleep well, practitioners and parents are advised to seek professional advice for achieving a good sleep pattern. This is available from several organisations.
Jivan, like many other young people with septo-optic dysplasia, has a poor sleep pattern: he appears to have very little sleep, and frequently has a disturbed night. It is not unusual for him to arrive at school having been awake since 2am. He frequently falls asleep in school. Jivan is frequently irritable, and staff believe that this may be linked to sleep deprivation. They are therefore supporting his parents in seeking advice for achieving a good sleep pattern.
Promoting healthy eating
Many sighted autistic young people eat a restricted range of foods, and this is also true of several of the individuals featured in the case studies in this guidance material. They include Sarah whose difficulties in this respect may, in part at least, have a basis in her sensory needs. Because Sarah's diet lacks several key nutrients, her health is compromised. Sarah is pre-occupied with meals and snacks, often presenting as anxious about them. It is possible she is concerned that the next meal or snack will contain food items she finds aversive.
With the long-term aim of providing Sarah with a healthier diet, a programme is in place to encourage her to eat a broader range of foods. When developing the programme, members of Sarah�s staff team consulted the dietitian. The programme is carried out in the classroom and involves presenting her with a food she is less keen on, though not yet one she actually finds aversive. A long term aspiration is that the programme will help to reduce Sarah's anxieties about food.
When the programme was first introduced, staff predicted it would raise Sarah's anxiety level. Therefore, a counting strategy is used to inform Sarah when to expect the end of the activity. The programme is used once per day. The first food used in this programme was yogurt. This was selected because, although Sarah did not like it, observations indicated she did not find it actually aversive. Initially, Sarah participated only to the extent that she allowed a teaching assistant (TA) to place a tiny amount of yogurt on her lips. As soon as this had happened, the yogurt was wiped from her lips and the activity was finished. Gradually, Sarah showed more willingness to engage with this, and tolerated the yogurt on her lips for slightly longer. It was then that counting was introduced to inform Sarah how long she should engage. Sarah has some understanding of number, at least to the extent that she rote counts to 20.
When counting was first introduced, the following procedure was used: as soon as the yogurt was placed on her lips, the TA quickly counted to 3, taking less than 2 seconds to do so. Sarah tolerated this well; indeed, she sometimes used her tongue to take a very small amount of the yogurt into her mouth, and then swallowed it. Nevertheless, as soon as the TA had counted to 3, any residue was cleaned from Sarah's lips, and the activity was ended. The activity was never presented again on the same day. In the next stage of the programme, having placed the yogurt on Sarah's lips, the TA then began to count to 3 slightly more slowly. Gradually, over the weeks, the rate of counting was slowed down so that counting to 3 took about 6 seconds. By this time, Sarah was removing most of the yogurt with her tongue and swallowing it. In the next stage, the TA placed the yogurt on Sarah's lips, said "Count to 4," and did so, slightly more quickly than she had been counting to 3. Sarah tolerated this. Gradually, Sarah took more and more of the yogurt, and counting was extended to 10, taking about 30 seconds. At this point, Sarah was given a dish containing yogurt and a spoon and guided to feed herself with the yogurt. The counting was then accelerated, so it took only about 15 seconds to reach 10. As this became well established, the counting was slowed down again, so it eventually took about 1 minute to reach 10.
By this time, Sarah was tolerating yogurt well, and the decision was made to introduce another food. Small pieces of banana were chosen, because it was considered likely that Sarah would tolerate them as they are soft. The strategy was modified slightly, so it was the pieces of banana were counted, rather than time. Initially, 3 pieces of banana were presented, one at a time; each time the TA placed a piece of banana in Sarah�s mouth, she counted. From the start, Sarah ate each piece of banana. As soon as the count reached 3, the activity was ended. Once Sarah was tolerating this well, the number of pieces of banana, and therefore the count, were gradually increased; she is now presented with 10 pieces of banana. Counting is still used; as Sarah cannot see how many pieces of banana remain, counting supports her understanding of how much more she is required to eat. The programme is still in place. The once a day rule still applies: Sarah is never asked to engage with this activity more than once per day.
This strategy could be seen as a form of desensitisation. Initially, it may have been possible to use the Time Timer� Audible to support Sarah. However, Sarah has no functional vision, so the visual aspect of the Time Timer� Audible would have been redundant. In addition, a useful feature of counting is the flexibility it provides. For example, early on in the programme, if it became apparent that Sarah was finding it harder than usual to engage with the activity, counting could be speeded up. It would have been more difficult to alter the Time Timer� Audible to take account of such needs. Furthermore, although the Time Timer� Audible provides an audible indication of the end of the timed period, as Sarah has no functional vision, it would not have provided her with a constant indication of how much time remained. In fact, counting has also been useful as it has provided continuity: it is still used with the pieces of banana.
A broadly similar strategy is in place to support Sebastian with regard to his tactile defensiveness. This is described in informing the young person of when to expect the current activity to end.
Jivan also has a restricted diet. He only tolerates mushy, paste-like foods, apart from prawn cocktail flavoured Skips. Although he is intolerant of solid food and does not readily eat dinner at school, no programme is yet in place to promote healthier eating. However, in school, he has learned to drink from a glass (held by an adult) instead of a baby's bottle.
Promoting healthier eating can be a complex matter. For further information on this, users of this guidance material are directed to the relevant part of the Resources section.
Some young people with visual impairment and autism have difficulties becoming independent in eating and drinking. This issue is discussed in promoting independent eating and drinking skills.