Criminal Justice System from a clinician's perspective. Dr Samantha Walker Calderstones NHS foundation partnership trust Who are we? • A large secure provision in the North West for people with a learning disability. • We have medium, low and “step down” facilities. • We cater for both male and female clients • We admit people on section and through home office jurisdiction • We also have individualised models of care around specific individuals who have “failed” in other services Our client group National Estimates ASC (reported in Emerson & Baines, 2010) • Individuals with co-morbid ASC and learning disabilities: 20 – 30% • Adults with learning disability and ASC in residential care: 2350% Calderstones Inpatient Services (July 2011) Approximately 20% of our inpatient population Psychological Formulation A psychological formulation provides a means to understanding how individuals’ difficulties have been generated and how they continue to present a problem. It is in essence, a story about the individual and the problems they experience. The formulation enables us to make informed judgements about the most appropriate support strategies and treatment approach. Example of a one page profile: Generally struggles to make eye contact, but will often make fleeting glances. Staff feel that he seems to look at the side of an individual rather than at them. When talking about a topic he feels is important he may make excess eye contact throughout the short interaction. Face is typically empty of expression and often would not know what he is feeling from expression. Does smile but not known to laugh. Does invade other’s personal space but seems to do this for comfort e.g. cuddling. Doesn’t do this in general conversation. Historically has engaged in this behaviour. IMPAIRMENTS OF SOCIAL INTERACTION ADDITIONAL AUTISTIC CHARACTERISTICS: Becomes overloaded very easily: this can occur in response to noise (blicks IMPAIRMENTS OF COMMUNICATION CLIENTS NAME TRIAD OF IMPAIRMENTS Communicates verbally Does appear to use gesture to communicate—this appears quite exaggerated and may be learnt. Only engages in conversation about things of interest to himself. Interjects into others conversations Appears to engage appropriately in reciprocal conversation but this is for a short time—he eventually gets the topic around to something of interest to himself IMPAIRMENTS OF IMAGINATION Has interests which historically have described as obsessive e.g. ‘ need to get back to Burnley’. This appears to have abated somewhat. Others interests are: his gaming console , cars and wildlife programmes. The team felt that these were appropriate in intensity and form for his age group. ASC as a key component Shared understanding Individualised Person centred Consider strengths as well as difficulties Focus on offending behaviour / difficulties which led to admission to services Once we have a diagnosis and a formulation... Individual Interventions Group Interventions Sharing the formulation Individual therapy using a range of models / approaches e.g. Cognitive Behavior Therapy , (CBT), Cognitive Analytic Therapy (CAT). Psycho-educational intervention Positive behavioural approaches Good Touch / Bad Touch Social Problem Solving Assertion Skills Managing Anger Adapted Sex Offender Treatment Group (ASOTP) Conversation groups (SALT led) Managing Meetings (SALT led) At all times remaining aware of the individuals ASC and moderating approaches and expectations regarding outcomes accordingly. ...and therapy runs alongside... Environmental Management Interactional Style Communication Strategies Pro-active problem solving Sensory Awareness Resources Staffing levels / personality Staff training Activities / goal setting ASD Friendly Treatment and care Plans ASD Friendly Management Guidelines THE AUTISM TEAM: Default Care Pathway ASC SPECIFIC DIAGNOSIS ASSESSMENT, FORMULATION AND TREATMENT /CARE PLAN ENGAGEMENT AND INTERVENTION TRANSITION PLANNING OFFENCE SPECIFIC / NON ASC CARE PATHWAY ASC TEAM CONSULTATION (as required) RESETTLEMENT Supporting an individuals communication • • • • • • • • • • • • • Total Communication Makaton Intensive Interaction Communication Profiles Environment (Noise, Lighting, Low stimuli, TV) Time of the day Clear and concise communication Picture boards/ planners/Diaries Social Stories sequences (comic strips) scripts picture exchange objects of reference Establishing a person-centred plan catering to an individuals specific preferences and needs • Person-centred support allows us to establish what and who is important to an • • • • • • individual; including daily routines, likes and dislikes, what is important to the person now, what is important to the person in the future and how this can be achieved. Helps us understand how to match support to the person’s needs Knowing how to use information about a person to improve quality of life It can be seen that person-centred planning will enhance quality of life and self esteem to grow. Person-centred planning is ideal for individuals with Autism as it focuses on the individual. Sometimes the tools may need to be adapted and terminology changed so that it is understood. Help’s someone understand their own autism Promotes empathy for the person you support, therapeutic relationships and ‘unconditional positive regard’ Helps understand what triggers anxiety and stress for the person you support Families/Parents/Carers are important! • Planning should build the person's circle of support and involve all of the people who are important in that person's life. Person centred planning is owned and controlled by the person (and sometimes with their closest family and friends). • These are the individuals the person wants to be part of developing their person centred plan and who can help them make things happen. These are the committed people in the person’s life who know and care about them. • It is a good way to learn how to work collaboratively with families and carers, other professionals and the person themselves Techniques and approaches to support individuals with an autistic spectrum condition to learn and develop new skills The planning process and people with autism • In order to make the person centred planning process meaningful for people with autistic spectrum disorders we have incorporated the SPELL approach by the National Autistic Society. That means the process has: • a clear structure (there are key questions to ask); • it focuses on the person’s positive attributes (their gifts and strengths); • there is an empathetic approach (for example, using the means of communication that the person understands best); • low arousal (i.e. too many people present at a meeting can be stressful for some); • links with the most important people and things in the person’s life. • Understand why it is important to support someone to take risks – risk taking is a part of human development How we reduce sensory overload, or increase sensory stimulation, by making adaptations to the physical and sensory environment Ways to help • Be aware: look at the environment to see if it is creating difficulties for people with an ASD. Can you change anything? • Be creative: think of some positive sensory experiences • Be prepared: tell people with an ASD about possible sensory stimuli they may experience in different environments. • Sight: Hypo (under-sensitive) Increase the use of visual supports. Hyper (over-sensitive) Reduce fluorescent lighting - use deep-coloured light bulbs instead. Wear sunglasses. Create a workstation in the classroom: a space or desk with high walls or divides on both sides to block out visual distractions. Use blackout curtains. • Sound: Hypo Use visual supports to back up verbal information. Hyper Shut doors and windows to reduce external sounds. Prepare a person before going to noisy or crowded places. Wear ear plugs. Listen to music. Create a workstation. • Touch: Hypo Use weighted blankets or sleeping bags. Hyper Warn a person if you are about to touch him or her; always approach him or her from the front. Remember that a hug may be painful rather than comforting. Gradually introduce different textures - have a box of materials available. Allow a person to complete activities themselves (eg, hair brushing and washing) so that they can do what is comfortable for them. How we reduce sensory overload, or increase sensory stimulation, by making adaptations to the physical and sensory environment • Taste: Some people with an ASD are hyper- or hyposensitive to taste, and may limit themselves to bland foods or crave very strong-tasting food. We have not included any ways to help because as long as someone eats a bit of a varied diet, this isn't necessarily a problem. For more information about ASD and restricted diets • Smell: Hypo Use strong-smelling products as rewards and to distract people from inappropriate strong-smelling stimuli (like faeces). Hyper Use unscented detergents or shampoos, avoid wearing perfume, make the environment as fragrance-free as possible. • Balance: Hypo Encourage activities that help to develop the vestibular system. For children this could include using rocking horses, swings, roundabouts and seesaws. For adults, try games like catching a ball or practise walking smoothly up steps or curbs. Hyper Break down activities into small, more easily manageable steps; use visual cues such as a finish line. • Body awareness: Hypo Position furniture around the edge of a room to make navigation easier. Put coloured tape on the floor to indicate boundaries. Use the 'arm's-length rule' to judge personal space. This means standing an arm's length away from other people. Hyper Do 'fine motor' activities like lacing Case Examples And Questions?