Case Study – Returning to Shared Spaces in the Community
C is an 11-year old boy with a diagnosis of autism. He is bright, inquisitive and enjoys verbal engagement. C loves animals of all types and especially his pet dog. He also enjoys playing and talking about computer games. When C was referred to Middletown Centre for Autism (MCA) he was attending his local grammar school with several accommodations to assist C at school, such as a reduced timetable, access to calm areas and permission to wear a modified uniform. However, his anxieties and sensory processing difficulties increased to such a level that he regularly developed symptoms which made him feel too ill to attend school. This continued until it reached a point where it was decided between school and parents he should remain at home until he had recovered and felt well enough to attend. During this difficult time, C’s anxiety increased to such an extent that he was barely able to leave the house for any reason.
On consultation with C’s parents, the following were identified as behaviours used by C to communicate anxiety when leaving his home:
All attempts to get C to leave his home were met with refusal. Even with some preparation and with C agreeing to a trip out, as the time drew near, he would engage in delaying behaviours such as continuing to play his game or watching TV, getting dressed very slowly or finding other types of distraction. When C did leave the family home, the outing would frequently end in C having an emotional outburst that would require the whole family to return home.
C was hypersensitive to certain tactile and auditory inputs. This was especially the case with clothing. He was unable to wear school uniform comfortably and had stopped wearing parts of it. This created disciplinary issues in school from staff who were not aware of his condition. To help C with sensory issues around the uniform, school had permitted accommodations to allow him to wear a school branded Lycra PE uniform. At home he would wear Lycra undershirts and cycle shorts. Once he had stopped attending school and with his anxiety at extreme levels, he began to refuse to wear clothes at all as he found them increasingly restrictive. This also then made it more difficult for him to leave the house. His parents reported that C became increasingly anxious at the thought of being in busy noisy places.
After a period at home, where C’s anxiety lowered to a level where he was able to re-engage, a program was introduced to expose him to the world outside his home.
C identified that he would like to walk his dog to the local dog exercise area and let his dog play off lead with other dogs. All the steps involved were identified and recorded on a Fear Ladder with the initial rung being C walking his dog on the lead to the entrance gate. This was slowly extended to C entering the area, then allowing his dog off the lead in the area. The Fear Ladder helped C prepare for the trips out as he faced his fears. As time passed, other dog owners started to chat with C’s mother and then to C. As the conversation was about dogs, C was comfortable engaging in this interaction. Role play situations were used at home to prepare and help C identify questions he could ask the other dog owners about their dog.
C was very anxious in busy places due to the unpredictability of crowds and unexpected loud noises but did not like wearing ear defenders, so initially further trips from his home were to museums during the week when the environment was quiet and not crowded. Again, the Fear Ladder strategy was used with initial trips to be museum being for very short periods of time, agreed in advance with C. The length of time was increased in advance of each subsequent visit. Upon arrival, using the map of the museum, C planned which exhibits he wanted to see and where they were located. Using the map allowed C identify where the exits were and meaning C could leave at any point should he need to do so. A social narrative was created and used to outline expectation for C’s visit which included strategies he could use if he started to feel uncomfortable or wanted to leave the museum. Portable visuals for relaxation breathing exercises and grounding activities were made for C which he carried on a key ring in his pocket.
Following a number of successful trips to the museum, further outings using the same strategies were organised for places that interested C and that were busier and noisier, such as the zoo, an open farm and the local bowling alley. Prior to each outing, C looked at the setting’s website to familiarise himself with the environment, he also collected a map of the zoo on arrival. C planned what he wanted to do in each of these settings.
Using the above strategies and gradually increasing C’s exposure to situations which made him feel highly anxious, C was able to successfully return to accessing shared spaces in the community for events that were fun to him. Similar strategies of gradual exposure were used to help C visit shops and cafés in his local area, where he progressed from entering the premises to purchasing and interacting with staff. Towards the end of the referral, C was able to begin a gradual transition back to attending school full time.