2011_Layout108/09/201117:40Page supported by supported This guide hasbeen

The : The Autism Act developing specialist skills in autism practice

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 2

ESSENTIAL GUIDE

This guide has been written by Jill Aylott, Centre for Professional and Organisation Development, Faculty of Wellbeing, Sheffield Hallam University

Contents

3 Introduction 5 A note about terminology 5 Defining autism to guide best practice Environments and sensory issues Autism as a sensory perceptual impairment Barriers in the environment Use of reasonable adjustments to enable access to the environment Communication, information and processing Understanding behaviour Use of reasonable adjustments to change personal behaviour Attitudinal barriers 16 Diagnosis and services Transition 18 References 19 Summary

RCN Publishing Company Ltd To subscribe call 0345 772 6100 The Heights, 59-65 Lowlands Road www.learningdisabilitypractice.co.uk Harrow, Middlesex HA1 3AW www.mentalhealthpractice.co.uk For further information contact: ISBN: 1873853858 [email protected] Cover photograph: Science Photo Library © Copyright RCN Publishing Company Ltd 2011. All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission of the publisher.

2 october :: 2011 Autism 2011_Layout108/09/201117:40Page3 specific legislative responsibility to: December 2010 (DH2010c). The Autism Act 2009 seeksto give healthandsocialcare organisations April 2010 (DH2010b) andstatutory guidanceto implement Lives The billwas passedandrequired thepublicationof anautismstrategy paper organisations andhadall-party support. a private member’s billinNovember 2009. The billwas supported by acoalitionof 16autism The NationalAutistic Society drafted theAutism Act, whichwas taken forward by CherylGillanas that peoplewithautismandtheirfamilies face, andto campaignandlobby for legislationchange. was formed in2000 to work withthemainpoliticalpartiesto raise awareness of thedifficulties 2 People withautismare ‘falling through gapsinservices’(Loynes 2001, Departmentof Health(DH) Introduction guide willexplore how servicesmightanticipate theneedsof peoplewithautism.Itsaimsare to: requires publicsector organisations beproactive inidentifyingtheneedsof disabledpeople.This format. Itisnot appropriate to wait untilapersonwithdisability seeksto useaservice– theact changing apolicy, changingthestructure of thebuildingorproviding information inanaccessible requires ‘reasonable adjustments’to theway thingsare doneinpublicservices–for example, The Equality Act 2010 replaced mostof theDisability DiscriminationAct 1995. The Equality Act 006, NationalAutistic Society 2010). The AllParty Parliamentary Group for Autism (APPGA) 4 4 4 4 4 4 plan' f f autism, whilemaking‘r a specialist tr pr they needto beto identifyandadequately planways to work withpeople withautism. who didonly45percentwere receiving servicesspecifiedintheassessment(Loynes 2001). health andsocialcare. may beirredeemable becauseof theirinherent difficulty withnew situations’(Allard 2009). it wrong for ayoung personontheautismspectrumcanhave catastrophic consequencesthat ‘Transition servicesare stillfailing mostyoung peopleontheautismspectrum’,andthat:‘Getting Provide allchildren withastatement of anautismspectrumdisorder withadrawn-up 'transition Ensure thatthediagnosisof autismisaccompaniedby anassessment of need.Before theact, Review how thisknowledge mighthelpto identifyandplanto meettheneedsof adultswith Ensure thatadultswithautismare involved inlocalserviceplanning.Local authoritiesare not Provide allstaff withstatutory training inautism,withfront linestaffrequired to have more Explore anunderstandingof autisminadulthood(ortransition to adulthood)thathelps ew more ablepeoplewithautismwere accessingcommunity care assessments,and of those ware of thenumber of peoplewithanautismspectrumdisorder livingintheirlocality, which in March 2010 (DH2010a); thiswas followed by thepublication of athree-year delivery planin actitioners to provide apositive experience for peoplewithautism seekingto accessservicesin or progression into adultservices.Before theact,aninquiryinto ‘transition’ found that: aining inmeetingthespecificneedsof adultswithanautismspectrumdisorder. easonable adjustments’to theservicesto enablethisto occur. Fulfilling andRewarding Lives Fulfilling andRewarding october ::2011 3 in

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 4

4Provide a clear pathway for the can be enabling, while others can be disabling development of leaders in the field of (Swain et al 1993). A social model of autism in health and social care who will understanding autism is needed to understand ‘champion’ the implementation of the how barriers in health and social care can have Autism Act 2009. a disabling and distressing effect on the person This guide is aimed at people in a specialist role with autism if service providers lack knowledge who will lead the planning, development and of autism and fail to make some level of commissioning of services with local authorities reasonable adjustment. and GP consortia. A report from the National People with autism are sometimes referred to Audit Office (2009) stated that ‘80 per cent of as having an ‘invisible’ impairment, and GPs feel they need additional guidance and identifying how reasonable adjustments can be training to manage patients with autism more made to make services more accessible may not effectively’. Although the employment, police be easy. But, reasonable adjustments need to be and probation services are not legally required made to: to respond to the Autism Act 2009, the Autism 4Premises – by exploring how the Strategy (DH 2010a) and Statutory Guidance environment can be better accessed by (DH 2010c) could help improve the services in people with autism. these areas. The vision of the act is that: 4Processes – by exploring how appointments ‘All adults with autism are able to live fulfilling can be scheduled better. and rewarding lives within a society that accepts 4Communication – by exploring how and understands them. They can get a diagnosis documents can be presented in a way that and access support if they need it and they can can be better processed by people with depend on mainstream public services to treat autism. them fairly as individuals, helping them make the This guide also discusses the development of skills most of their talents.’ and knowledge in autism practice to explore: The Autism Strategy (DH 2010a) outlines the 4Autism as an impairment of sensory need for staff to have training in autism. But, perception. unless training helps staff to develop their skills 4The use of an environmental audit to ensure in making reasonable adjustments under the organisation-friendly access for people Equality Act 2010, little will change in the lives with autism. of people with autism and their families. Simply 4The use of a communication profile to providing training using a medical model is develop a personalised pathway through insufficient, because this will only provide health and social care and to make information about the condition of autism in reasonable adjustments as part of the isolation from the environment that defines the person’s care plan. characteristic behaviours that are part of the 4A systematic approach to understanding condition. Some environments the meaning of behaviour.

4 october :: 2011 Autism 2011_Layout108/09/201117:40Page5 barriers thatprevent accessto servicesby the experience for serviceusersandto challenge and for thisknowledge to beusedto improve problems faced by peoplewiththecondition, definition of autismto helpthemto identifythe Association 1994). Practitioners needa definition usedinDSM-IV(AmericanPsychiatric autism differently from themore clinical thr To understandautismspectrumconditions Defining autismtoguidebestpractice and autismspectrumconditionthroughout. condition. This guidewillusetheterm autism families may prefer theterm autismspectrum disorders, whereas peoplewithautismandtheir Diseases [ICD-10]) refer to autisticspectrum Manual [DSM-IV],International Classificationof official diagnosticcriteria (Diagnostic Statistical stimuli present inparticularenvironments. The positive andnegative aspectsdepending onthe autism asanimpairment,whichwillhave factors external to themselves, recognising autism spectrumconditionare disabledby emerged. This suggeststhatpeoplewithan some environments butnot inothers has idiosyncratic) thatmay beseenandevidenced in characterised by certainbehaviours (some an understandingthatitisacondition model of definingautismasadisorder towards 2000). Amovement away from themedical disorder’ (Gerland2000, Jackson2002, Lawson are dissatisfied withtheterm ‘autisticspectrum Some of thesesuggestthatpeoplewithautism writt Many websites andautobiographical accounts A noteaboutterminology ough thesocialmodel,we needto understand en by peoplewithautismare available. barriers raised by: section of theguidewillexplain thelikely people withautismandtheirfamilies. This the autismspectrum.Fear of changewas the mainprecipitators of stress for peopleon anticipation andcertainsensorystimuli were Survey Scheduleandfound thatfear of change, stress ineightspecificareas, asshown inTable 1. people ontheautismspectrum.They identified instrument’s validity withasampleof 180 al instrument. Goodwinet al autism istheStress Survey Schedule(Groden instrument to assessstress inpeoplewith in thispopulation(Goodwin develop tools thatassessreactions to stressors stress inautism,littlework hasbeendoneto non-autistic peers.Despite growing awareness of environmental stressors compared withtheir excessive physiological reactivity to autism spectrum.People withautismshow improve accessto servicesfor peopleonthe in which'reasonable adjustments' mightmost (Williams 1998a, 1998b, 1998c). This isthearea stimulating anddemandingenvironments and distress, particularlywhen they are inhighly cause peopleto experience highlevels of stress Environments andsensoryissuesAutism can greater accessto healthandsocialcare services. that couldgive peopleontheautismspectrum It willidentifypossible'reasonable adjustments' 4 4 4 Gillott andStanden(2007) usedtheStress 2001), aninformant-rated, 49-question cognitiv w Communication andinformation, and Attitudes from healthandsocialcare Environments andsensoryissues. orkers. e processing issues. (2007) tested the et al 2007). al et The only october ::2011 5 et

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 6

TABLE 1 Eight areas of stress identified by the Stress Survey Schedule

Area of stress Example situations

1. Changes and threats Having a cold; change in task and new directions; going shopping; change in environment; transition in locations; transition from preferred to not preferred activity; engaging in an activity not liked; being unable to communicate; needing to ask for help; participation in group activity. 2. Anticipation and uncertainty Having a change in plans; waiting for an activity; having unstructured time; waiting generally. 3. Unpleasant events Waiting to talk about a desired topic; having personal objects missing; following a diet; receiving criticism and being told 'no'; having something marked as incorrect; a change in teacher; losing at a game. 4. Pleasant events Receiving a present; playing with others; receiving reinforcement; having something marked correct; receiving tangible reinforcement; having a conversation; receiving verbal reinforcement. 5. Sensory/personal contact Being in the vicinity of noise or disruption by others; being touched; receiving hugs and affection; feeling crowded. 6. Food-related activity Waiting at a restaurant; waiting for food. 7. Social/environmental interactions Being in the vicinity of bright lights; being unable to assert oneself with others; someone else making a mistake. 8. Ritual-related stress Having personal objects or materials out of order; being prevented from completing or carrying out a ritual; being interrupted while engaging in a ritual.

(Groden et al 2001, Goodwin et al 2007)

prominent and could apply to people or The study by Gillott and Standen (2007) also locations. Williams (1998a), in identified elevated levels of anxiety in adults with writes: ‘The constant change of most things autism compared with adults with intellectual never seemed to give me a chance to prepare impairments. The types of anxiety with high myself for them. Because of this I found scores were panic/agoraphobia, separation pleasure and comfort in doing the same things anxiety, obsessive-compulsive disorder and over and over again.’ generalised anxiety disorder.

6 october :: 2011 Autism 2011_Layout 1 08/09/2011 17:40 Page 7

This stress experienced by people with autism particular sensory difficulties. A sensory has been referred to as 'exposure anxiety', which perceptual impairment is different from a describes the way people with autism protect sensory impairment, which suggests a loss of themselves from stimuli in the environment sight or hearing, and has been defined as being (Williams 2002). Exposure anxiety explains why more complex as it encompasses all the senses a person with autism may be able to (Shabha 2006). A sensory perceptual communicate verbally and through other impairment is characterised by ‘turbulent, effective means in an environment that is quiet fluctuating, inconsistent and unreliable and without high levels of distracting stimuli. perception where individuals cannot make However, in a busy environment with high noise connections with their own environment’ levels and bright lights the person may ‘shut (Shabha 2006). down’ and be unable to speak, sitting in a corner A sensory perceptual impairment can affect and rocking. Others might simply seek to run the person in different ways: away. Many of the services provided to people 4The person may struggle to remember across health and social care are in environments information in a different environment. that are often busy, noisy, stimulating and Grandin (1984) explains how she processes demanding. information visually and how this affects her Autism as a sensory perceptual impairment remembering certain basic information: Approximately 70 per cent of people with autism ‘Learning sequential things such as maths will have a ‘sensory perceptual impairment’ was very hard. My mind is completely visual (Cascio et al 2008). Leekam et al (2007) found and spatial work such as drawing is easy. that 90 per cent of children with autism had I taught myself drafting in six months. I sensory abnormalities, while 94.4 per cent of have designed big steel and concrete cattle Crane et al’s (2009) sample reported extreme facilities but remembering a phone number

levels of sensory processing on at least one part or adding up numbers in my head is still ESSENTIAL GUIDE RCN PUBLISHING of the sensory assessment. Bemporad (1979), difficult.’ writing of Jerry, a young man with autism, states 4Perception may be delayed in a new and that: ‘The recurrent theme that ran through all different environment, which means that Jerry's recollections was that of living in a people may need to pause outside or inside frightening world presenting stimuli that could a door for a few seconds while they adjust not be mastered. Noises were unbearably loud, their perception. smells overpowering, nothing seemed constant, 4For some people, the sensory inputs get everything was unpredictable and strange.’ mixed up and the person goes into ‘sensory Sensory abnormalities will exist across all five overload’. At this point they will not be sensory modalities, as well as kinaesthetic and able to process verbal instruction and will proprioceptive sensation (Harrison and Hare need support to come out of this state 2004). Table 2 (page 8) summarises the of sensory overload.

october :: 2011 7 Autism 2011_Layout 1 08/09/2011 17:40 Page 8

TABLE 2 Sensory difficulties in people with autism

Sensory abnormality Examples

1. Hyper- and hyposensitivity to stimulation ‘Noises that would make me cover my ears or avoid them and fluctuation between the two were: shouting, noisy crowded places, polystyrene being touched, balloons being touched, noisy cars, trains, motorbikes, the sound of felt tip or marker pens when colouring in’ (Joliffe et al 1992). 2. Distortion – for example, depth may be ‘At home I would spend hours in front of the mirror, wrongly perceived or still objects may be staring into my own eyes and whispering my name over seen as moving and over, sometimes trying to call myself back, at other times becoming frightened at losing my ability to feel myself’ (Williams 1998a). 3. Sensory tune-outs – for example, sound or ‘Usually I claw large chunks of skin and flesh from my vision may suddenly black out and return upper arms or sometimes my thighs and shins. The pain is so intense that I am totally incapable of focusing on anything else around me... It puts me in total control. Rather than “out there” penetrating and “hurting me” it is now me hurting me’ (Blackburn 2000). 4. Sensory overload ‘Many conversations going on at once will become a confusing blur. As the person with autism can’t process them to decipher their meaning’ (O'Neill 1998). 5. Difficulties in processing from more than ‘These people had, uninvited, tried to take away my choice one channel at a time at being touched, though to them it was more a tap on the shoulder. These were the people who out of their own selfishness, would rob me of my sense of peace and security’ (Williams 1998a). 6. Multi- and cross-channel perception. For example, ‘Sometimes there are also perception difficulties because the perception of sound may be accompanied by autistic people are concerned with the space immediately perception of colour or taste surrounding their bodies, they tend to prefer proximal senses: touch, taste, smell to their distal senses sight and hearing’ (O'Neill 1998).

7. Difficulties in identifying the source channel Williams (1998a) describes herself as having a ‘mono- of the sensory stimulation channel’, not being able to see and hear at the same time, while Blackburn (2000) talks about how touch (used as a prompt) can severely distract from the verbal request, as the energy required to process touch is more overwhelming than that to process auditory instruction. (Adapted from Harrison and Hare 2004)

8 october :: 2011 Autism 2011_Layout108/09/201117:40Page9 Disorders (DISCO)(Leekam Interview for SocialandCommunication al et dysfunction, includingtheSensoryProfile (Kern Various tools are available to assesssensory suggest thatthepersonisbeingoverwhelmed stimulatory behaviours. Suchbehaviours may instead may display stereotypical andself- the effect theenvironment hasonthemand People are unlikely to beableto communicate some peoplewithautismindifferent ways. and walls orstripesontheradiators – willaffect lighting, sound(acoustics)andpatterned flooring Barriers intheenvironment For example, individual issuitableandappropriate. that theservicecommissionedonbehalfof the 'sensory curriculum'couldbecreated to ensure spectrum condition.Itwould beexpected thata environments for peoplewithanautism instrument beusedto create more appropriate room. HarrisonandHare (2004) argue thatthe may enjoy trampolining orvisitinga example. Somepeoplewithkinaestheticneeds gives an enjoyable leisure activities.Box 1 or for support,aswell asto explore relevant and requirements for adaptation intheenvironment teams andwithcarers canhelpto identify for peoplewithautism’. development of more appropriate environments argue thatitsuseshould‘facilitate the screening andindividualassessment. The authors (Harrison andHare 2004), whichcanhelpwith Sensory Behaviour Scale(Table 3, page10) accessible instrumentfor practitioners isthe by atrained psychologist orpsychiatrist. Amore instruments are complex andwillusuallybeused Using theSensoryBehaviour Scaleacross 2007, Dunn1999) andtheDiagnostic et al et 2007). Both Behaviour Scale Example ofusetheSensory the following: Sensory Behaviour Scale,Rory scored highon values of thelearningdisability service.Onthe tensions exist between Rory’s needsandthe adult learningdisability service,butoften The family usesrespite care servicesfrom the carer. services for Rory ashismumisfull-time and sister. Hisfamily dependsonrespite care condition andlives athomewithhisparents Rory is29years old.Hehasanautismspectrum 4 4 4 4 4 crowded areas. Appropriate planningisneeded for himto avoid and hisunsteadiness of gait. consideration of thevestibular needsof Rory ‘Reasonable adjustments’intheservicerequire need to relate to theSensoryBehaviour Scale. All activitiesfor Rory attherespite care service Behaviour Scale. understand thecore elementsof theSensory more work isneededto helpthestaffteam to if thevideosare ‘ageappropriate for Rory’, and repetitive routines. Somestaffhave questioned Some of theDVDs have music andare based on remote control. bedroom; hewillneedto learnto usethe agrees for Rory to have accessto aTV inhis service hasonlyonetelevision, sotheservice watching hisfavourite DVDs. The respite care (kinaesthetic) andthathedoesthiswhile flaps hiswristsandjumpsupdown A planningmeetingfor Rory identifiedthathe BOX 1 Vestibular –ongoing. Proprioception –ongoing. Kinaesthetic –ongoing. Olfactory –ongoing. Auditory –ongoing. october ::2011 9

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 10

TABLE 3 Outline of the Sensory Behaviour Scale

Does the person: Ongoing In past No or N/A Don’t know 1. Visual a. Watch bright lights? b. Twirl his or her fingers in front of his or her eyes? 2. Auditory a. Make unusual vocalisations? 3. Olfactory a. Smell other people? b. Smell parts of his or her own body? 4. Taste a. Put objects in his or her mouth? b. Engage in play with saliva or other bodily substances? c. Like any unusual foods/tastes (please give details)? 5. Tactile a. Hold and manipulate small objects? b. Like to be tightly wrapped up in clothes and/or bedding? 6. Kinaesthetic a. Flap his or her wrists? b. Jump up and down on the spot? c. Twirl round and round? 7. Proprioception a. Have difficulty in dressing and feeding him/herself? 8. Vestibular a. Walk with a noticeable gait? 9. Temperature a. Seem to be unaware/tolerant of temperature extremes 10. Sensory preferences a. Tend to use touch/taste/smell to examine objects and situations more than using vision and hearing?

(Adapted from Harrison and Hare 2004)

10 october :: 2011 Autism 2011_Layout108/09/201117:40Page11 to staff.Staffmembersneedto beproactive to environments andthenexplain thesedifficulties recognise thedifficultiesthey encounter in class oruniversity course. who isusingaday serviceorattending acollege purchase appropriate lightbulbsfor aperson 2010, a‘reasonable adjustment’would beto bounce off everything. UndertheEquality Act as they seea‘60-cycle flicker’ andreflections causes severe problems for peoplewithautism, behaviours (Shabha2006). Fluorescent lighting flickering lightsare triggersfor self-stimulating examined. Highlevels of lightintensity and classes) andtheintensity of lightshouldbe appointment rooms orcollegeuniversity which comesthrough anorthfacing window.’ during thedaylight hoursIlike natural light photography orneedlework after dark) and (these are lightbulbsoften usedfor interior ideal after darklightingisfrom “daylight” bulbs lighting gives meaheadacheandeye ache.My more thanabouthalfanhourunder fluorescent more littlewhite bitsflyingaround). Spending visual distortions (for example, there are many which my eyes becometired andaugmentallmy and fluorescent tubelightingincrease therate at dreaded fluorescent tubelighting.Both sunlight shiny surfaces. Everywhere Igothere isthe out towards mefrom placeswhere thesunhits blinding andvery longspikes of sunlightcome streaming through thewindow, thebrightnessis lighting: ‘To addto my problems, thesuncomes information. ConsiderHale's(1998) thoughtson person to process andretain instructionsor sensorially, andthiswillmake itdifficultfor the It isnot always easy for adultswithautismto The source of light(natural daylight isbetter in (2010) (Box 2). Second,peoplewithautismcan impact assessmentinrelation to theEquality Act environment shouldbereviewed as partof the access to theenvironment Use of reasonable adjustmentsto enable while supportingAlisonatuniversity. request thatstaffwear clothing withoutpatterns the pattern isout of sight.’ my visionto gofuzzyandremain fuzzylongafter around inamesmerisingfashion andcancause impossible. The pattern appearsto bejumping black andwhite stripedshirtisalmost conversation withsomeonewhoiswearing a problem. For instancetryingto have a room. Any highlycontrasting pattern isa The patterns are hard to escapeinthissmall whirling mesmerizingmesswhichhurtsmy eyes. highly patterned. This causesmeto seea carpet andduvet cover inmy studyroom are on livinginauniversity hallsof residence: ‘The environments. For example, Hale(1998) reflects additional stimuliinthesealready difficult moderate environment. person to withdraw andadjustto amore ‘saturated by stimuli’sothatthey canenable the need to recognise whenthepersonisbeing help to managethese situations,andstaffwill members andsupportstaff.Othersmay need ways to dealwithsuchsituationsfamily have beensupported inthepastto reflect on when intheseenvironments becausethey may condition mightdevelop management strategies 2010. Someadultswithanautismspectrum suggest acourseof actionundertheEquality Act identify factors thatcausepeopledistress andto It would bea‘reasonable adjustment’to Some peoplemay not beableto copewith First, thephysical october ::2011 11

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 12

be desensitised to the environment (and gradual staff and see the environment (without any exposure to new people) before the day they intervention occurring). attend the hospital appointment, the new college 4On the day of the planned intervention, class or the induction day at the university. The introducing the person to photographs of process of desensitisation will vary from person the people who will be carrying out the to person, but ideas for doing this include: procedure. 4Introducing photographs in a schedule to 4Using a virtual visit to the hospital with prepare the person for what is going to software that orientates the person to the happen at the hospital or social services environment (and replicates acoustics). appointment. Communication, information and processing 4Taking the person on a trial visit to meet the Some ‘reasonable adjustments’ can be made to the communication methods used by staff. In BOX 2 unfamiliar environments, a lot of verbal Environmental audit for access information will not be processed by the person and will sound like ‘blah blah blah’. Visual 1. Lighting information is a good way to enable easier 4 Some flickering lights can cause difficulties if access to people with autism. present in a consulting room. Visual information, including photographs, 4Is there natural night in the consulting room? Natural light may have a more relaxing effect. videos and diagrams, is easier than written or 4Is there fluorescent tube lighting? verbal information for people with autism to 2. Flooring process. Visual input is the primary source of For example, large black and white floor tiles may information for people with autism (Quill 1995). cause difficulties with orientation and movement for Cihak (2011) found no single preferred means of some people. visual communication that was more effective 3. Acoustics (between static picture scales and video-based This can cause the person to have sensory overload schedules). This suggests that and be unable to process standard information. need to be tailored to individuals, or generalised 4. Spatial to enable better access rather than relying on The room needs to be large enough for people to verbal or written instruction. This is important define the spatial distance between themselves and the hospital staff member. A small confined space for people with autism attending appointments, can cause excessive stress. People need to have where they will need some sort of visual some control over their environment. scheduling of the stages in the process. How 5. Transition many stages to make available to the person at The person should be supported to take an item of once will depend on the person’s cognitive ability. interest that will help to calm him or her when in a Letters might be better set out in a landscape strange environment. format, so that the events of an appointment can be scheduled from left to right. Department

12 october :: 2011 Autism 2011_Layout108/09/201117:40Page13 fcommunicatingwhenapersonmay not have of sensoryorigin.Behaviour often serves asaway a presented by apersonwith autism willhave Understanding behaviour used intheinstructionbeingchanged. immediately being repeated orthelanguagethatis orientate him/herself withouttheinstruction person shouldbeallowed afew secondsto they recognise. Whenarequest ismade,the People shouldalways bereferred to by thename et al when theirnameiscalled(Cascioet people withautismwillfail to orientate themselves Sensory perceptual difficultiesmeanthatsome It isimportantto: provided inthecommunicationprofile (Table 4). environments. This information mightbe ‘de-stressor’ for somepeoplein the person’s area of specialinterest canactasa 1996). Encouraging arapport by talkingabout have timeto process thesensation’ (Grandin withdraw, becauseournervous system doesnot as: ‘Whentouched unexpectedly, we usually person unlesstheisasked isimportant, communicate withtheperson.Not touching the profile isinplacethatrecommends how bestto person’s behaviour, exploring ifacommunication dh.gov.uk/webfm_send/377. accessed atwww.valuingpeoplenow. practice inproducing 'easy read', thiscanbe of Healthguidancehasbeenissuedonbest 4 4 4 More effort shouldbemadeto listen to the communication o body language. ( Focus onlistening to thenon-verbal Avoid theuseof sarcasm andunnecessary Avoid excessive verbal communication which iswithoutinstruction). f theperson. Not allbehaviour 2008). T because assoonshespitsthestaff retreat and two weeks, Mary's behaviour hasworsened with herwhensheisnot spitting.Over thepast and to praise thepositive timesthatthey engage decided to ignore Marywhenshespitsatthem reason Maryspitsisto gainattention andhave leave heralone.Staffmembersbelieve thatthe Mary haslearntthatwhenshespitsatstaffthey staff approaches Mary, shestartsto spitatthem. worse. They explain thatevery timeamemberof and thatherbehaviour seemsto begetting members are worried aboutMary'sbehaviour with two other peoplewithautism.Staff following situationwithMary: behaviour isto avoid contact.Considerthe attention-seeking whenthefunctionof the in theteam. For example, believing apersonis the functionof abehaviour may leadto dissent have for theperson.Alackof understandingof the functionthataparticularbehaviour may staff to obtain somesortof consensusabout instrument canbecompleted withteams of the person’s behaviour. Sometimesthis excellent placeto startafunctionalanalysis of (Durand 1990) (Table 5,page20) isan important. These are: possible functionsfor behaviour willbe difficulty inautism,differentiating between four awareness of therole of sensoryperceptual necessarylanguage.Withagrowing the he 16-questionMotivation Assessment Scale 4 Mary lives inasupported livingenvironment 4 4 4 (tangible). Sensory. Serving thepurposeof communication Seeking contact(attention). Avoiding contact(escape). october ::2011 13

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 14

TABLE 4 An example of a communication profile

(This is based on a real person who had a minimum of two male staff members on each shift to work with him in his flat. Staff often expressed difficulties they experienced in understanding his communication.)

Question Example 1. Does the person use verbal John Brown makes his needs known by vocalising various sounds. The communication? If so, how is this sounds used vary in loudness and pitch depending on his mood. John uses used in communication with others sounds that can communicate happiness and sadness. If staff do not and how effective is it as a means attend to the noises, the sad ones will escalate and result in some form of of communication? negative behaviour. His most commonly used sad sound is ‘na-na, na-na’. If the na-na sound continues and he starts to grind his teeth and to rock back and forth, he is becoming even more unhappy about something. 2. What non-verbal methods of John claps his hands to let staff know that he wants something. If staff do communication are used? not understand, he may take them by the hand to show them what he is trying to communicate. If staff have still not listened, he will become agitated and start to sit on his hands and rock backwards and forwards. He may then start to make a na-na sound if he continues to be unhappy. After grinding his teeth, he may become frustrated and try to attack a member of staff. 3. Does communication change when As John becomes more anxious, his Makaton signing becomes more anxiety levels increase? If yes, how vague and difficult to interpret and understand. The sounds he makes does this change? become louder and higher pitched. 4. What is the person’s special John loves garden tools; he likes the variation in form rather than using interest? them. He likes to visit garden centres and look through catalogues. 5. What is the meaning of the person’s John will point to the vehicle’s keys and sign for you to give him some non-verbal communication? (When money; he will stand by the window and sign for driving a car. He will also they do X, they mean Y) do drawings of past trips to garden centres. All the above suggests that he would like you to drive to the garden centre to buy new tools. 6. Does the person have his or her No. own words for things? 7. How does the person express Grinding teeth; grunting sounds becoming louder and louder; repetitive anxiety? Makaton signing for garden tools; rolling eyes; sucking in cheeks and biting the side of his mouth; pulling at his ears and teeth; flapping his hands in the staff’s faces; swinging his arms and body from side to side; shallow breathing; pallor and clammy skin. 8. What needs to be in place in the John’s day needs to be structured. If the planned activity does not occur, environment to help the person not to an alternative needs to be done instead because he does not understand feel anxious? cancellation. Staff working with John need to support him in a confident manner and include him in all aspects of the daily routine.

14 october :: 2011 Autism 2011_Layout108/09/201117:40Page15 communicating to other professionals viathe reading thecommunicationprofile and the personwithautism.This can bedoneby adapt theirbehaviour, whencommunicatingwith willsometimesneedto personal behaviour Staff Use of reasonable adjustmentsto change discernable through presenting behaviour. any underlyingillhealthifnopattern is assessment tools thatcanbeusedto identify Carr andOwen-DeSchryver (2007) developed the injurycausedby hisself-injuriousbehaviour. discovered whenhewas X-rayed asaresult of was only undetected for sometime.It serious abscessonhistooth, whichhadbeen fractured his jaw. X-rays showed thathehada David, banged hisheadsomuchthathe injurious behaviour. For example, ayoung man, communication whopresents withsevere self- right questionsof apersonwithoutverbal sick. Itisnot easy to know how to askthe behaviour were higherwhenthepersonwas frequency andintensity of problematic Owen-DeSchryver (2007) found thatthe behaviour iscausedby pain.Carrand the shouldalertstaffto thepossibility that This have nopattern andnosinglereason for it. Sometimes thepresentation of behaviour will behavioural managementstrategy bedevised. the possiblefunctioncananappropriate Scale to findout thefunctionof Mary'sbehaviour. all shouldcomplete aMotivational Assessment management strategy mightbewrong andthat specialist explains to theteam thattheir Mary hashadnopositive feedback. The autism engage withMarywhensheisnot spitting,so ignore her. Staffhave hadnoopportunitiesto Only after theteam members have agreed on disturbed andjustplainweird.’ Reading the ‘I told himhow I’d beencalledcrazy, stupid, towards them.Williams(1998a) writes: negative experiences of other people'sattitudes Attitudinal barriers People withautismreport ineffective socialrelating. otherwise, thismay leadto overload and member of staffbefore heorshespeaks; take time.The personmay needto process the with autismto thememberof staff.This may and challengingbehaviour isneeded. questions whenanunderstandingaboutcomplex to theirbody. Itwould alsohelpto asktheright in caringfor peoplewhorelate to thesensesclose would helpcaregivers to overcome theirprejudices However, understandingthesensoryimpairment autism asakey definingarea of thecondition. in autismwillfocus onthesensorydomainof profile. This isproblematic becausenot alltraining autism, itremains excluded from theindicative which isthediagnosticmanualfor diagnosing DSM-IV (AmericanPsychiatric Association 1994), even thoughsensorydysfunction ismentionedin confusing world. Kern al et distal sensesbecausethisisaway to copewitha relate to theirproximal sensesmore thantheir vital to helpstaff understand thatsomepeople were not motivated to provide supportto him. play withhisspit,andasaresult staffmembers difficult andvery challenging’, becausehewould with thebroken jaw was describedas‘revolting, even ifthey have spoken language.The young man autism may not have thewords to explain pain, explore thefunctionof behaviour. People with patient’s notes. Every effort shouldbemadeto Guidance isneededondesensitisingtheperson Training onautismfrom asensoryperspective is (2007) explain that october ::2011 15

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 16

autobiographical accounts gives a sense that the Under the NHS Community Care Act 1990, all pressure is on people with autism to become people with a learning disability are entitled to a ‘normal’. Williams (1998a) writes: ‘These “helpful” community care assessment, although this does people were trying to help me to “overcome my not guarantee that a service will be provided. ignorance” yet they never tried to understand the However, once a diagnosis has been made way I saw the world.’ people with autism have not previously been While many people with autism have automatically entitled to this assessment, as exceptional talents, a general societal prejudice local authorities argued that some people with about autism spectrum conditions suggests that autism did not have a learning disability. In a people ascribe a negative social role to autism as National Autistic Society (2010) survey of 1,400 ‘difference’ rather than a positive one. The adults with autism and carers, 63 per cent positive aspects of autism should be explored stated that they did not receive support to meet and the abilities promoted rather than the their needs. The Autism Act 2009 now makes it disabilities. Encouragingly, the first-year delivery clear that this assessment cannot be denied on plan Towards Fulfilling and Rewarding Lives (DH the basis of IQ. People who have a social 2010b) outlines a long-term vision for adults impairment clearly need support, and this will be with autism to develop an increasing awareness the responsibility of the lead professional for and understanding of autism in the wider autism in local areas. community. This document contains plans to A diagnosis of autism will give people who go ‘develop a nationwide campaign to tackle stigma to university the right to learning support. The so often attached to autism’ (DH 2010b). number of university students with autism increased more than fourfold between 2003 and Diagnosis and services 2008 (National Audit Office 2009), and The Autism Strategy (2010a) recognises the appropriate support will need to be developed. stigma present in the wider society for people A diagnosis of autism is a catalyst for a with autism and their families, and the Autism carers’ assessment under the Carers Act seeks to remove that. How the diagnosis is Recognition and Services Act 1995. Carers and given to people with autism and their families families live in an environment with high levels can be unsatisfactory. Beresford et al (2007), in of stress, and they should be made aware of their study of 25 families (with a total of 28 their right to request an assessment. Social children with an autism spectrum condition aged services should draw up a plan for the carer between three and 19 years), found that parents and communicate it to their GP. had experienced negative communication about Transition Children with autism need a their child’s diagnosis of autism. National transition plan between the ages of 13 and 19 Institute for Health and Clinical Excellence years. A health action plan can also aim to (NICE) guidance on the diagnosis of autism will develop social skills and strategies to enable be published in 2012. self-care and independent living. Multi-agency

16 october :: 2011 Autism 2011_Layout108/09/201117:40Page17 with autismbegantransition between activities on. Astudyby Cihak(2011) found thatchildren helping thepersonto understandwhatisgoing cues inscheduling,isanimportantcomponentof communicate with children, andtheuseof visual could getonwithhiswork. assistant was ableto reassure Jamessothathe acknowledged by theteacher. The classroom ‘change’ inenvironment, andthiswas not ‘anticipation’ andfrom theprospect of a James’s stress was generated from process any other information. Inthisexample, distracting mechanism,andhewas not ableto required of him. Hisstress acted asasufficient was not goingto concentrate onother tasks James’s stress andanxiety were dealtwith,he assistant butnot theteacher. communication was picked upby theteaching school. The observation shows how his interest inthetransition from hometo asummer express hisneedto have anitem of hisown complex communicationdifficultiestriesto Box 3illustrates how a14 year oldwith observation withJames(nameschanged)in be complex andrequire key observations. The planning. Transitions for peoplewithautismcan micro-scale (everyday perspective) to larger-scale transition planning(DH2010d). engagement of allchildren intheprocess of without me’,whichemphasisesthe Excellence advocates ‘no decisionaboutme adult services.The white paperEquity and children goingthrough thetransition to planning isrequired to meettheneedsof Effective means needto beinplace to illustrates how until Box 3 The example in Transitions mustbeconsidered from a person to person, buteven peoplewithsevere planned process of change.This varies from a way thathelpsthemto understandthe should beengagingpeopleinthetransition in anxious isnot goodpractice. Bestpractice opportunity to avoid thepersonbecoming different services. larger scaleevents suchasatransition to respite care; itshouldalsobeusedto explain day service,anemployment placementor a enabling communicationfor micro activitiesin scheduling shouldbeastandard process of exposed to visualschedules.The useof in theclassroom more independentlyafter being

Example of transition

9.30am: teacher says: ‘No, I have said no videos to be taken to Bewley Camp.’ James says: ‘Just one video, please, just one video, okay Mr Adams?’ Mr Adams gets on with taking the class: ‘Yes, now Jack, you will be a prison officer, Simon a pig farmer, and Sam Clarke is going to be a photographer’. James says: ‘Mr Adams is being silly’. James is still unconvinced that the teacher will let him take a video with him to Bewley Camp. Almost ten minutes later James initiates communication with Mr Adams. 9.39am: over to James, and James lifts his shirt showing his abdomen. The teacher says ‘Put it away’, and James says: ‘Just one video for Bewley Camp, just one more, just one more, just one video, just one video.’ 9.43am: hears James. She says: ‘Yes you can keep it in your bag,’ and she prompts him to get on with his work. BOX 3 Leaving communicationto thelastpossible

Lesley, the support assistant, comes in and

James calls ‘Mr Adams’, the teacher looks

James says: ‘I will take four videos.’ The october ::2011 17

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 18

learning difficulties and autism should be ability to understand), which could be in the engaged in the transition process through the form of photographs. People could be helped use of ideas such as: to understand what they will be doing that 4A visual long, thin map, such as a wallpaper day. The photographs could be removed at border, with events that the person the end of the day and new photographs put recognises, such as birthdays and Christmas, in the next morning. which is used to count down to an event 4Others may be at the point of understanding such as changing services or respite care ‘now’ and ‘later’. The use of Makaton signs of locations. now and the picture of an activity can be 4A large wall calendar with marked monthly presented, then a Makaton sign of later with or weekly events (depending on the person’s an alternative picture presented.

References with autism: a multidimensional Implementation of the Autism Allard A (2009) Transition to psychophysical study. Journal of Strategy. The Stationery Office, Adulthood: Inquiry into Transition Autism and Developmental London. to Adulthood for Young people Disorders. 38, 1, 127-137. Department of Health (2010d) Equity with Autism. National Autistic Cihak DF (2011) Comparing pictorial and Excellence: Liberating the Society. www.appga.org.uk/ and activity schedules NHS. The Stationery Office, London. Resources/Past-Reports.aspx (Last during transitions for students with Dunn W (1999) Sensory Profile. accessed: August 1 2011.) autism spectrum disorders. The Psychological Corporation American Psychiatric Association Research in Autism Spectrum USA, San Antonio TX. (1994) Diagnostic and Statistical Disorders. 5, 1, 433-441. Durand MV (1990) Severe Behaviour Manual of Mental Disorders. Fourth Crane L, Goddard L, Pring L (2009) Problems: A Functional edition. American Psychiatric Sensory processing in adults with Communication Training Publishing, Arlington VA. autism spectrum disorders. Approach. The Guilford Press, Bemporad JB (1979) Adult recollections Autism. 13, 3, 215-228. New York NY. of a formerly autistic child. Journal of Department of Health (2006) Better Gerland G (2000) Finding out About Autism and Developmental Services for People with an Autistic , High Disorders. 9, 2, 179-197. Spectrum Disorder. The Stationery Functioning Autism and PDD. Beresford B, Tozer R, Rabiee P, Sloper P Office, London. Jessica Kingsley Publishers, (2007) Desired outcomes for children Department of Health (2010a) London. and adolescents with an autism Fulfilling and Rewarding Lives: Gillott A, Standen PJ (2007) Levels of spectrum disorder. Children and The Strategy for Adults with Autism anxiety and sources of stress in adults Society. 21, 1, 4-16. in England. The Stationery Office, with autism. Journal of Intellectual Blackburn R (2000) Within and London. Disabilities. 11, 4, 359-370. without autism. Good Autism Department of Health (2010b) Goodwin MS, Groden J, Velicer WF, Practice. 1, 1, 2-8 Towards ‘Fulfilling and Rewarding Diller A (2007) Validating the stress Carr EG, Owen-DeSchryver JS (2007) Lives’: The First Year Delivery Plan survey schedule for persons with Physical illness, pain, and problem for Adults with Autism in England. autism and other developmental behavior in minimally verbal people The Stationery Office, London. disabilities. Focus on Autism and with developmental disabilities. Journal Department of Health (2010c) Other Developmental Disabilities. of Autism and Developmental Implementing Fulfilling and 22, 3, 183-189. Disorders. 37, 3, 413-424. Rewarding Lives: Statutory Grandin T (1984) My experiences as Cascio C, McGlone F, Folger S et al Guidance for Local Authorities an autistic child and review of (2008) Tactile perception in adults and NHS Organisations to Support selected literature. Journal of

18 october 2011 NURSING STANDARD Autism 2011_Layout108/09/201117:40Page19 Kern JK,Trivedi MH, Joliffe T, LandsdownR,Robinson C Jackson L(2002) Harrison J,HareDJ Hale A Groden J,DillerA,BausmanM NURSING STANDARD Grandin T used to illustrate thekey areas of support. people withautismsothatreal examples canbe 2010. Training inautismshouldbefacilitated with ‘reasonable adjustments’under the Equality Act needed, andthisincludestheareas required for sensorydomainis to understanding autism from a health services.Amove beyond ‘basic’ awareness role working inlearningdisability andmental autism a This guidehighlightstheneedfor more training in Summary 144-174. Orthomolecular Psychiatry.13,3, Grannemann BDetal Communication. 26,3,12-19. (1992) Autism:apersonalaccount. Kingsley Publishers,London. Guide toAdolescence.Jessica and AspergerSyndrome:AUser 727-730. Developmental Disorders.34,6, Journal ofAutismand autistic spectrumdisorders. abnormalities inpeoplewith Assessment ofsensory Ingatestone, Essex. Your World 31, 2,207-217. Developmental Disabilities. Journal ofAutismand developmental disabilities. persons withautismandother a stresssurveyschedulefor et al Vintage Books,New York NY. From MyLifeWith Autism. Pictures: andOtherReports (2001) Thedevelopmentof (1998) wareness for people whohave aspecialist (1996) . ArchimedesPress, My World isnot Freaks, Geeks Thinking in (2004) (2007) National AuditOffice Loynes F Leekam SR,NietoC,LibbySJ, Lawson W Quill KA O’Neill JL National AutisticSociety S accessed: August22011.) http://tinyurl.com/3tjzbol (Last Parliamentary GroupforAutism. Autism. TheAllParty 894-910. Developmental Disorders. Journal ofAutismand children andadultswithautism. the sensoryabnormalitiesof Wing L,GouldJ Kingsley Publishers,London. Autism SpectrumDisorder. Jessica Glass: APersonalAccountof Autism. 11,2,123-134. with Autism:Strategiesto London. People. JessicaKingsleyPublishers, of Aliens:ABookAboutAutistic accessed: August22011.) http://tinyurl.com/3nadz6c (Last the AdultAutismStrategy. Exist, theAutismAct2009and London. Through Adulthood Supporting PeoplewithAutism ensory correlationsinautism. (2001) (1995) (1998) (2000) The Impactof Teaching Children Through theEyes Life Behind (2007) Describing enable effective long-lastingchangeto occur. (Equality Act 2010) whichwillbethedriver to lobby for theuseof ‘reasonable adjustments’ people’s talents.The challengewillbeto argue and promote agreater enablement and contributionof of theAutism Act thatthelegislationisinplaceto of theAutism Strategy andwithinthejurisdiction general societalattitudes.Itis,however, thevision communication andinformation, andchallenging barriers intheenvironment, withtheuseof Enabling accessto servicesrequires challenging . NAO, (2009) (2010) 37, 5, I Williams D Swain J,FrenchS,BarnesC, Williams D Williams D Williams D Shabha G Publishers, London. Soul Finding.JessicaKingsley to theBlind:SoulSearchingand Kingsley Publishers,London. Spectrum andBeyond.Jessica Responses intheAutism An ExplorationofSelf-protection Anxiety –TheInvisibleCage: Thomas C Kingsley Publishers,London. the World ofAutism Somewhere: BreakingFreefrom Publishers, London. an AutisticGirl Autobiography of Nowhere: TheRemarkable Press, London. Publications/Open University Environments. Barriers –Enabling Facilities behaviour inspecialneedsschools. environment onindividuals’ the impactofsensory London. Socialization. DelmarPublishers, Communicationand Enhance . 24,1/2,31-42. (2006) Anassessmentof (1998b) (1998a) (2002) (1998c) (1993) october 2011 19 Sage . JessicaKingsley Exposure Nobody Somebody Like Colour Disabling . Jessica

Nursing Standard Essential Guide Autism 2011_Layout 1 08/09/2011 17:40 Page 20 s date date TABLE 5 TABLE

Name Rater Name Rater description Behaviour Setting description identify those situations in which an individual i designed to Scale is a questionnaire Assessment Motivation Instructions: The decisions can be made concerning the selection of informed more this information, From in certain ways. behave to likely that is of select one behaviour the questionnaire, complete To and management strategies. distraction prevention, appropriate a as good is not example, for ‘Aggressive’, specifically. very identify the behaviour It is important that you particular interest. one the and circle each question carefully read be rated, to specified the behaviour have Once you as ‘hits his sister’. description this behaviour. of observations number that best describes your 0 = 1 Never, = 2 Almost Never, = Seldom, 3 = 4 Half the Time, = Usually 5 = 6 Almost Always = Always. Motivation Assessment Scale (Durand 1990) (Durand Scale Assessment Motivation

20 october :: 2011 Autism 2011_Layout108/09/201117:40Page21

Questions Never Almost Seldom Half the Usually Almost Always never time always 01 2 3456

1. Would the behaviour occur 0 1 2 3 4 5 6 continuously, over and over, if this person was left alone for long periods of time? For example, several hours.

2. Does the behaviour occur following 0 1 2 3 4 5 6 a request to perform a difficult task?

3. Does the behaviour seem to occur 0 1 2 3 4 5 6 in response to your talking to other people in the room?

4. Does the behaviour ever occur to get a 0 1 2 3 4 5 6 toy, food or activity that he or she has been told they cannot have?

5. Would the behaviour occur repeatedly, 0 1 2 3 4 5 6 in the same way for very long periods of time if no one was around? For example, rocking back and forth for over an hour. october ::2011 21 6. Does the behaviour occur when any 0 1 2 3 4 5 6 request is made of this person?

7. Does the behaviour occur whenever you stop attending to this person? 0 1 2 3 4 5 6

Continued over page

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 22 always time ver ne 01 2 3456 Never Almost Seldom Half the Usually Almost Always behaviour to upset or annoy you when you upset or annoy to behaviour Questions take away a favourite toy, food food toy, a favourite away take or activity? the behaviour? performing person enjoys looks, smells and/or tastes, (It feels, sounds pleasing?) when you upset or annoy to behaviour do get him or her to trying to are you ask? what you him to attention paying not are you sitting in are if you example For or her? with interacting room, a separate person. another or food the person toy, give you he or she has requested? activity TABLE 5 TABLE

8. occur when you Does the behaviour 09. that this you Does it appear to 1 010. do the Does this person seem to 2 0 111. do the Does this person seem to 3 1 2 0 412. 2 shortly after stop Does the behaviour 1 3 0 5 3 4 2 1 6 5 4 3 2 6 5 4 3 6 5 4 6 5 6 Motivation Assessment Assessment Motivation Scale

22 october :: 2011 Autism 2011_Layout108/09/201117:40Page23

13. When the behaviour is occurring, 0 1 2 3 4 5 6 does the person seem calm and unaware of anything else going on around him or her?

14. Does the behaviour stop occurring 0 1 2 3 4 5 6 shortly after (one to five minutes) you stop working or making demands of this person?

15. Does this person seem to do the 0 1 2 3 4 5 5 behaviour to get you to spend some time with him or her?

16. Does the behaviour seem to occur 0 1 2 3 4 5 6 when this person has been told that he or she can’t do something he or she had wanted to do?

Results Sensory Escape Attention Tangible

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

october ::2011 23 Total score Mean score

Relative ranking

The questionnaire is designed so that you look at what response you gave to each question and you insert the number for that question next to it.. You then complete this process for all 16 questions and add up the total score in each of the four columns. The column with the highest number is the likeliest function of the behaviour. This is, however, not a definitive answer and other forms of data collection, such as ABC charts, should to be used to gain a wider picture.

RCN PUBLISHING ESSENTIAL GUIDE Autism 2011_Layout 1 08/09/2011 17:40 Page 24

rcnbulletinjobs

RCN Bulletin Jobs Visit the RCN Bulletin Jobs website to see how it can connect you to hundreds of nursing jobs online

• Register FREE – use www.rcnbulletinjobs.co.uk to search and apply to hundreds of nursing jobs online • Quick and easy to use – all in one online environment • Hundreds of new posts every month – post your CV and let employers search your details

Visit us now at www.rcnbulletinjobs.co.uk