From firestarting to back into the community, a pathway of care
Background
Tom was born 8 weeks premature and was slow to learn to walk and talk. His mother was a single parent with an alcohol problem and tom was exposed to a number of stepfathers. Tom was often left for long periods of time without proper supervision and was a very overactive as a toddler which annoyed his mother’s partners and often resulted in violent physical abuse from them. Tom also had problems tolerating loud noises and would only eat a very restrictive diet. He had problems learning to dress himself and tie his shoelaces. His delayed toilet training meant he wet the bed until he was 9 years old for which he was severely punished, often having to sleep in the bath. Tom was also on the Child Protection Register from the age of 4 but as his mother moved multiple times between London and Nottingham it was difficult for the services to keep track of Tom and meant he attended several different schools. He was reported as being aggressive to other children at school and was unable to sit still and concentrate in lessons. He was frequently disruptive in class and often refused to go to school or ran away.
Into Care
Tom was finally taken into care when he was 10 years old and had three sets of foster parents within a year. He was hostile and argumentative towards the other children in the family and on one occasion, severely injured the family dog by kicking it inflicting such damage that the dog had to be put down. Following that event, Tom was then placed in Residential Children’s Home but he was regularly out at night involved in antisocial behaviour. He set a small fire in his room and was placed in a residential service by himself with 24 hour carers from an independent organisation. He absconded four times within a twelve month period from residential placements before he was placed in a Secure Social Services setting where he was aggressive towards the staff and refused to go to education sessions. Tom was accused of exposing his genitals to another young person but this was never proven.
Assessment and Diagnosis
Tom was 16 when he was seen and assessed by a Consultant Psychiatrist from St Andrews. He was diagnosed with a Learning Disability and combination of developmental problems which often cluster together called DAMP syndrome (Deficits in Attention Motor-control and Perception) which meant he had Attention Deficit Hyperactive Disorder and was also on the Autistic Spectrum. In addition, he had motor coordination problems called Developmental Coordination Disorder.
Tom also had a variety of sensory sensitivities related to his autism which made it more difficult for him to tolerate some environmental triggers like high pitched noises or bitter tasting foods. His experience of abuse and neglect was also likely to have severely affected his mental development and his ability to regulate his emotions and this is called Developmental Trauma Disorder.
Admission
Tom was admitted to the Adolescent Service at St Andrew’s at Malcolm Arnold House in Northampton. The department specialises in helping young people with complex developmental disorders that present a risk to themselves and others. This service has a comprehensive multidisciplinary programme which includes input by:
• Psychiatry,
• Psychology,
• Education,
• Occupational Therapy,
• Speech Therapy,
• Physiotherapy,
• Dietetics
• and Nursing staff.
The unit has a Solution Focussed philosophy which seeks to engage young people by helping them work towards a realistic ‘preferred future’. The programme includes a comprehensive 12-week assessment, moving on to a longer-term treatment including:
• Remedial Education,
• Anger Management,
• Relaxation,
• Social Skills training (including Mind Reading Programme developed by Cambridge University),
• Offence related groups (based on the G-map Challenge Group model),
• Individual Behavioural programmes,
In addition to these programmes, a wide variety of occupational and recreational activities are introduced including structured exercise and gym work, swimming, Tai Chi and the Duke of Edinburgh Award.
During the later stages of the programme, Tom was encouraged to take college courses in horticulture, animal care, catering and information technology
Progressive Improvement
Gradual but continuous improvement was monitored over a 12 month period, slowly increasing his access to the community. Whilst on a specialist programme he learned to brush his teeth properly for the first time and his personal hygiene improved. He had specialist physiotherapy for his Coordination Disorder and took part in the Rebound Programme. He had specialist Relaxation training, Aggression Replacement Training and Social Skills (Skillstreaming) training and accepted medication for his ADHD.
His sensory problems were assessed and he had a sensory programme using specialist equipment to meet his sensory needs. Tom engaged in Art Psychotherapy and also the music programme and produced a rap CD. He learned budgeting skills including how to shop at the supermarket and cook food in a training kitchen. His outcomes were monitored using the HoNOS CA and HoNOS secure Outcome scales and also the Modified Overt Aggression Scale. Tom took part in the Duke of Edinburgh Award and developed an interest in the Wildlife and Animal Care Programme and in Horticulture. Tom went on orienteering expeditions and gained his Bronze Duke of Edinburgh Award. He also obtained several Entry level qualifications in Education and was working towards his Sports Leadership award. Tom had successful contact with his mother who he had not seen for two years.
Tom was placed in the community with a specialist provider of Autism services, closer to his mother, tested initially on leave from hospital and then a Community Treatment Order with follow up from a local learning disability mental health team. Tom attends a nearby Agricultural College with support and is undertaking some Large Animal Care qualifications and hopes to use his skills to work with horses in the future.
This is a hypothetical case study created from a number of service users. All names and identifiable information have been changed or removed and where relevant, consent has been obtained.