Case study 3
Child’s name & age:
Main areas of concern:
Inconsistent attendance at school, increasing incidence of school refusal, minimal friendships, refusing to leave house
Outline of case study
EF was referred to Middletown Centre for Autism as his attendance at school was inconsistent and there were an increasing number of days on which he would refuse to go to school. Concerns were raised by school and his mother that there was a risk he would soon refuse to go to school at all.
The Special Educational Needs Coordinator (SENCO) reported that on days when EF did attend school, he would rarely stay for a full day. He would frequently leave school during the day and walk home, and he may then not return to school for several days. There were no identified triggers before the times he left school as he never had visible emotional outbursts and never informed teachers that he was feeling upset. When he was in school, he was spending increasing periods of time in the SENCO’s office as he seemed to seek the solitude and quiet of her office. He would sometimes complete work in this room but would often sit silently looking out the window.
At Break and Lunch times, EF usually stood alone in a dark corner of a corridor. He refused to go out to the playground. In group or paired work in classes, he only participated minimally. He was reported to have difficulty answering questions and rarely initiated interaction in class.
Overall, in school he was reported as being very passive with no obviously challenging behaviours but significant withdrawal.
EF’s mother described him as very anxious. He would interact with her but had difficulty tolerating the noisy and very active behaviours of his younger siblings. He therefore frequently withdrew to his bedroom. He had some friends who lived in the neighbourhood but they were all younger than him. He had told his mother that he would like to make friends of his own age but refused to go to local youth clubs or sports clubs.
EF’s mother also expressed concerns with his reluctance to shower and brush his teeth.
Assessment and analysis
The Adolescent Adult Sensory Profile (Brown & Dunn, 2002) was completed with EF. This assessment was considered appropriate as he presented with adequate receptive and expressive language to complete this assessment.
Observations were carried out in school and information was gathered through discussions with EF’s mother and school staff.
Other assessments were carried out by the transdisciplinary team, including social skills assessments, speech and language assessments and life skills assessments, but this case study will focus on the sensory processing assessment and analysis.
EF presents as sensory over responsive, particularly in his tactile and auditory systems.
EF is very sensitive to noises and this was one of the key factors in his tendency to leave school in the middle of the day and was also one of the main reasons he was refusing to attend school. There was a pattern of school refusal on days he had Technology and Home Economics. He had commented that he disliked the noise of equipment in these classes. EF also had difficulty coping with the noise of his classmates talking, both during class and in the playground, and disliked the noise of the school bell.
EF stated that he found it difficult to understand what other people were talking about when “they all talked at once” and that he then didn’t know how to join in a conversation. This explained his social withdrawal in school and explained why he found it difficult to go to youth clubs etc.
EF is also over responsive to tactile (touch) input, which was then causing poor tolerance of the sensory input in activities such as showering and brushing teeth. This tactile sensitivity may have also contributed to his social withdrawal due to limited tolerance of the unpredictable touch from others e.g. in busy corridors, in the playground.
Some over-responsiveness to smell and visual input was noted. Sensitivity to smell may have contributed to his difficulty in Home Economics and his avoidance of showering. Sensitivity to visual input will have increased his anxiety in crowded environments such as the corridor and playground.
EF rarely sought out sensory input but his mother reported that he appeared to be calmer and more able to interact when he held a fidget object.
There were no significant patterns of sensory under-responsiveness. Although EF seemed to be very passive in the classroom and rarely responded to questions or participate in class discussions, this appeared to be due to sensory overload and an inability to process multiple input simultaneously.
|Leaving school during the day||
|Refusing to go to school||
|Seeking out time in the SENCO’s office||
|Avoidance of interaction with others||
|Difficulty attending youth clubs, sports clubs etc.||
|Reluctance to shower and brush teeth||
EF was permitted to opt out of some classes (e.g. Technology, Home Economics) and at these times he went to the SENCO’s office to complete assigned work.
EF was given visual passes (small laminated cards) to indicate when he needed to leave class. He was then permitted to go to the SENCO’s office and have time to calm himself. The number of passes was not limited as it was felt that EF would only use these when he definitely needed a calm break. This could be reviewed if he was missing too much class due to calm breaks. Various calming activities were offered initially (e.g. bouncing on therapy ball, squeezing stress ball, listening to music) but EF preferred to read or draw during calm breaks.
EF was permitted to leave class a few minutes after everyone else so that he was moving through the corridors when they were less crowded. This reduced unpredictable noise and tactile input.
Anxiety management techniques
In one-to-one sessions, EF was taught a range of anxiety management techniques which he could use in school and at home:
- Heart Math (Take Ten): a computer programme which taught him how to control his breathing when feeling anxious
- Progressive muscle relaxation: EF found it useful to clench his fists, hold for a count of 10 and then shake out. He would repeat this several times.
- Photo album: EF’s album contained his favourite photos of his pets.
A weekly friendship group was set up promoting shared activities in a quiet setting. The quiet setting of a classroom with a limited number of people was less overwhelming for EF than the busy playground. It was therefore easier for him to process interactions and to eventually participate. Each group started with a calming activity which then promoted his ability to interact. He became more relaxed in the group setting as the weeks progressed and made friendships which then extended outside the group into the classroom.
A youth club run by a voluntary organisation for young people with Asperger Syndrome and Autism was located near EF’s home. He started attending this as he found it less overwhelming that other youth clubs, and this eventually led to him joining a football club in the local area.
A range of options was offered to EF to use in the shower. He was able to choose between a sponge, facecloth, bath brush or loofah. He chose the loofah and found that this helped him to tolerate the shower. He used the stop watch on a mobile phone, which he set outside the shower door, and gradually set this timer to spend longer and longer in the shower. He started with 20 seconds, and this was very gradually increased to 3 minutes over a period of several weeks. A fragrance-free shower gel was used.
An electric toothbrush was introduced and this helped him to tolerate tooth brushing. He again used a stop watch on his phone to set himself targets for brushing his teeth for longer times.
Alongside these strategies, social stories were used to reinforce the importance of personal care and hygiene.
The intervention strategies used with this child/young person were introduced after comprehensive assessment. These strategies were individualised to his/her specific needs and will not be appropriate for every child/young person.