Background

Phil* joined the Forum School (TFS) three years ago from a difficult family background, including a history of witnessing domestic violence and potentially traumatic events. His presentation when he arrived with TFS included behaviour such as not listening to adults, physically aggressive behaviours towards himself and others, emotional outbursts and mood changes.

A particular area that Phil had struggled with was being able to cope with the ending of activities and transition into new ones.  He often became upset and dysregulated when activities came to an end, as well as on occasion, becoming stuck. There were instances of injury to others, himself and property damage during these times and Emergency Action for Safety (EAS) was more often than not utilised. For example, when he first arrived, Phil struggled to come out of the toilet, as he couldn’t end the task.

Phil also struggles in the home when it comes to time for bathing, he had refused to have a bath from the day he arrived at TFS. Another area that the team at TFS identified that Phil struggled with was shared interaction and communication. He is a caring boy and likes to have fun but sometimes he struggled with appropriate play with staff and other young people.

Support provided by TFS

The team around Phil wanted to support him to try and reduce the amount of EAS used, and how to help Phil cope better with endings. Staff worked hard to build positive and trusting relationships with Phil using the PACE approach and found that he began to show care and affection for them. These positive relationships were vital when it came to helping Phil manage difficult situations.

One ending the team at TFS particularly targeted was the ending of vehicles. Previously, Phil had been refusing to leave the vehicle after a journey and became distressed and physical when staff asked him to leave. He couldn’t leave unless EAS was used. The team worked in stages, using the GIBBs model to adapt the plan, learning what worked best for Phil and how to make it easier for him to transition. As the staff continued to build relationships with Phil, the EAS faced less resistance. Staff realised that when Phil was immediately removed from the situation after getting off the vehicle’s transitions were easier so began to use a Planned Action for Safety (PAS) to do this. It appeared that Phil felt safer with the adults around him making the decision to leave the bus for him. He also began to ask staff whether they were okay after PAS had been used. Another safety issue was that Phil would sometimes try to chase the car/minibus as it drove away so staff began to move him directly from the car to his home after trips and allowed him time to regulate on his own. Staff found that being out of sight of the vehicle made it easier for Phil to transition to a new activity. They also discovered that a hug vest and squeezes assisted Phil with regulating himself after the ending of the activity. Phil’s schedule was also presented to him on the drive back, with a fun activity, such as library, as a motivator to get off the vehicle when he returned to school. Even with all these measures put in place staff wanted to continue to develop this so that eventually he would be able to end a trip without any PAS at all.

Endings all throughout the day were also targeted to make transitions between other activities as well as home and school easier whilst the work with the trips was going on. The clinical psychologist gave suggestions that Phil is made aware of all the small endings that happen within his day so that he knows that he already does some transitions without knowing. Social stories were also provided to Phil about endings. An ending timer and song were also introduced to Phil to represent the ending of different activities, which was utilised in a variety of settings.

The team at TFS did a lot of work with Phil around his difficulties with bathing. They worked to build relationships with him and get to know him and the things that trigger him around bath time. They avoided his triggers and gently encouraged him into the bath using a PACE approach and designating time for water play in a paddling pool in the summer and putting slime into the bath to encourage interaction with the bath water. Toys were also provided to Phil to encourage play in the bath. They also worked in stages around this difficulty, when he did get in the bath they did not pressure him to do any cleaning, it was enough that he was willing to try. They found that having the same staff was very helpful in this process, and for days when he did not get in the bath, alternative arrangements were made by care staff.

Speech and language therapy have been working with Phil around shared interaction and doing activities with other people in order to improve his communication and ability to interact with other people. Staff also supervised Phil's play with peers and reinforced appropriate touching.

Recently the therapy team have started doing work with Phil around his eating through a group activity called Food explorers. The group involves touching, smelling, playing with and tasting different foods each week to try and desensitise the young people to new foods and try to encourage them to expand their diet using the 32 steps to eating.

Where is he now  

After all the work adults have done with Phil around endings, there have been multiple vehicle trips where PAS was not resisted by Phil, no one was injured and he took himself off to house to regulate. On one occasion, in February 2024, Phil made a choice to get out of a car on his own after a trip and move of his own volition to the next activity on his schedule that had been made available by staff 10 minutes before arrival and the previous day, this has positively continued. There have also been improvements with the transition back to home after the ending of the school day.  Phil has also been known to ask for the ending timer and song.

Staff observed that Phil is learning how to regulate himself, and showing that he can use the strategies that adults have taught him, for example going to his room alone when he is angry. Phil is also voicing his choices to staff in various ways.

The work done with Phil now means that he enjoys outings and can end this himself, he has baths occasionally, more often in the holidays, and has become more tolerant of bathing, although still does not regularly.

After the work done with the speech and language team Phil began to tolerate other people joining in activities that he was doing and began to listen to staff comments about the activity that he was doing.

Most recently, Phil attended his annual review in a room full of 7 adults and sat happily the whole time. Phil’s social worker has noticed the incredible progress that he has made and after this meeting said ‘I just wanted to share that it was an absolute joy to be a part of Phil’s review this morning. Having him join and engage in his own way was simply wonderful. I honestly cannot believe how far he has come in the 4 years I have known him. Thank you to you all for your persistence and determination to keep going, when at times it felt near on impossible.’

Comments from Karen Varney Consultant Clinical Psychologist

The first thing that struck me is the sort of PDA flavour of Phil where actioning even things he finds pleasurable or needs is hard for him and the actual sense of relief he seems to have when trusted others take control.  This is obviously complicated by his adverse history which is why the building of that trust has taken so long.

I think the practicing of car journeys more frequently is a good idea but I also felt that every day has got load and loads of micro-endings in it.  They are so small that we don’t even notice them much of the time. Perhaps making him aware when he has completed or finished something well, on his own or without a fuss might help him to feel like a more competent “finisher” and not someone who needs other people to take control.

I was also struck by a sort of “Disney” feeling of him being rescued from his own situation or crisis which he almost seems to like or be grateful for.  Perhaps being rescued from crisis is one of his fantasies and I note that he was fine when the Police actually did rescue him from some family related crisis.  Perhaps a script about staff helping and protecting and looking after might be welcomed by him as it feels like his early life lacked anyone doing these things for him.

*Name has been changed