AUTISM, ASPERGER’S, AND MENTAL HEALTH Autism and Asperger’s help guide, including understanding selfharm and sensory difficulties related to high functioning and low functioning impairment.

Kelly Bristow

Contents Behavioural Strategies for Anxiety....................................................................................................4 Behaviour and Anger!.....................................................................................................................5 Asperger's and Confidence...........................................................................................................5 Self-Portrait......................................................................................................................................6 Role Play..........................................................................................................................................6 The Importance of Self-Awareness..............................................................................................6 Things that irritate Me.....................................................................................................................7 Amazing Me.....................................................................................................................................7 Emotional regulation.......................................................................................................................7 Breathing and Counting.................................................................................................................8 Behaviour contract..........................................................................................................................8 Autism and Depression......................................................................................................................8 Sticking to Routines........................................................................................................................9 Strategies.........................................................................................................................................9 Positive Reinforcement..............................................................................................................9 Prevention..................................................................................................................................10 Containment..............................................................................................................................10 Skills for Emotion Recognition................................................................................................10 Challenges of Autism....................................................................................................................11 Strategies...................................................................................................................................11 Using Visuals.............................................................................................................................11 Scripts and Social Stories........................................................................................................12 Building Vocabulary..................................................................................................................12 Social Interactions with Asperger's Disorder.............................................................................12 Social Rules...............................................................................................................................13 Role Playing...............................................................................................................................13 Why Role Play?.........................................................................................................................13 Steps for Role Playing..............................................................................................................14 Sarcasm - Challenges of Autism.............................................................................................14 Body Language.........................................................................................................................14 Use Visuals................................................................................................................................15 Modelling....................................................................................................................................15

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Why Empathy Matters..................................................................................................................15 Why Do people Self Harm...........................................................................................................16 How do young people harm themselves?.....................................................................................18 Reasons why young people self-harm.......................................................................................18 The Myths of Self-harm may be believed to be:.......................................................................19 What to look out for:.....................................................................................................................20 Other signs include:......................................................................................................................20 Strategies.......................................................................................................................................20 DON’T..............................................................................................................................................21 DO....................................................................................................................................................21 What to do:......................................................................................................................................22 Urgent medical treatment...................................................................................................................22 Psychological Treatment for Self-Harm............................................................................................22 Medication Treatment for Self-Mutilation.......................................................................................23 People who self-injure generally share these characteristics:..........................................................24 Sensory awareness for low functioning autism, learning disability and other brain related traumas..25 Hypersensitive is Avoiding...............................................................................................................26 Hyposensitive is Seeking..................................................................................................................27 Vestibular.............................................................................................................................................27 Hyposensitive (seek)........................................................................................................................27 Hypersensitive (avoiding).............................................................................................................28 Proprioception.................................................................................................................................28 Hyposensitive (seeking)...................................................................................................................29 Experimenting with two senses;......................................................................................................30 Tactile..................................................................................................................................................30 How to help.....................................................................................................................................31 USE MOVEMENT (proprioception)...................................................................................................31 Auditory and sound.............................................................................................................................31 Hypersensitive (avoiding).................................................................................................................31 Hypo sensitive (seeking)..................................................................................................................31 Olfactory smell.....................................................................................................................................32 Taste....................................................................................................................................................32 Hypersensitive (avoid).....................................................................................................................32 Visual...................................................................................................................................................33 2

Hyposensitive (seek)........................................................................................................................33 Hypersensitive (avoids)....................................................................................................................33

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Autism, Asperger’s, & Anxiety Children with autism face a variety of unique challenges at school. Completing class assignments, working with peers, reading, writing, and communicating with teachers are everyday tasks that cause stress. It's no wonder many children and young people with autism also struggle with anxiety issues. Anxiety is a leading factor in the distress often observed and treated in mental health. It can have a devastating and crippling effect on the developing child and their wellbeing. While children with autism are unique in their challenges and abilities, symptoms of anxiety may include some of the following: •Racing heart or muscle tension •Sweating •Crying, throwing tantrums, and yelling •Stomach aches •Repetitive behaviours, such as rocking, pacing, or tearing paper Children with low functioning autism are unable to verbally express how they're feeling, which makes it difficult for parents, carer’s and teachers to assess what is really going on. Behaviour is one of the only guides that can help to understand and analyse what is occurring for the nonverbal child. For verbally able children, there is the added confusion of mind blindness, where they are unable to interpret facial expression and body language. However, whether certain people have been diagnosed with anxiety, or you suspect they become anxious in certain situations, there are several behavioural strategies that can help.

Behavioural Strategies for Anxiety As a parent, carer or teacher, you're probably aware of the specific situations that cause anxiety. Exam stress, social engagement, public speaking etc, Here are a few examples of school events that may cause anxiety for students with autism: •Breaks during the day •Attending the regular education classroom •Getting on/off the school bus or taxi •Fire drills •Transition periods between classes •Group work

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There are two main strategies that are widely used and accepted by experts in anxiety. Read through these strategies and adapt them to fit the child or young person’s needs. Working together with parents will help these strategies have the biggest impact. Behaviour and Anger! How does a child with Autism and Anxiety understand the difference between anxiety and anger? They might struggle to name their warning signs, but you should suggest the following to help them to learn about their body and what these signs mean, such as; •Face getting warm or hot •Hands clenched into fists •Heart beating faster and faster, while breath gets shallow Once you can help your child to identify their signs, look for strategies in how you can help them with triggers to their anger by looking at writing out their angry feelings; 'I feel angry when _____. I can tell I am angry because _____. This can have a powerful effect on supporting the child to learn about their anxiety and pick up cues as to what or when they get angry, add in pictures of their physical responses and triggers, as people with autism, are more responsive to pictures than written words! Red Amber Green! Colour Coding Anger using the traffic light system! It can be difficult to know what triggers anxiety for your child, or for teachers to know how to spot when a child with autism is getting upset and angry. By using a traffic light system, the chid can learn to colour code their feelings and this can be expressed by use of card exchange with parent, carer or teacher. Green – I feel good, I am happy. Amber - I feel anxious, I don’t know why but I am worried. Red – I am angry. Asperger's and Confidence Everyone with Asperger's is different and unique, there are some characteristics they tend to share. Many students with Asperger's tend to demonstrate a high ability to 5

excel in one or more academic fields, they also have good working memories, and enjoy engagement with various aspects of popular culture. At the same time, Asperger's tend to struggle with social skills, language development, and selfconfidence. Confidence often grows out of competence and strong relationships. When students with Asperger's have a hard time fitting in or making close connections with peers, their confidence might suffer. How to help Self-Portrait Many young people like to work visually and whether or not their strength is in the visual arts, they will benefit from engaging in this activity. If the young person dislikes drawing, use another method such as cutting out from magazines or getting pictures from the internet that allows them to create a self-portrait. Add into the portrait other subjects that empower or make them feel good, such as favourite hobbies or interests. A bit like creating a vision board. Role Play This is a great activity for helping students practice different scenarios where confidence can make a difference. Role play is an integral aspect of developing social skills and social interaction. By creating scenarios that relate to the young person can enable good communication and support social training, enabling enhancement to all areas of social integration. Scenario examples could be such as meeting a new child, meeting a parent's friend, making a presentation at school, or going shopping. Get the young person to act out how they would behave in these situations. Encourage them to take risks as this can help them uncover some of their insecurities as they develop their self-confidence to try these kinds of encounters. The Importance of Self-Awareness One of the ways you can help students with Autism/Asperger access their strengths more readily is to help them understand themselves. This means facilitating them in developing self-awareness. •Develop better strategies for self-regulation •Advocate for himself in difficult situations •Reflect on his own learning •Access his strengths as part of overcoming his challenges

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Things that irritate Me This activity gets at the fact that many students with autism experience sensory overload easily and benefit from knowing the situations that bother them. By getting them to identify the things that bother them, helps them in learning about themselves and finding suitable coping strategies to function.

Amazing Me Developing self-awareness can also mean improving students' self-esteem or sense of self-efficacy. One of the best ways to help a child or young person develop self-awareness is to write up or fill a vision board with pictures relating to themselves, all about me! This helps them to look at their strengths. This can include things they like, their family and friends, don’t forget to ensure you include their strengths. Social Stories and Scripts. When things become too much or too confusing, a social story is an effective strategy to help support the child to follow to a set sequence. Story boards ad social scripts are useful in helping a child follow a sequence to succeed in a task, such as getting dressed. Emotional regulation Social stories are helpful to identify emotions, because they give children and young people a safe way to process and make sense of emotions. Social stories also provide children with autism with explicit language and strategies they can use with themselves and others in moments of struggle. Social stories about the following topics help to understand the complexity of emotions and help children learn about their anxiety and anger: Feeling Sad Feeling Angry Feeling Excited Calming Down

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Breathing and Counting Counting and breathing are an ideal strategy to use to help manage unhelpful emotions and to overcome anxiety or to manage anger as this can be a way to make the extreme feeling relax a bit and avoid causing trouble through a disproportionate response. Taking a deep breathe into the stomach and holding for a count of two or three is effective, a couple of deep breathes like this helps to re-ground and calm when faced with anxious situations. Behaviour contract One strategy you can use to help modify behaviour is a behaviour contract, or a document that the young person and all involved parties sign to agree to specific behavioural goals and stipulations. When using a behaviour contract with students who have autism, it is especially important to remember the following guidelines: Keep the language in the contract clear and simple so that all parties involved can really understand it. Make sure that goals are attainable. Provide the necessary scaffolding and support so that the young person can achieve the behavioural goals. Build reminders of the behaviour contract into the daily routine. Involve family members in the contract so that there is consistency in expectations at home and school.

Autism and Depression One thing that students with autism may struggle with is depression. Depression varies tremendously from one individual to the next. Children who have autism and severe depression can be very difficult to communicate with and might require treatment beyond the parameters of the school. Children with milder depression might benefit more from behavioural interventions, or strategies that function on the level of their behaviour in and outside of school. Identifying and Stopping Thoughts This is particularly helpful when depression expresses itself as anxiety or compulsions, which is not uncommon for people with autism. 8

Once the young person can identify their difficult thoughts, teach them to say something internally that will help calm or redirect the difficult feelings. For instance, envision something they love to do or to repeat a word in their mind. This can be very meditative and soothing for autistic people with depression. Sticking to Routines Routines are very important to all those with autism. This is even more true when there is evidence of depression. Two of the aspects of life most frequently associated with depression are sleeping and eating. Excess or limited sleep and food can be both a symptom of depression and something that exacerbates it. Children and young people that maintain a consistent routine around mealtimes, bed times, and, if relevant, snack and nap times can go a long way toward alleviating depression in young people on the spectrum. Some people with autism are also diagnosed with ADHD. Attentiondeficit/hyperactivity disorder (ADHD) is a brain disorder characterized by inattention and impulsive behaviours that can impact development. The combination of these two disorders creates major barriers to school success. These problems are common symptoms of autism and ADHD. •Has trouble working in a group with his peers •Fails to complete his assignments •Acts out when there are changes to his schedule and routine •Has trouble focusing on lengthy activities •Needs to be redirected and prompted to keep working Strategies Keep in mind that all children with autism are unique, and those who also have ADHD will manifest a variety of symptoms and behaviours. Positive Reinforcement Children and young people with ADHD are frequently corrected and reprimanded for behaviour. By creating a more positive and encouraging environment. Positive reinforcement is when we reward for good behaviour in a way that increases the likelihood of them repeating that behaviour. •Extra time on the computer 9

•Extra breaks from schoolwork •Stickers, treats, or small toys •A positive note or phone call home Prevention The best thing to do to prevent any anxious meltdown is discover what leads up to their tantrums. If you have a good understanding of these causes, then you can take steps toward preventing tantrums. For children who have frequent tantrums, a chart that documents what comes right before the tantrum can be a useful guide. An ABC chart, Antecedent, Behaviour and Consequence •Where was the tantrum? •What time of day was it? •What was happening around the environment?

This is a way of seeking a concrete precedent, for the tantrum. A child may have an outburst at the end of the day when everyone is packing up their bags to go home. Once you identify the antecedents, then you can find an appropriate solution to alter the routine! Containment Though prevention is very important, containment happens on multiple levels. This might mean removing the person to a different area where there are no sharp objects. Containment also means letting them know they are being held, emotionally, during this tantrum. Saying 'I am right next to you. I see you are feeling frustrated.' Unless it is necessary for safety reasons, refrain from touching students who are having tantrums. Stay calm and let the person know you will not abandon them. Do not restrain a person in distress, this only exacerbates the problem!

Skills for Emotion Recognition Emotion recognition or understanding what feeling you or another person is experiencing, can be a real challenge.

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Learning to recognize emotions, however, is very important. When you can recognize your own emotions, you have better self-regulation and self-management skills. Recognizing the emotions of others can help children develop empathy, behave kindly toward others, and form more meaningful social connections. To teach emotion recognition skills to children with autism, you will have to address the embedded concepts explicitly and use strategies that help your students make sense of emotions, what they are, and why they matter.

Challenges of Autism Before you start teaching emotion recognition skills to your it might be important to review or learn why exactly these skills can be especially challenging for them. First, autism impacts students' social and emotional development. Many people with autism do not naturally form connections with others and struggle with self-regulation and empathy. That means that these aspects of emotional recognition have not received the incidental practice they do in the early childhood of a typically developing child. Also, many children with autism may also have language delays, meaning that it takes them a longer time than is typical to learn to express themselves verbally. This means that vocabulary associated with emotions may be new and challenging for them to understand. Strategies Although emotion recognition can be very hard for children with autism, it is certainly not impossible. As there are things you can do to teach the skills they need to recognize and respond to their own and others' emotions. Using Visuals Many children with autism are visual learners, meaning that they learn best using images and graphic organizers. To teach emotion recognition, it can help to work with photo cards that show faces and body language typically associated with specific emotions. Emoticons work best as these express the pictorial image of an emotion. Concrete pictures are most effective ad children and young people have a hard time understanding and grasping abstract images, as they are too vague and confusing.

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Hanging a chart with labelled facial expressions can also be helpful, as can giving them a chance to sketch the feelings they experience in different situations before asking them to describe these emotions in words. Scripts and Social Stories Using scripts and social stories can be very helpful in teaching children the language associated with emotion recognition. For instance, you might create a social story about recognizing your own sadness or acknowledging someone else's anger. You can also have children memorize and practice dialogues they can use when speaking with others about a variety of emotions. Building Vocabulary For children with language delays, building the vocabulary around emotions is crucial. After all, it can be hard for a child to show recognition of an emotion if she does not know the word for it! Children with Asperger's Disorder can have difficulties with social interactions, especially with peers, strategies for teaching social cues and finding opportunities to model appropriate social interaction is useful in helping the Asperger to understand and communicate, effectively.

Social Interactions with Asperger's Disorder You’re raising a smart kid. You notice that they learn things quickly and memorize facts in school easily. Your child usually gets good grades and does well on tests in class. In fact, they know every species of dinosaur that ever existed. Every football player in the premiere league and every type of bird that exists. But when it comes to recess, you have a tough time. They don't like talking to your classmates, and they usually walk away when you are trying to tell them something. Sometimes they even call your child weird and laugh at you. This type of alienation can cause frustration and anger, so they play alone. Asperger's Disorder is a high functioning form of Autism that usually causes a child to struggle with social interactions. This includes a lack of non-verbal cues and eye contact, high pitched or loud volume of voice, and interrupting others. Usually, children with Asperger's want to interact and play with peers but do not understand social cues and nonverbal communication with other children. It is important to

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provide clear rules and modelling to help them fit in and gain meaningful relationships. Social Rules Children with Asperger's Disorder are usually fast learners and memorize things quickly, especially when clear and precise facts are given. A great strategy for teaching the Asperger's child is providing them with specific social rules for social interactions, just as they would have classroom rules for behaviour. Some examples could include: •Use eye contact when speaking to others. •Greet someone you see by saying, 'Hello, how are you today?' •Remember to listen when others are speaking. Sometimes providing a list of rules to keep handy to review before social interactions occur (before lunch, at recess, before visiting the park, etc.). Since memorization is usually a strength for an Asperger's, the rules will usually be remembered and referred to often by the child or young person. Role Playing Role playing is the process of acting out or performing a certain situation. This helps the child with Asperger's Disorder become more confident and prepare for certain interactions. The parent, or carer can perform a role play example, so the Asperger's young person can rehearse some conversations they may have during an interaction. Some examples of role playing scenarios are: •Making a new friend. •Asking a group if you can join an activity. •Playing a board game. •Solving problems involving bullying, teasing or arguing. It is also important to practice conversations during role play. Having a conversation can be something that comes very natural and easy for typically developing peers. However, for a child with Asperger's, it can be challenging. Focus on the tone/pitch of voice, the back and forth in the conversation, and even how to start and end a conversation appropriately.

Why Role Play?

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Children with Asperger’s and Autism often struggle with both social interactions and novel situations. When a social interaction occurs in an unfamiliar setting, the situation becomes even more challenging. The purpose of role playing is to familiarize children with the types of situations that may occur, and to equip them with language and actions to appropriately participate in those situations. Steps for Role Playing The following steps will help you to set up role play activities for your students. 1.Choose a situation that will occur in the student's natural environment and for which the student should be prepared. 2.Identify the people involved in the situation. 3.Develop a simple script. 4.Model the role play for the student. 5.Practice the role play in the classroom, with the student taking the appropriate part. 6.Support the student while the student practices the role play in a practice setting. 7.Support the student while the student performs the script in an authentic setting. Journaling and Comic Book Conversations are also a good way to develop through role play Sarcasm - Challenges of Autism Recognizing sarcasm might be particularly challenging for those affected with autism, for a variety of reasons. •They may not have an intrinsic awareness of the role facial expressions and tone of voice play in communication. •They probably have fewer experiences with normative social interactions than their typically developing peers. •They may retreat into their own minds and fantasy worlds quite readily, thus missing out on the subtleties of communication with others.

Body Language We communicate our feelings in a variety of ways. Avoiding eye contact might indicate that we are embarrassed or guilty about something. Touching someone's arm might be a flirtatious move and rolling our eyes can show that we are annoyed at something.

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Body language is a form of communication without words. It involves using gestures, intended or unintended, to communicate something. The trick with body language is that it's subtle. It is easy to miss or misinterpret. Some examples of body language include making eye contact, folding your arms or nodding your head. Individuals with autism have an especially difficult time reading body language, an important part of communication and social interaction. Children with autism often need specific instruction to learn how to pick up on nonverbal communication. A few ideas of how you can teach children to understand nonverbal communication will help them fit in with their peers, have conversations and make friends. Use Visuals Using visuals to support your objective helps because children do not have to rely solely on spoken language for comprehension. You can show pictures of facial expressions to demonstrate different emotions. Some examples of emotions to focus on include happy, excited, sad, scared, worried, bored, tired and mad. Using photos of actual people making these expressions will help your child generalize this skill in real situations. Modelling Modelling is a strategy where one person demonstrates a skill while the other person observes. Try modelling some different gestures, or types of body language for the student to see. You might consider doing the following: •Fold your arms •Look around the room •Tap your foot •Shift your weight •Step away from the student •Put your hand out for a handshake •Clap your hands Explaining that we communicate with others by doing different things with our bodies, like shaking hands when we want to engage with someone or stepping away when we don’t. Explain examples of body language that communicate something, whether it's boredom, disinterest or excitement. Why Empathy Matters Children with autism really struggle to show empathy, or the ability to understand and relate to the feelings and experiences of others. After all, empathy can help us reach a variety of goals such as: 15

•Be a good friend to others •Reduce aggression and bullying •Become more patient with ourselves as well as others •See things from different perspectives Breaking Empathy Down Empathy is not a simple phenomenon, and it is not a skill that can be taught easily in a one-off session. In fact, empathy has many different components, •Knowing the vocabulary associated with feelings and emotions •Working to see the same issue from different perspectives •Responding to the feelings of other people •Recognizing body language and facial expressions that tend to indicate specific emotions •Regulating our own emotional responses to be attuned to those of the people around us

Self Harm A national survey of more than 10,000 children found that the prevalence of selfharm among 5-10 year-olds was 0.8% among children without any mental health issues, but 6.2% among those diagnosed with an anxiety disorder and 7.5% if the child had a conduct, hyperkinetic or less common mental disorder. The figures increase dramatically for 11-15 year-olds, with the prevalence of self-harm at 1.2% among children without any mental health issues, but 9.4% among those diagnosed with an anxiety disorder, and 18.8% if the diagnosis is depression Why Do people Self Harm There are lots of reasons why people self-harm. It could be because of feelings or thoughts that are difficult to deal with. Some people self-harm because it feels like a method for releasing tension. It’s a physical pain you can deal with, rather than a feeling or emotion that can be hard to cope with. Self-harm can also be used as a way of punishing yourself for something you feel bad about.

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Sometimes people self-harm because they feel alone, angry or not good enough. Self-harm can be personal and complicated, so it’s okay if you don’t know the reasons behind self-harm. Some young people start self-harming after a stressful event, like being bullied or abused. It could also be a reaction to something like pressure to do well at school. It’s not always a really big thing that leads to self-harm. You might not even be sure why it started. Children and adults with autism may engage in self-injurious behaviours, also known as self-harm. Self-injurious behaviours are actions that the child performs that result in physical injury to the child’s own body. The cause of self-harming behaviours remains as much a mystery as the cause of autism. It is thought that the behaviours may be caused by a chemical imbalance, sinus problems, headaches, attention-seeking, seizures, ear infection, frustration, seeking sensory stimulation/input, sound sensitivity, or to escape or avoid a task. There many ways to treat self-injurious behaviours. The method chosen may depend upon the perceived cause of the self-injury and/or the bias of the professionals involved. As a professional, the first stimulus to rule out would be any medial causes, such as, ear pulling could indicate ear pain. Hitting in the face and biting on surfaces could indicate tooth pain. Once a biological cause has been ruled out, then you can look at the other options. Is it sensory related, as biting surfaces can also indicate an imbalance with proprioception, then the appropriate method of relief can be used? If neither biological, nor sensory seems to be the cause, and remedies are having no effect on the self-injurious behaviour, then strategies to reduce this would be used through behavioural methods. If the self-injurious behaviour is driven by attention, then tactical ignoring of the selfinjurious behaviour may extinguish the behaviour. This would have to be accompanied by giving the child attention for appropriate behaviour when it occurs, known as positive reinforcement. Of course, if the child is seriously hurting himself or herself, this may not be an option. Reinforcing other behaviour that makes the selfinjurious behaviour impossible to perform may also be recommended (e.g., reinforcing the child for manipulating toys, which keeps the hands occupied and prevents face-slapping). If the self-injurious behaviour is caused by frustration, it may be that teaching the child a way to cope or communicate will prevent the self-injury. Simply giving the child constructive things to do may prevent boredom, which could lead to self-injury.

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Alternatively, the behaviour could be driven by a chemical imbalance, and then treating the child with appropriate medications may be a perfect answer. There is a theory that children who injure themselves do so to release opiate-like chemicals in the brain. Naltrexone is a medication that inhibits the release of these opiate-like chemicals in the brain and the belief is that this will remove the reason for the selfinjury.

How do young people harm themselves? Cutting or scratching (arms, legs etc) Banging, head banging or bruising Biting oneself Picking at skin Hair-pulling Scrubbing with abrasives, such as bleach Swallowing harmful substances. Starving, anorexia, and bulimia Reasons why young people self-harm Young people often cannot explain why they self-harm, especially when the selfharm itself is a means of communicating what cannot easily be put into words or even into thoughts (it has been described as an inner scream). Self-harm is a way of expressing very deep distress. Afterwards, people feel better able to cope with life again, for a while. Self-harm can be a way to help someone to cope with painful emotions that threaten to overwhelm them such as: Rage Sadness Emptiness Grief Self-hatred Fear Loneliness Guilt It is rarely one single event or experience that causes a young person to self-harm, but a multi-faceted combination. Research has shown that the experiences most closely linked to self-harm in young people are: Mental health problems (including hopelessness and depression) 18

Family issues (such as parental criminality and/or family poverty) Disrupted upbringing (being in local authority care, parental marital problems, separation or divorce) Being abused Continuing family relationship problems Even among health care professionals there can be myths and negative attitudes surrounding self-harm and assumptions may be made about why a young person is self-harming and therefore how to treat them. Some young people have reported experiences of an unsympathetic attitude from staff when they have presented with injuries. The National Institute for Health and Clinical Excellence (NICE) has produced guidelines on the treatment of self-harm, explaining the need to explore the underlying reasons someone may be self-harming, rather than focusing on the injuries themselves. The Myths of Self-harm may be believed to be: Manipulative - Myth Attention seeking - Myth For pleasure - Myth A group activity - Myth Only carried out by those who are interested in ‘Goth’ sub-culture - Myth A failed suicide attempt - Myth Evidence of borderline personality disorder – Myth

Children and young people who self-harm may discover that inflicting pain changes their mood, which then may become habit-forming. Cutting, for example, releases endorphins, which produce brief feelings of calm, and serotonin, which is moodlifting. Within a safe, nurturing, open organisation children and young people may feel more able to share feelings, but those who self-harm often find it difficult to ask for help, because they: 1) Think it will be a one-off event that they can manage 2) Want to put it to the back of their minds 3) Feel they have nobody with whom one to share their feelings 4) Have no idea how to access services 5) Are concerned that their coping strategy will be taken away from them if they are prevented from self-harming 6) Feel worried they will be judged as attention seeking or stupid 19

7) Believe their physical injuries are not serious enough to need help anxiety that disclosure of self-harm will limit their future career opportunities 8) Are concerned they will lose control over the situation if their behaviour becomes public knowledge. Not knowing how to broach the subject is often what prevents concerned individuals from probing. Yet concern for their well-being is often what young people who selfharm need most.

What to look out for: Unexplained burns, cuts, scars, or other clusters of similar markings on the skin can be signs of self-injurious behaviour. Arms, hands and forearms opposite the dominant hand are common areas for injury. (However, evidence of self-injurious acts can and do appear on any body part.) Other signs include: Inappropriate dress for the season (consistently wearing long sleeves or trousers in summer) Constant use of wrist bands or other coverings Unwillingness to participate in events or activities that require less clothing (such as swimming or other sports) Frequently wearing bandages Unusual or inexplicable paraphernalia (e.g. razor blades or other implements, inappropriate medication) Heightened signs of depression or anxiety. Strategies DISPLACEMENT REINFORCING Snap an elastic band on your wrist PHYSICAL Think about not wanting scars CREATIVE Go to the gym, play an instrument, draw COMFORTING Write poetry CONSTRUCTIVE Cuddle a soft toy/pillow FUN Write a to do list Go to a movie Inform yourself as much as you can about self-harm. The more you understand the better the outcomes for you and the young people.

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DON’T Think the problem does not exist or will go away, you will be wrong. If you work with children and young people, at some point one of them will self-harm. Educate yourself! Keep the information in this document to yourself. Everyone who works with children and young people should have an understanding of mental health and emotional well-being and be aware of the effects of stigma. Make assumptions, they are unlikely to be correct and you will risk alienating the young person altogether. Feel that you have to be able to cope. It is fine to be honest about your own fears, but make sure you have other people or organisations to help you. Try to work alone. The burden will be too great on you and will not be helpful to the young person. You do not need to breach confidentiality, just be sensible about what you can and cannot do.

DO Make it your business to inform colleagues. The more people know about self-harm, the less stigmatising it will be. You also need the support of your organisation as you cannot act in isolation. Try to be a good listener by allowing the young person to speak without interruption or judgement. If a young person feels able to open up to you it could be a great breakthrough, so tread carefully. Look after yourself – it is hard to support someone if you are feeling overwhelmed or out of your depth. Make sure you also have a source of support for yourself. Set boundaries around what you can offer and be clear with yourself and your organisation about what you cannot offer, and which other individuals or organisations can be used for help.

ABCDE Appearance and atmosphere: what you see first – everything, including physical problems. Behaviour: what the individual in distress is doing, and if this is in keeping with the situation. Communication: how the individual in distress is communicating, what they say and how they say it. 21

Danger: whether the individual in distress is in danger and whether their actions put other people in danger. Environment: where they are situated, and whether anyone else is there who will either Exacerbate the situation or offer support. Although it is argued that that self-harm is the opposite of suicide, that is, a way of coping with life rather than giving up on it, there is an equally valid argument that they are both linked in being a response to distress.

What to do: If a wound is bleeding profusely or if you suspect the young person has swallowed any form of toxic substance, including overdosing on medication and/or alcohol, you must get the young person to A&E straight away. The most helpful actions you can take are: -Recognise a potential emergency and contact emergency services on 999 immediately. -Assist the emergency services by giving clear directions about the location of the young person, their name, your name and your relationship to the young person. -Reassure the young person and gently but persistently ask neutral questions to establish what has happened. -Accompany the young person to the A&E department and wait with them until other arrangements are made. -Convey to A&E staff all the facts you have gathered. -Remain until you are sure the young person is happy for you to leave and is receiving appropriate treatment.

Urgent medical treatment If a young person has a wound that is anything beyond purely superficial, they will need medical treatment. In this case you need to get the young person safely to primary care, whether a GP Clinic, Walk-in Centre, or Minor Injuries Unit. If in doubt, contact emergency services on 999.

Psychological Treatment for Self-Harm There is both general and specific psychological treatment for self-harm. General treatment includes treatments that are not centred specifically on the self-harming

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behaviour. Psychotherapy, for example, may explore many aspects of a person's life in an attempt, to curb or stop self-injury behaviour. A recent study, though, identified that psychological treatments specific to self-harm have better success than those that are more general in nature. One such treatment is cognitive behavioural therapy (CBT). This type of treatment is short-term and very goal-oriented. This psychological treatment for self-injury focuses on identifying dysfunctional emotions, behaviours and thoughts (causes of self-harm) and then analysing them and replacing them with more positive ways of dealing with life. For example, a person might tend to magnify the negative of a situation rather than seeing it. Cognitive behavioural therapy would work to identify that thought pattern, challenge it and replace it with one that is more realistic and positive. Another treatment that works to eliminate self-harm is dialectical behaviour therapy (DBT). Dialectical behaviour therapy is typically used in those that have a personality disorder along with self-harm behaviours – this combination is common with borderline personality disorder too.

Medication Treatment for Self-Mutilation Psychiatric medication treatment for self-mutilation isn't common, but often people who self-injure need medication for co-occurring disorders like depression or bipolar disorder. If the person has no co-occurring disorder, medication may actually be discouraged, as medication can work to cover-up feelings that a person has to work through in order to stop the self-harm behaviour.

Self-injury treatment centres and programs exist when more intensive treatment is needed. Self-harm treatment centres may exist solely to handle self-mutilation, or they may treat other mental health issues as well. Self-injury treatment centres may offer programs that are: •Inpatient – a live-in self-harm treatment centre where the program is seven days a week •Intensive outpatient – a program that typically operates six-seven hours per day, Monday-Friday •Group psychotherapy – a program that may be two hours, once a week A self-injury treatment centre can provide many services. These services include: 23

Self-injury evaluation for proper program placement Individual, group and family therapy Impulse control management Education and support Medication and case management Aftercare planning Self-harm treatment centres typically provide a team of caregivers for each patient. This team may include: Psychiatrists, Clinical therapists, Registered nurses, Behavioural health support staff, Expressive therapists,

People who self-injure generally share these characteristics: •strongly dislike/invalidate themselves •are hypersensitive to rejection •are chronically angry, usually at themselves •tend to suppress their anger •have high levels of aggressive feelings, which they disapprove of strongly and often suppress or direct inward •are more impulsive and more lacking in impulse control •tend to act in accordance with their mood of the moment •tend not to plan for the future •are depressed and suicidal / self-destructive •suffer chronic anxiety •tend toward irritability •do not see themselves as skilled at coping •do not have a flexible repertoire of coping skills •do not think they have much control over how/whether they cope with life •tend to be avoidant •do not see themselves as empowered Unfortunately, many people don't understand self-injury. Many think self-harm is simply about getting attention. However, this is rarely ever the case and, generally, not one of the causes of self-injury. People self-injure to relieve tension and unwanted emotions. If someone is committing self-injury for attention, they are probably asking for help and need the attention.

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Sensory awareness for low functioning autism, learning disability and other brain related traumas. Sensory processing is integral to human existence, we all process sensory information from the environment which helps us to understand and recall memories associated with sensory stimulus. Two of the most common sensory organs are sound and vision. Over time, and with aging, the natural abilities of the senses fail, and we begin to use prosthetics like glasses or hearing aids, to enable us to engage in the environment. However, for people with a learning disability or with a diagnosis of autism, the sensory system is more fragmented and out of balance, which affects the person - behaviourally. In other words, the non-verbal person will act up or act out, to express what they are feeling inside. Often these episodes of acting out, can be damaging to the individual. By not understanding the reason behind the meltdown, the person’s needs are overlooked and could potentially cause another more disastrous scene, if their needs are not met. An example; A child who is non-verbal gets irritated, so they grab a cup and start drinking the water from the toilet bowl. Initially, the first thing you would do is tell them NO? that what they are doing is dirty and dangerous. The child on the other hand, is repeating a previous behaviour! The non-verbal child doesn’t understand this concept and hits you for stopping them or saying no. Before long, the original incident is forgotten, and a battle of wills ensues for the care giver and child. The child is offered a drink from the tap, the child receives the drink and throws the drink across the room? The care giver stops offering a drink and may even choose to ignore the behaviour. The child then gets something bigger and throws it at the TV, smashing the screen. Pandemonium ensues? Were the child’s needs met? No! The next time the child wants to communicate that they dislike something is to repeat the earlier behaviour of drinking from the toilet bowl, but the child is not doing this to get a drink. He’s doing this to get your attention to something, as this was the most recent memory the child has, that he recorded to memory. What the child is saying is; I don’t like the sound of the TV, turn it off, make it stop! The outcome: Broken Television. Child’s voice is heard or seen, in the chaos. Child stopped the noise, reduced the internal distress and irritation and is now being verbally punished, by caregiver!! When someone with limited verbal ability or has a brain injury and is unable to express what they are feeling, whether this feeling is fear or pain, they seek out or they avoid, certain stimulus. An example; a child that dislikes the texture of tight 25

clothing against his skin, may express this by aggression, irritation or anxiety. The child, unable to verbally explain that the clothing is uncomfortable, will inevitably react until either the clothing is removed, or they are soothed, by some other sensory object. Sensory processing is more easily understood when you analyse the anxiety and look deeper at the situation. As the earlier example shows, it’s not always clear what is being communicated and often, people will revert to a behaviour that got them results the previous time, even if the result was to get your attention! Sensory processing is an integral practice for every human individual. The main five senses are; sight, smell, taste, touch, and sound. Additionally, to this are another two senses, that are vital to human functioning. These two additional senses are vestibular and proprioception. The senses are activated by stimulus that records the response to memory which will also attach a specific sensory response. Such as; during early childhood, your mother made you wear something that not only felt heavy or uncomfortable, but also made you feel anxious and irritable. Your body made a mental note of the uncomfortable experience, the memory was attached to an emotional response and stored in the memory bank, for future reference. The next time you wear the said item, your anxiety will spike again, even at a time when you are at your most calm and serene. The emotional attachment relives the prior experience, thus creating another anxiety provoked situation, which could potentially escalate, into a neurotic or psychotic meltdown. As an adult, you avoid or have aversive reaction, to the item or texture! Anxiety is the common denominator in sensory processing, the effects of anxiety can be traced back to the original experience, which is the true cause of the person’s distress. The anxiety and how it is expressed helps us to identify what is causing the upset and when or where the original cause was created. Some sensory experiences may not have a pre-determining experience that can be reflected upon, some sensory experiences are due to an imbalance in the brain, which may have been caused at birth, or through a traumatic brain injury. Anxiety is a principal component to sensory processing – Anxiety is either hypersensitive or hyposensitive, and this is expressed in the persons behaviours!

Hypersensitive is Avoiding Anxiety or aversion to sensory stimulation and may not feel pain.

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Hyposensitive is Seeking Urges and compulsions, unable to recognise messy clothes and may demonstrate high pain threshold. Self-injurious behaviours If you were to put the two concepts at opposite ends of a spectrum, you would see that on end is the lower, unresponsive elements and at the other end is the higher, hypo response.

Hypo 10 + ----------- 5 + --------0

Normal 1 2 3 4 5 6 7 8 9 10

Hyper 0- --------- 5- ------------10 –

Most of us, who have a balanced sensory system range between the 3 to 6 level of anxiety. If one is late for an important event or meeting, the average person will feel their internal anxiety levels rising to hypo arousal, between feeling uptight and agitated. Hyper sensitivity and blocking out or numbing the internal chaos arising, to enable the person to function, the internal distress is avoided. Therefore, hypersensitive is to avoid uncomfortable stimulus, heightened anxious reactions are noticeable in the interaction and in the person’s behaviour. Hyposensitive, is to seek out and satiate the internal sensory drive, to enable, engage and/or motivate the person.  

Vestibular The vestibular is the sensory function that contributes to the sense of balance and spatial awareness and is directed by the inner ear, and the balance of water within the cochlear, within the cochlear is a labyrinth. For example, when you consume alcohol, your brain starts to feel lightheaded, your body starts to feel out of your control, you begin to slur words and your balance, or stride is impacted. These physical actions are evidence of the vestibular gyroscope within the inner ear, that has lost is stable position. Another example is someone who has an inner ear infection, these inner ear infections can have a detrimental impact on the physical body, thus Meniere's disease and also labyrinthitis are two ear disorders, that may not impact on sound, but does impact on the body’s ability to equilibrium or balance.

Hyposensitive (seek) Enjoys rocking, swinging Needs vigorous activity to get into gear (may present as hyperactive) 27

Adopt odd posture Need to be on the move to focus Restless Therapy Ball – bouncing on or lying over. Swings Use weight with movement. Rocking chair Vestibular dysfunction can be identified by the person’s behaviours; are they avoiding, irritated and anxious. These signs indicate that the person is uncomfortable and highly agitated. Think about how it feels to be sea sick, travelling on a choppy sea inside a boat, this experience is what is occurring inside the vestibular canals! Hypersensitive (avoiding) Ridged in posture Fearful of movement Don’t like travelling in vehicles Gravitational insecurity (don’t like feet off the floor) Difficulties changing direction and speed May lock joints to stabilise body Controlled, predictable movement (Linear). Reassure and explain what is expected (environmental obstacles) Adaptation i.e. rails etc. (Something for support) Weighted vests or blankets Balance boards Though proprioception is vital to sensing our bodies position in space and developing a sense of ownership of your body. This is especially clear when you consider just how easy it is to get your sense of your own body to contradict with what you see with your eyes.

Proprioception The brain integrates information from proprioception and vestibular system into its overall sense of body position, movement and acceleration. The central nervous system runs throughout the human body, alongside of this, is the peripheral nervous system, which corresponds with the internal and external environment. Proprioception is the bodies awareness of itself in the space it holds. Rather than sensing external reality, it is the sense of the orientation of one's limbs in space. This is distinct from the sense of balance, which derives from the fluids in the inner ear. Without proprioception, we'd need to consciously watch our feet to make sure that we stay upright while walking. 28

Proprioception doesn't come from any specific organ, but from the nervous system. Its input comes from sensory receptors distinct from tactile receptors — nerves from inside the body rather than on the surface. Inside the ear canal, we have a vestibular canal and the sense of balance is dependent on the flow of air along the fine hairs within the ear canal, allowing the flow air within the ear. When this system is affected or impaired, imbalance, unsteadiness and poor verbal communication is observed. The ear canal houses millions of tiny hairs, that instructs the sound waves to flow through the ear and to the brain. When this system is damaged or impaired, poor balance and poor hearing can be observed. Proprioception runs alongside the central nervous system and the peripheral nervous system. The two nervous systems are the bodies channels to receive information from the external environment and also to send internal information to the brain for the neural response needed to complete the task. Many disorders demonstrate evidence to the internal damage of the sensory processing system. The senses can work individually, but they tend to work with another of the senses for memory or emotional storage and retrieval. Proprioception -Lack of body awareness – sense of self – trouble distinguishing self from non-self.

Hyposensitive (seeking) May appear to be aggressive/ rough in approach Exert too much pressure Difficult in manipulating small objects (buttons) Stomp when walking Push, bang and pull too hard Chew on objects and clothing Enjoy tight clothing, belts, jackets Self-Injurious behaviours Activities to try: Any activities that requires movement Weight (deep tactile pressure) this makes movement more strenuous Around the home: 29

Hoovering, sweeping Laundry, hanging out wet washing Gardening Shopping, carrying heavy objects The brain — particularly the cerebellum — takes information from all of these proprioceptive inputs to try to determine the location and movement of body parts. But the way we sense our body and its motion generally involves more than just proprioception.

Experimenting with two senses; Take a banana or melon, pinch your nose and chew the food. Can you TASTE ANYTHING? Before swallowing, release your hand off your nose and swallow the food……What happened? Blindfold a friend and try to instruct them to direct food into your mouth, with your hands behind your back…..Frustrated yet! Close your eyes and touch your nose. If everything is working properly, this should be easy because your brain can sense your body, as well as its position and movement through space. This is called proprioception. But how does this "sixth sense" work — and what happens when it clashes with other senses? Sensory processing = over stimulation and under stimulation of the senses.

Tactile Tactile or touch, it the ability to experience and identify, sensations against the body and skin. Sometimes tactile deficits can overlap with proprioception deficits. Tactile can be anything from soft touch, to hard pinching and crushing sensation, against the body. Children who are sensitive to touch sensations and can be easily overwhelmed by, and fearful of, ordinary daily experiences and activities. The sensory system is most noticeable by observing behavioural human responses. Someone who records low on the sensory scale, will avoid the stimulation by acting out uncharacteristic, or in an irritated manner, due to the increased anxiety inherently felt. Tactile sensory stimulation can be light touched, such as a feather stroking gently against the skin to the opposite and needing deep pressure massage. Often, with tactile deficits, the person needs either tighter clothing, to enable the peripheral nervous system to understand where their body is, or they may need looser clothing, to reduce the anxiety felt, from tight items. People will either react aggressively, or look scared, anxious or in pain. 30

How to help Reassure the person you know they don’t like touch. If touch is necessary, inform the person beforehand and use deep pressure touch Be aware of our own input and any environmental stimuli. Remember it could be something that seems insignificant to us.

USE MOVEMENT (proprioception) Chewy tubes can have a powerful effect for oral tactile seeking behaviours. It's all about the way in which one's nervous system interprets touch sensations and stimulation. I suspect you too would react with a "fight back" or "flee" response if any of the above listed items to YOU felt like sandpaper rubbing against your skin or 10 spiders crawling up your arm that you can't get off. This is the lived experiences for someone who has an impaired sensory system.

Auditory and sound Sound is often overlooked for people with autism and learning disability, yet this sense is usually the one that is overwhelmed the most, along with visual. A sensory impairment in sound can be due to the environment being too loud and distracting, even the hum of the fridge can drive a sensory audio sensitive into a frenzy of anxiety. Some people wear earphones to help block out sound, sound therapy is most beneficial for someone with a prominent auditory impairment.

Hypersensitive (avoiding) Hands over ears Sleeping problems Grimacing Flee noisy situations at all costs Responds negatively to unexpected or loud noises. Unable to concentrate, sit still Makes repetitive sounds to block out surrounding sounds Sometimes a small sound proof room or a dark room can be extremely calming for the overstimulated child. If neither option is available, consider a corner that can be used as a cave that can be covered with dark blankets to give the effect of a closed off space. This helps the over stimulated child some down time way from the bombarding stimulation around them and enable them to manage self-control.

Hypo sensitive (seeking) Activity with movement (proprioception) Pre-warn Use ear plugs 31

Facilitate the person to leave a noisy environment to find a quiet space.

Olfactory smell Sensory deficits with smell and taste can be isolated, (singular) or they go hand in hand. Thus, someone who has a poor sense of smell, will also have a muted sense of taste. Someone with poor sense of smell may be drawn to strong scent, including offensive scents. Someone who has an over active sense of smell, will be offended and irritated by this. Some perfumes can impact on the therapist/client engagement affecting recovery. Offer a variety of tastes, texture and smells to explore before meal times, bearing in mind that these need to be powerful i.e. grapefruit, olives, lemon. It is important that these are changed on a regular basis to ensure a variety and to ensure the maximum effect. Hyposensitive (seek) Smell self, people and objects Smear faeces Seeks strong odours Pica (eats anything even the inedible) Mouths and licks objects Regurgitates

Taste Taste can sometimes be under responsive due to the person preferring spicy, sweet or bland flavours. Smell and taste can both have a direct impact on the autistic person. Some people seek out and eat dangerous substances to enable them to TASTE something. The sense of smell is designed to indicate if something is safe to consume. When this is impaired, the person eating faeces' or any other harmful substance is consuming the substance, to EXPERIENCE FLAVOUR. This is seeking sensory behaviour.

Hypersensitive (avoid) Sensitive to smells can be over arousing Memories are triggered by smells 32

Prefer bland food Will use tip of tongue to taste May gag easily Dislikes brushing teeth Think about perfumes and body smells Always pre-warn the person what is coming next Always take it slow never force stimulation

Visual Visual impairment is also a critical sensory system for the person with autism or brain injury. The visual sense can be overwhelmed by the bright lights in a room, or even the wallpaper on the lounge wall can have a stimulating and excitation effect on the visually sensory impaired.

Hyposensitive (seek) May be fascinated by strips/patterns Is attracted to light Looks intensely at objects & people Likes playing in water Likes moving parts (wheels) People that flick their hands in front of their eyes or rock back and forth are seeking stimulation. This is called stimming, where the person repeatedly waves a hand in front of their eyes or clicks their fingers consistently, are seeking visual stimulation. Some children want to rip up paper and flick it into the air or become fascinated or stare into space. Bright lights, flashing hand balls, pictures with detail and colour all attract the seeking sensitive child.

Hypersensitive (avoids) Sensitive to lights i.e. bright fluorescents & flashing lights Red & bright yellow can be overwhelming Eye contact may be painful Speed of things can appear larger & more frightening Flicking fingers or objects in front of their eyes Hesitates or refuses to go up & down stairs Things to try; Soft lighting i.e. lamps (avoid florescent lights) 33

Use soft colours Do not force eye contact Understand that a sensory need is a physiological need!!!! Our brain needs it so we can function, the same way a diabetic needs insulin. Before we expect a person to do a functional task, we need to give them a sensory “fix”. Be guided by what a person can tolerate, be aware when they are over/under aroused. The just right challenge. We offer people a sensory fix throughout the day as you do with a nutritional diet to enable a consistent calm and alert state. People will gravitate to activities that give them what stimulation they need in order to feel as calm and orientated as possible. When one sensory system is out of sync it is almost certain that others will be too. Things to help sensory processing deficits TheraBand – for proprioception and to stimulate the muscles Peanut ball or trampoline for vestibular stimulation Weighted blanket Pressure vests Weighted or heavy clothing Reducing stimulation from environment Feathers and other soft materials for tactile stimulation Chewing tubes for oral stimulation and proprioception Activities at home to support proprioception Hoovering Mopping Carry heavy loads Pulling or dragging a heavy bag Smells or favourite scents on clothing Activities in the environment Carrying items during shopping trips Trampoline, hopping games. Weighted back pack for walks  

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