What more can be tried?

    Case study

    Situation: Gareth Green is 16 years old and is on a full care order until he is 18. He has no family contact – they want nothing more to do with him. He has had a series of foster care, children’s home and residential school placements, all of which have broken down for mainly behavioural reasons. He has not lived at home now for more than eight years. He has recently been diagnosed with attention deficit hyperactivity disorder (ADHD) and Asperger’s syndrome. Gareth is prescribed Risperdal (medical name Risperidone, a new “atypical” anti-psychotic drug thought to be less toxic with fewer unwanted effects than older drugs) by his psychiatrist for his agitation, mania and aggression. 

    Problem: Gareth has repeatedly assaulted vulnerable female staff at the crisis centre where he has been placed for the past 18 months. His social worker believes the staff are well intentioned but untrained. Following a recent attack on a female member of staff, he was arrested by police and cautioned. Gareth has been referred to a specialist child and family service, with disappointingly little progress. He is also oblivious of upsetting students at his current school placement out of borough. He is a tall, strong young man who can be quite intimidating; he sometimes masturbates in front of staff and touches them. The social worker is now at a loss about what to try next.

    Panel responses

    Karen Fletcher
    Having only recently being diagnosed with ADHD, Gareth has lived with the negative effects of this condition for most of his life. Not only do young people with ADHD underachieve at school, most have poor self-esteem, especially those who have not been diagnosed. They will have been labelled as disruptive and constantly told off for bad behaviour.

    Gareth has also been diagnosed as having Asperger’s syndrome – a mild form of autism (more than half of young people with ADHD are likely to have an associated condition, known as a co-morbidity). This affects his social behaviour, including his ability to pick up social cues, and causes difficulties with communicating, co-ordination and social relationships. Both conditions are probably significant in the problems he has experienced at home, his current behaviour patterns and apparent oblivion to upsetting his peers.

    First, we need to ensure that he is taking the right medication and then educate Gareth, his carers and teachers about his conditions, helping Gareth come to terms with them. Those working and living with him need to understand that how he acts is part of his biological make-up, which he cannot help. However, it can be managed.

    Gareth needs to be taught organisational skills, understand the consequences of his behaviour and learn social skills. Carers and teachers must think before they act; don’t get into downward-spiralling arguments as those with ADHD never back down (I know from experience). You must learn to ignore all but the serious misbehaviours, keep instructions simple and use an unemotional, controlled voice.

    Routine is essential as is building self-esteem, and good behaviour should be rewarded frequently. Gareth should be encouraged to try out sports, hobbies and interests and find something to excel at.

    Gareth and his carers also need to learn anger management techniques and work on sex education. Finally, Gareth may benefit from a support group for teenagers with ADHD to help build self-esteem, and to look at tips for organising themselves, how to use their ADHD positively and what type of training and careers may best suit them for adulthood.

    Jill Thorburn
    As a 16-year-old looked after by the local authority Gareth is an eligible young person under the Children (Leaving Care) Act 2000. This means he is entitled to a personal adviser, financial support and a pathway plan. He is currently appropriately placed but the local authority has a responsibility to make arrangements for his accommodation into adulthood.

    As Gareth has complex needs, his pathway plan should take account of a referral to a transition co-ordinator to facilitate the move between children and adult services. The transition co-ordinator would work with the personal adviser to ensure a fluid assessment process.

    In consultation with the psychiatrist Gareth’s existing medication should be reviewed. Risperidone is an anti-psychotic drug and may not be appropriate for ADHD or Asperger’s syndrome. Consequently it should be assessed whether the two true components (attention deficit and hyperactivity) of the four aspects of ADHD are present. This may be evident as his medication has not positively affected his behaviour.

    It is likely that Gareth is statemented as having special educational needs under the Education Act 1996. Therefore, the school special educational needs co-ordinator would need to be involved and offer education colleagues raised awareness of a behaviour management plan for the remainder of his educational placement. This plan should be multi-agency and include the learning mentor and Connexions personal adviser. This would also increase Gareth’s contact with people outside of his school and care home. For example, a Connexions personal adviser would be able to look at Gareth’s interests and leisure activities. This is particularly important because of his lack of family contact. Part of the wrap-around package may be funded through additional money available to the school through stage five code of practice for special educational needs to purchase additional one-to-one support within the school environment.

    A behaviour and risk management plan needs to be agreed between all those involved in Gareth’s care. A training programme for the care home staff is required and this may be therapeutic crisis intervention coupled with an individual crisis management plan. Consideration for these techniques would be based on assessment of Gareth’s communication abilities.

    User view

    Gareth has obviously had very little stability over the past eight years, writes Mark Houston. Lack of stability, particularly during childhood, is hard for anyone, but for someone with an autistic spectrum disorder, it is even worse. 

    Gareth is clearly frustrated with life. He has only recently been diagnosed with Asperger’s syndrome and ADHD; he has probably been misunderstood by other people for the majority of his life.  

    His anxiety levels are probably very high. I doubt he has anyone he feels he can confide in regarding his worries. Asperger’s causes him difficulties with understanding other people. He is probably unable to verbalise his feelings and emotions in the way that most people can and hence his frustrations come through by means of violence.  

    At 16 years old, Gareth is sexually developed and physically attracted to others. But, added to his inability to work out what behaviour is and isn’t appropriate in different situations, Gareth is unable to deal with his sexual frustrations in what most people would regard as an acceptable way. He needs specialist support in this area. 

    In my opinion, Gareth has been wrongly placed at his current unit, where the staff are not trained sufficiently. But there is no instant fix. Stability is crucial and he must feel he is with people with whom he can discuss his feelings. I believe that people might be able to understand how he is feeling if he is given the right support. 

    It is still important that Gareth is given opportunities to mix with other people, with support. I would want Gareth to be following parts of the national curriculum, but, balanced with that, there needs to be a strong focus on learning social, communication and life skills. 

    Because of Gareth’s social difficulties it may not be appropriate to place him in a mainstream school, but it would be equally inappropriate to place him in an environment where everyone else has severe social difficulties, giving Gareth no role models to follow. For this reason, I believe that he should be placed with experienced foster carers who are able to devote their time to him and don’t have other children living with them. It is critically important that social services still have a lot of involvement with him and give full support to his foster carers. I believe that, after a time, Gareth will make significant progress. 

    Mark Houston is a care leaver who was diagnosed with Asperger’s syndrome when he was 13.

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