Matching needs with provision to make a dog’s doodah EHCP (Part 2)

Dog in a bow tie with the words Matching needs with provision to make a dogs doodah EHCP (Part 2)

This is the follow up post about the dog's breakfast EHCPs produced by Oldham. In part one, I outlined what's wrong with Oldham's EHCPs, its autism SEND provision and why. In this post, I'm going to show you how I've worked on the plan of a young man I'll call Dan Smith. Dan is a 15-year-old young man who is not a pupil at BFS, who has recently been diagnosed with autism, and who has some very serious mental health difficulties.

Before I share Dan’s Plan, I will nail my colours to the mast in terms of my personal philosophy, and that of Bright Futures School, on autism education and support, as this is front and centre later on when we look at provision to meet needs.

Those of you who have followed my previous posts on SNJ will know that I am a Relationship Development Intervention (RDI) Consultant and that RDI is one of the few autism interventions that meets the criteria outlined in NICE clinical guidelines CG170 for social communication interventions that seek to work on the core difficulties at the heart of autism.

It is my firm belief, based on personal experience with my own son as well as experience in supporting other children and young people at Bright Futures School, that it is the impact of autism that presents the greatest barrier to autistic children and young people accessing the curriculum in schools. If a child experiences sensory overload, or cannot cope with uncertainty and unpredictability, or cannot take part in joint engagement with another, or struggles to regulate their emotions, or cannot take on board the perspectives of others in order to inform their decision-making, or has great difficulty making and maintaining friendships, or does not lay down episodic memories of competence and success, then they are going to find it difficult (for some it is impossible) to engage in learning and in wider school social opportunities.

Compensation vs. remediation

We can work around, or compensate for these difficulties – which is what most schools tend to do. Or, we can jump waaaaay outside the box and actually put in place the conditions that give these kids another chance to master the developmental milestones that they have missed (or partially missed) when autism took them down a different developmental pathway. In doing so, we work directly on those core autism difficulties and it is possible to actually decrease the severity of a child’s autism. So says this research published in The Lancet in 2016, which followed up the biggest randomised controlled autism trial ever – the PACT study.

The ‘conditions’ I refer to above have a name – the ‘guided participation relationship’ (GPR) which I have written about previously for SNJ. I have also shared video footage of what the GPR looks like and the impact it has on a child’s ability to engage in learning (and more broadly, in life) by sharing this video footage of one of our pupils at BFS before we used RDI and 12 months after using RDI at school. That is powerful footage and tells you everything you need to know about what is possible when using a social communication approach that meets the criteria in the abovementioned NICE guidelines.

So you can see that when it comes to Section F, my additions are going to involve recommendations for social communication provision.

Dan’s EHCP

Back to Dan’s EHCP - I started off with a forensic analysis of the ‘expert reports’ that accompany the EHCP: in this case, this consisted of his ADOS diagnostic letter from the Clinical Psychologist, a report from the CAMHS worker who worked with him for over a year, and a report from the Educational Psychologist.

In Section B of his EHCP (below) the ordinary text is what was included by the local authority’s EHCP officer. The text in bold is what I included after going through the expert reports with a fine toothcomb to make sure that all the needs were identified at Section B.

Section B

[Section B Parents proposed amendments in bold. Parents proposed deletions in boldstrikethrough]

Dan’s Special Educational Needs
Communication and Interaction
Need 1: Eye contact was poorly modulated and tended to be avoidant

Need 2: Dan can struggle to read peoples moods using their facial expression

Need 3: - Dan’s language used can be dry and matter of fact in tone.

Need 4: Mum notes he can be very literal and black and white in his thinking. He can appear matter of fact in the things he says.

Need 5: Dan can have a glazed look when spoken to and he is monotone in his response.

Need 6: Mum notes he never exaggerates and can lack imagination. In Dan’s ADOS assessment it was noted that he showed little spontaneous creative activity and that there was no symbolic representation of objects

Need 7: Dan can be very minimal in his response during conversation, he appears to struggle opening up to people and he showed no examples of emphatic gestures

Need 8: - While Dan has a group of friends he sees less of them.

Need 9: Dan did not express any enjoyment throughout his assessment, gave minimal descriptions of his own affect and struggled to provide answers when asked about these

Strength: - Dan has had a group of friends in secondary school and they still keep in touch via social media though Dan sees less of them now.

Need 10: Dan’s insight into friendships lacked the insight that might be expected for his age

Need 11: Dan showed limited indication of responsibility for his own actions

Cognition and Learning
Need 12: - Dan has a diagnosis of dyspraxia and experiences difficulties associated with this condition, like problems with personal organisation, feeling overwhelmed in situations, motor planning and very slow production of written work.

Strength: - Dan presents as an able boy and some recent ability testing carried out by Mrs P, School SENDCo, suggested that his verbal ability is above average and nonverbal ability in the average/low average range.

When Dan was regularly attending in Year 9, his attainments were close to age related expectations albeit with slow progress in some subjects and some effort grades rated only as ‘satisfactory’ or below that.

Need 13: - In March 2016 the majority of his grades (8/13) were at Level 5a or above, though for half of those subjects Dan received an effort grade of C or below. It maybe that his increasingly passive and depressed presentation was perceived as a lack of effort, though he was receiving higher effort grades in other subjects (like Science, Drama and PE).

Need 14: - Dan’s reading and spelling development were reported as being slower than others and parents requested an assessment for dyslexia which Mrs P carried out. The assessment results did not indicate dyslexic difficulties, with reading accuracy, spelling and reading comprehension all in the average range An assessment of Dan’ handwriting showed that he had a significantly slow rate of writing.

Need 15: - Dan agreed that frustration can arise from having a ‘quick mind’ and slow production. He also noted that he has always found personal organisation hard, being in the right place at the right time with the right things and this can make him feel anxious and overwhelmed.

Need 16: - School reports had described him initially as overly talkative (“he’s a distracter”), often needing refocussing on tasks. More recently, his presentation in class was lethargic and withdrawn.

Social, Emotional and Mental Health
Need 17: - Dan can struggle to read people’s moods by their facial expression; possibly he finds this easier by tone of voice. Dan can become distressed if people don’t give him focus when he’s talking to them. He often prefers to isolate himself and Mum notes he can be very insular. Often Dan is known to sit on his own at parties and at school. He will prefer the company of younger children when at family gatherings.

Strength: - Dan has a keen interest in computers where he can spend hours discussing the components with friends, and is able to build them from scratch. He also is an excellent drawer and uses his computer to do this. Dan will talk at length to people about things that he is confident with and things that spark his interest.

Need 18: - Over the last 18 months Dan has struggled with profound feelings of depression. He has withdrawn from social activities and social contact with peers, and presented with low mood, low appetite, excessive sleeping and poor self-care. He is struggling with feelings of low self-esteem and hopelessness and ‘stuck’ in a vicious cycle of not feeling able to access experiences that would challenge his negative state of mind.

There are days when Dan will engage with some activity, either work sent from school or following his own interests, though he needs to be actively prompted to do anything and sustaining interest in activity is hard for him.

Need 19: His motivation for doing any activity is very low and there are times when he will not get out of bed or leave his room. He has withdrawn from activities he used to enjoy, like Youth Club, Duke of Edinburgh scheme and brass band. His self-care is low, with personal hygiene becoming an issue, especially around changing his clothes which he is reluctant to do.

Dan went through a period of self-harming and was reported to be involved in a social group who were interested in exploring self-harm. He threatened suicide on one occasion and was taken to Accident and Emergency.

Need 20: - Dan can get upset easily if there are changes to routine or activity he is expecting. He will need a clear explanation giving, and needs preparation to adjust to the change. He struggles to follow lists and needs instructions being given to him clearly and directly. Dan has been known to become very distressed if he loses a possession. He is likely to notice small changes to his environment.

 Download this needs chart as a PDF here

As you can see, I've numbered each of the needs (above) in order to ensure that these can each be mapped to provision in Section F.  Seven needs are missed/omitted in ‘communication and interaction’. ‘Cognition and learning’ and ‘social, emotional and mental health’ are well described, based on what’s in the reports.

Section F–SEND Provision - More lowlights!

However, when it came to provision, this is where it went spectacularly pear shaped!

This has been added as three images so you don't think it's something to aspire to and try to copy it. Click each image to enlarge. To enlarge further, right click to "open in new tab"

I’m not going to go through each point here because, well…..meh, but let’s just take a quick look at a couple of examples:

‘Work should be undertaken with Dan around evidence-based practical self-help strategies’  ……..eh? What does that mean? What work? What self-help strategies? To address which need and to achieve what? Over what time frame and what are the success criteria?

‘Close cooperation between home, school and external agencies with positive messages and good practice shared between services involved overarching outcomes.’ ……..again, eh? Close cooperation on what? For what purpose and to address which need? Positive messages about what? Good practice in achieving what? Over what time frame and what are the success criteria?

‘Information to be provided using visual means to support further instructions’……nowhere in any of the expert reports is there a reference to visual strategies being appropriate for Dan. But let’s just throw that one in there, because that’s what all children and young people with autism need, innit?

‘Support to be provided around improving his social interactions with peers within the education setting’…….what support? Over what time frame and what are the success criteria?

*Sigh*

Section G – Health Provision

Again, a photo or poor practice that you can enlarge if you feel like it...

Bad EHCP Section G - Health
Bad EHCP Section G - Health

‘For Dan to form therapeutic relationship enabling him to open up and think about emotional experience and difficulties’…….therapeutic relationship with whom? Healthy Young Minds (CAMHS) are listed as the provider for this input but letters from both the Clinical Psychologist and the HYM support worker state clearly that Dan was unable to form a therapeutic relationship with either practitioner. They worked with him for 18 months so if it’s not come together in that time, it ain't happenin’. Both practitioners recommend in their letters that Dan is provided with experiential learning in an environment that uses a social communication approach. This is omitted from the EHC Plan.

Dan to have a personalised programme giving him an insight into responses in different social situations, support skill development and confidence. Intervention in this area should start with discussions with Dan about social situations he finds easy and those he finds difficult, with exploration of the trigger pathways in thinking and feeling that are connected to these situations. The programme should be delivered weekly and in combination with goal setting and behaviour rehearsal in real life situations’………….again, HYM are recorded as the provider for this input – but they don’t even make this type of provision….!!!

Para 9.73 of the SEN Code of Practice states that where health or social care provision educates or trains a child or young person, it must appear in section F rather than Section G. Provision in Sections B and F is capable of being appealed at SEN tribunal. Provision in Section G is not. A ‘personalised programme giving him an insight into responses in different social situations, support skill development and confidence’ sounds to me like provision that ‘educates and trains’ a child.

I’ll just leave that there.

Section H1 - Social Care - the pain continues

Bad EHCP H1 Social Care
Bad EHCP H1 Social Care

‘Dan will be engaging in purposeful leisure and social activities enabling him to develop appropriate friendships and relationships with peers’……because by engaging in purposeful leisure and social activities Dan will automatically and miraculously start to develop appropriate friendships. He just will. Despite the fact that he is already engaging in some purposeful leisure and social activities and hasn’t developed any meaningful and lasting friendships over the past 15 years and despite the fact that he hasn’t mastered the appropriate developmental milestones that would enable him to be successful in making friends.

And in any case, surely that is an aspiration, not a statement of provision….?  Dog’s breakfast……I rest my case, m’lud.

Mapping provision to each need - the way we do it

One of my all-time bugbears with all of the EHCPs I’ve seen is that it is extremely difficult to see how provision relates to needs, as the sections are so far away from each other and there is no cross-referencing. In my view, this makes it very easy for authors of EHCPs – by accident or by design – to omit key provision from the Plans.

In order to address this for Dan’s EHCP (and for all EHCPs I am now subsequently involved in), I have put together a simple table that allows provision to be directly mapped to each need.

All of the provision can be met by a social communication approach (such as RDI) which meets the criteria outlined at 1.3.1 of the NICE guidelines GC170. Because what else has been shown by peer reviewed research to address core autism difficulties? Here goes…..

Needs from Section B Provision required at Section F
Need 1: Eye contact was poorly modulated and tended to be avoidant Dan should be supported by adult guides (including parents) on a 1-1 basis to work on understanding and using all the channels of non-verbal communication during authentic activities.

This should be done by suitably qualified adult guides within a communication framework that the guide can use to enable Dan to step into his co-regulatory (socially reciprocal) role in activities that provide numerous opportunities to engage with mental challenges in a playful, curious, manner. Dan needs this provision for 4 hours per week across different adult guides on a 1-1 basis and progress can be monitored against different levels of mastery of each objective.

Need 2: Dan can struggle to read peoples moods using their facial expression
Need 3: Dan’s language used can be dry and matter of fact in tone.
Need 4: Mum notes he can be very literal and black and white in his thinking. He can appear matter of fact in the things he says.
Need 5: Dan can have a glazed look when spoken to and he is monotone in his response.
Need 6: Mum notes he never exaggerates and can lack imagination. In Dan’s ADOS assessment it was noted that he showed little spontaneous creative activity and that there was no symbolic representation of objects Dan needs to be supported to better manage uncertainty and unpredictability by using the non-verbal information from adult guides to help him decide what to do when faced with a challenge. The guide should pitch the challenge at the edge of Dan’s competence and then scaffold and then spotlight Dan’s success so that he can lay down episodic memories of himself competently managing uncertainty.

Dan should also be supported to manage uncertainty by participating in ‘stop and think’ scenarios where he can generate a number of options for different responses to uncertainty and link his feelings to each of the responses.

This should be done on a 1-1 basis by suitably qualified adult guides within a communication framework that the guide can use to enable Dan to step into his co-regulatory (socially reciprocal) role in activities that provide numerous opportunities to engage with mental challenges in a playful, curious, manner. Dan needs this provision for 4 hours per week across different adult guides on a 1-1 basis and progress can be monitored against different levels of mastery of each objective.

Need 7: Dan can be very minimal in his response during conversation, he appears to struggle opening up to people and he showed no examples of emphatic gestures Covered by provision for needs 1-5
Need 8: - While Dan has a group of friends he sees less of them. Covered by provision for needs 10 &11
Need 9: Dan did not express any enjoyment throughout his assessment, gave minimal descriptions of his own affect and struggled to provide answers when asked about these Dan needs to be supported by adult guides to recognise his own and others’ emotions and to be able to use this recognition of emotion to inform his communicative responses.

This could be achieved by doing mind mapping and role play work relating to real life situations where both partners take turns to play out their own and their partner’s feelings in response to different ways of responding to a challenge.

This should be done by suitably qualified adult guides within a communication framework that the guide can use to enable Dan to step into his co-regulatory (socially reciprocal) role. Dan needs this provision for 4 hours per week across different adult guides on a 1-1 basis and progress can be monitored against different levels of mastery of each objective.

Need 10: Dan’s insight into friendships lacked the insight that might be expected for his age Dan needs to work with a variety of adult guides across all settings who can support him to take equal responsibility for communicative ‘housekeeping’ (initiating interaction, making communicative repairs, ensuring the listener is ready for their turn, ensuring that actions are taken to keep the interaction on track, to elaborate on interactions to maintain partner’s interest).

This should be done by suitably qualified adult guides within a communication framework that the guide can use to enable Dan to step into his co-regulatory (socially reciprocal) role during activities that provide numerous opportunities to engage with mental challenges in a playful, curious, manner. Dan needs this provision for 4 hours per week across different adult guides on a 1-1 basis and progress can be monitored against different levels of mastery of each objective.

Need 11: Dan showed limited indication of responsibility for his own actions
Need 12: - Dan has a diagnosis of dyspraxia and experiences difficulties associated with this condition, like problems with personal organisation, feeling overwhelmed in situations, motor planning and very slow production of written work. Need recommendations from expert report/s
Need 13: - In March 2016 the majority of his grades (8/13) were at Level 5a or above, though for half of those subjects Dan received an effort grade of C or below. It maybe that his increasingly passive and depressed presentation was perceived as a lack of effort, though he was receiving higher effort grades in other subjects (like Science, Drama and PE). Dan needs to be supported by an adult guide on a 1-1 basis to work on responding to and using experience-sharing communication rather than instrumental communication.

He also needs to be supported to take part successfully in co-regulatory interactions where joint success can be spotlighted so that he lays down episodic memories of competence and reciprocity. This will start to develop his motivation for social interaction, which in turn will lead to increased enjoyment of connecting with others.

Dan needs to be supported by an adult guide to seek and share different perspectives and to use this information in order to help him decide how to respond reciprocally.

This should be done by suitably qualified adult guides within a communication framework that the guide can use to enable Dan to step into his co-regulatory (socially reciprocal) role during activities that provide him with numerous opportunities to engage with mental challenges in a playful, curious, manner. Dan needs this provision for 4 hours per week across different adult guides on a 1-1 basis and progress can be monitored against different levels of mastery of each objective.

Need 14: - Dan’s reading and spelling development were reported as being slower than others and parents requested an assessment for dyslexia which Mrs P carried out. The assessment results did not indicate dyslexic difficulties, with reading accuracy, spelling and reading comprehension all in the average range An assessment of Dan’s handwriting showed that he had a significantly slow rate of writing. Need OT recommendations
Need 15: - Dan agreed that frustration can arise from having a ‘quick mind’ and slow production. He also noted that he has always found personal organisation hard, being in the right place at the right time with the right things and this can make him feel anxious and overwhelmed. Covered by provision for need 6
Need 16: - School reports had described him initially as overly talkative (“he’s a distracter”), often needing refocussing on tasks. More recently, his presentation in class was lethargic and withdrawn. Covered by provision for needs 9, 10, 11, 13
Need 17: Dan can become distressed if people don’t give him focus when he’s talking to them. He often prefers to isolate himself and Mum notes he can be very insular. Often Dan is known to sit on his own at parties and at school. He will prefer the company of younger children when at family gatherings. Covered by provision for needs 8, 9,10,11,13
Need 18: - Over the last 18 months Dan has struggled with profound feelings of depression. He has withdrawn from social activities and social contact with peers, and presented with low mood, low appetite, excessive sleeping and poor self-care. He is struggling with feelings of low self-esteem and hopelessness and ‘stuck’ in a vicious cycle of not feeling able to access experiences that would challenge his negative state of mind Covered by provision for needs 9, 10, 11,13
Need 19: His motivation for doing any activity is very low and there are times when he will not get out of bed or leave his room. He has withdrawn from activities he used to enjoy, like Youth Club, Duke of Edinburgh scheme and brass band. His self-care is low, with personal hygiene becoming an issue, especially around changing his clothes which he is reluctant to do. Covered by provision for need 9,10,11,13
Need 20: - Dan can get upset easily if there are changes to routine or activity he is expecting. Dan needs to be supported to better manage uncertainty and unpredictability by using the non-verbal information from adult guides to help him decide what to do when faced with a challenge. The guide should pitch simple challenges at the edge of Dan’s competence and then scaffold and then spotlight Dan’s success so that he can lay down episodic memories of himself competently managing uncertainty.

Dan should also be supported to manage uncertainty by participating in ‘stop and think’ scenarios where he can generate a number of options for different responses to uncertainty and link his feelings to each of the responses.

This should be done by suitably qualified adult guides within a communication framework that the guide can use to enable Dan to step into his co-regulatory (socially reciprocal) role during activities that provide him with numerous opportunities to engage with mental challenges in a playful, curious, manner. Dan needs this provision for 4 hours per week across different adult guides on a 1-1 basis and progress can be monitored against different levels of mastery of each objective.

Download Matching needs to provision  as a PDF here

Simples, right? Dan’s Mum has recently submitted the above amendments to the EHC Officer and has made a request for a Personal Health Budget to meet needs relating to mental health.  We’re going to be about as popular as a dose of the Pox.

Is the table that maps provision to needs the dog’s doodahs? Maybe not (it made a good title though J)……but at the very least it enables us to make sure that a specific provision is outlined for each individual need which then makes progress much easier to monitor. And……erm….the EHCP is now compliant with the law.

Challenges to services

It is clear that Dan’s needs as identified in ‘communication and interaction’ and ‘social, emotional and mental health’ are needs that arise as a direct result of the core difficulties in autism. This is true of all the other EHC Plans for children with autism that I have seen or been involved with.

Yet none of the recommendations made in any of the Speech and Language Therapy, Educational Psychology and Clinical Psychology reports relating to any of these children’s EHC Plans met the criteria outlined in the NICE guidelines (CG170) for approaches that seek to address core autism difficulties.

We have come full circle as this relates directly back to some of my observations of what might contribute to poor autism-related practice – in particular that the condition of autism is poorly understood by expert professionals whose reports are used to make recommendations in EHC Plans; that recommendations that are based on ‘received wisdom’ that has little or no evidential basis in peer reviewed research or evidence-based practice;   and that autism is a condition that results in developmental gaps yet recommendations for provision are not informed by a detailed assessment of the child/young person’s developmental gaps.

In future posts, I will share some of the challenges I have made to services on these and other, related points, together with their responses.

Tin hats at the ready………

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Zoe Thompson
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Zoe Thompson

Head of Development at Bright Futures School
Zoe Thompson is the Head of Development at Bright Futures School. At Bright Futures School, alongside the academic curriculum, we run a curriculum that helps to foster social and emotional development in children with autism. Recognising that autism is a developmental disorder, we use an approach that seeks to fill the developmental gaps that kids have missed out on. We work on a range of competencies including social referencing, joint attention, co-regulation and self-regulation.
Zoe Thompson
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