ASD assessment and Safeguarding challenges Dr Rachel Brooks

Safeguarding challenges What do we mean by safeguarding ? Why safeguarding should be part of our assessment. What particular issues arise in children with social and communication disorders

Case history 11 year old child diagnosed with severe autism Serious incidents of DA 2006 and 2008 resulting in MARAC process 3 The Multi Agency Risk Assessment Conference is a formal conference, convened in response to all cases of domestic violence where the risk is identified as “high”. The purpose is for agencies to share information to identify those at a high level of risk of serious harm and construct management plan to provide professional support to all those at risk, including children in families

Serious case review Further incident of DA 2010: mother wishing to separate from husband and moved into hotel with child. Other child remained with father Mother disengaging from support services. School attendance deteriorating Police called to hotel and found child’s body: mother said she had strangled him and attempted to take her own life 4

Safeguarding ‘the process of protecting children from abuse and neglect, preventing impairment of their health and development, and ensuring they are growing up in circumstances consistent with the provision of safe and effective care that enables children to have optimum life chances and enter adulthood successfully.’ Working together definition Be healthy Stay safe Enjoy and achieve Make a positive contribution Achieve economic wellbeing Every child matters Be healthy Stay safe Enjoy and achieve Make a positive contribution Achieve economic wellbeing Every child matters

How likely are we to meet Safeguarding issues? Population risks of child abuse and neglect 9% Gilbert et al Lancet vol 373 issue 9657 Jan Physical abuse Sexual abuse Emotional abuse Neglect Physical abuse Sexual abuse Emotional abuse Neglect

How likely are we to meet safeguarding issues in the ASD population? Cumulative risks to disabled children 31% 8% of sample had a disability 25% of all maltreated children had a disability Children with ASD? Association between disability and child abuse ASD – no greater risk Greatest risk – Psychological and emotional problems – Learning difficulties Spencer 2005 Pediatrics vol Children with ASD? Association between disability and child abuse ASD – no greater risk Greatest risk – Psychological and emotional problems – Learning difficulties Spencer 2005 Pediatrics vol

Why are children with ASD be vulnerable ? Poverty Mental health problems Low educational achievement Alcohol and drug misuse Inter personal violence Gilbert et al 2009 see previous slide Communication Social naivety Multiple carers and settings Challenging behaviour Communication Social naivety Multiple carers and settings Challenging behaviour

Autistic phenocopy Result of gross emotional and physical neglect ‘Rumanian orphans’ After adoption presentation gradually changed and were left with conduct disorder Girl aged 12 History of gross neglect and violence in infancy ?? Also physical abuse LDs Social naivety Some routines and rituals ADOS not typical of ASD Functionally autistic in classroom Girl aged 12 History of gross neglect and violence in infancy ?? Also physical abuse LDs Social naivety Some routines and rituals ADOS not typical of ASD Functionally autistic in classroom

Autistic Phenocopy? Boy asylum seeker Early abuse and domestic violence Full multidisciplinary assessment as a young child gave a diagnosis of ASD Settled in safe environment ASD symptoms faded away Now has diagnosis of Specific Language Delay Boy asylum seeker Early abuse and domestic violence Full multidisciplinary assessment as a young child gave a diagnosis of ASD Settled in safe environment ASD symptoms faded away Now has diagnosis of Specific Language Delay

Safeguarding within the assessment process Developmental assessment Hearing test Physical examination ASD specific history Play assessment SLT assessment OT assessment School observation Blood tests Cognitive assessment Repeat appointments Second opinions Etc.etc. Childs problems and parents frustrations catalogued in presence of child Child excluded from understanding their own diagnosis Diagnostic labelling as an end in itself Childs problems and parents frustrations catalogued in presence of child Child excluded from understanding their own diagnosis Diagnostic labelling as an end in itself

Challenging behaviour 1 Challenging behaviour can be a predisposing factor or a result of abuse. Frustration leading to emotional abuse Boy aged 13 Very ritual bound and parents struggling to help him with transitions Frightening objects used to move him on Support staff condoning the scary object use Boy aged 13 Very ritual bound and parents struggling to help him with transitions Frightening objects used to move him on Support staff condoning the scary object use

Challenging behaviour 2 Frustration leading to physical abuse Pushed into shower fully clothed Hit with stick Pushed into shower fully clothed Hit with stick

3 Fear leading to physical abuse Boy with LDs, 12 hits his mum and she hits back to protect herself Boy 16 high functioning Autism hits his mum, mums new partner intervenes to protect and hits him Boy with LDs, 12 hits his mum and she hits back to protect herself Boy 16 high functioning Autism hits his mum, mums new partner intervenes to protect and hits him

Restraint Lack of training and skills in managing ASD and challenging behaviour leading to unacceptable restraint 4 person hold on a 10 year old girl with ASD and LDs

Sexual abuse Children may act out what they have seen or experienced How do you tell the difference? 12 year old boy normal IQ with ASD suspended from school for sexual advances to girls in school History of inappropriate video material being viewed and available to children at home Was there more than this? 12 year old boy normal IQ with ASD suspended from school for sexual advances to girls in school History of inappropriate video material being viewed and available to children at home Was there more than this?

Investigating safeguarding concerns Referrals should be made as per guidance Children and YP with ASD are most likely of all to tell what they believe is the truth It maybe an opportunity to rethink levels of support to a family But the focus needs to be the well-being of the child