Special Needs

School nursing for autism specific needs: A positive contribution

In this article, Julie Fellows, a school nurse working exclusively with children and young people with autism, shares her experience and recommendations on caring effectively for their specific needs.
chool nursing can be challenging in any school. Delivering the same quality service to young people with autism and complex needs can be even more challenging. The role of the school nurse working with children and young people with autism requires working collaboratively with parents, multidisciplinary professionals, care and education staff. This article looks at my role as a nurse working in education to promote health and wellbeing and support young people with autism to achieve their full potential. Higford School is an independent school for young people with autism and complex needs. The age group ranges from 8 to 19 years old. The majority of the young people are residential, with a few who attend as day students and a few for respite care.

Working together to make a difference

There is substantial variation in severity and needs within the autism spectrum. Not one child with autism is the same and what works for one might not work for another. number of individuals who are able to communicate verbally. No two people with autism are the same, what works for one might not work for another and the necessity to individualise is of great importance. DSM-IV-TR (American Psychiatric Association, 2000) refers to the impairments of autistic disorders and how they may affect social interaction. When teaching students with autism it is important that individual characteristics are taken into consideration, such as not being able to express oneself or understand social cues and facial expressions. Very often the young person will avoid eye contact and react with inappropriate behaviour and a lack of empathy. People with autism find it hard to recognise and understand other peoples feelings (National Autistic Society, 2012), making the teaching role all the more difficult. I work within a small nursing team of three nurses all from different disciplines; learning disabilities, paediatrics and general trained. Our overall aim is to promote and support the students health and independence. This is achieved by integrated working across the care and education setting. We are part of a professional clinical multi-disciplinary team (PCMT) based at the school. This team consists of an educational psychologist, a speech and language therapist, an occupational therapist and the nursing team. We also have a visiting paediatric consultant. Having instant access to all these professional opinions, knowledge and experience is a big bonus. Child in mind meetings are held on a regular basis for each individual young person. These are attended by the PCMT, and education and care staff. The agenda follows the five outcomes in Every Child

Autism is a neurodevelopment disorder characterised by social impairment, communication difficulties and restricted, repetitive, stereotyped patterns of behaviour (National Institute for Neurological Disorders and Strokes, 2009). Children with autism are all very different (Janzen, 1996), and there is substantial variation in severity and needs within the autism spectrum. It can often be accompanied with learning difficulties, attention deficit hyperactive disorders, epilepsy, sensory issues, aggressive and self-harming behaviour; all of which need individual assessment. A large percentage of the young people at Higford School have severe learning disabilities and are on the autism spectrum, although there are a small Julie Fellows, GeneralNurse, HigfordSchool,Shifnal,Shropshire

448

British Journal of School NursingDecember2012/January2013Vol7No10

Lucie Carlier

Special Needs
Matters (Department for Children, Schools and Families, 2004): Being healthy Staying safe Enjoying and achieving Making a positive contribution Economic wellbeing. These outcomes are applied to each young person, and information is pooled and shared to enable the best outcomes for the individual. The National Autistic Society (2011) states that there is no known cure for autism; however, people with autism can learn and develop skills that increase their independence and improve their quality of life. Higford School aims to help the individual achieve the best possible outcomes when entering adult life. We provide education for individual needs, support with behaviour and address medication requirements. PCMT meetings are held on a regular basis to enable clinical staff to work collaboratively to meet the holistic needs of the young people. Multidisciplinary working benefits clients with complex needs and enhances continuity of care, providing a holistic seamless care service (Mental Health Commission, 2006). I started by developing a plan based on the National Healthy Schools Programme (NHSP) (DfES and DH, 2006) and introduced this to senior management. It was agreed that we would work towards Healthy School Status for the school. I made the four core themes (i.e. PSHE, healthy eating, physical activity, and emotional health and wellbeing) my priority of work. This is now being worked toward and improvement health targets have been set. around food. Jackson (1988) refers to this as being a problem for people with autism. The nursing team monitors and evaluates dietary intake for every student at Higford. A dietary analysis is carried out into the food groups eaten and comparisons are made to the the eatwell plate (Department of Health, 2011). We are then able to assess where we need to support the individual to improve intake of a particular food group. Nurse-led training is delivered to staff on diet and nutrition. Teaching staff deliver food group education to students along with cooking sessions to encourage students to try a more varied diet and textures of food. Accompanied shopping trips are carried out with students to encourage choices of cooking ingredients. This is integrated in the residential care setting to help young people meet targets of independence and activities of daily living. Fruit and dairy snacks are being encouraged in school to comply with standards and to meet healthy schools criteria. This has been nurse led and has involved much liaison with catering, care and education staff. This in itself has been a major task as children with autism find it very difficult to accept any change. A selection of healthy snacks and drinks are now offered daily in school to enable students to make their own choices and try new textures. Weight and growth monitoring is carried out by the nursing team, keeping a close eye on the young people who are taking antipsychotic medication such as Risperidone as this can result in weight gain (Phelps, 2007). A clinic is also held at Higford on a monthly basis with our visiting consultant paediatrician where this can be discussed in more detail. Weight management programmes and special diets are nurse-led. The National Institute for Health and Clinical Excellence (2006) guidelines on obesity recommend using a person-centred approach with advice and treatment taking into account peoples individual needs. Dysphagia and any sensory issues around food are addressed by our speech and language therapist and occupational therapist with joint nurse training for staff. Liaison with parents is on-going to obtain consent and keep them involved with the health and wellbeing of their children. This also encourages continuity when young people attend home visits. This has been a
449

Supporting nhsp themes

PSHE
This area consists of supporting sex education, preparing individual programmes to meet specific needs, and addressing communication and level of functioning. Quite often students have no verbal communication. One of my strategies, for example, has been to use social stories and visual supports to assist with communication; for example, when looking at the life cycle and gender identity. Some young people may not have the understanding of their own gender or other peoples. For the life cycle I use pictures of changes to the body at different ages and match items to age groups (e.g. dummy to baby ... etc.). Visual supports can help build confidence and raise self-esteem (The National Autistic Society, 2003). I work closely with a Speakeasy-trained member of staff who also plans and delivers sex education in the classroom, as well as delivering training to staff groups. This ensures continuity for the young person within residential care. Programmes have been delivered using guidance from The Childrens Learning Disability Team Leeds (2009) puberty and sexuality pack. This includes topics such as preparing for menstruation and hormonal body changes in puberty, masturbation, public & private places, appropriate greetings, self- esteem and personal hygiene. An individual may be having difficulties in one or more of these areas. Staff have successfully supported a number of young people through bodily changes that happen as a result of puberty. My role as a nurse has been to provide staff with the most up to date research, knowledge, support, decision making and planning.

School nursing perspective

Although each clinical member makes his or her own positive contribution, it is the school nursing role and perspective that will be discussed here. The nursing teams work involves general nursing duties, working together to promote health and maintaining a safe environment. This involves, for example, auditing and/or training for medication, first aid, monitoring epilepsy, attending medical appointments, carrying out looked after children medical assessments (requirements of placing authorities) and monitoring sleep patterns and toilet programmes. The nursing team is also a team within other teams (e.g. PCMT, education and care teams). My role is within education and can be varied to say the least. My main goal has been to apply school nursing strategies to benefit the young people at Higford School. This has been a challenge in itself and needed much research into school nursing to address the requirements for this role and then adapt and apply them specifically to young people with autism.

Healthy eating

People with autism can be very selective with what they eat and have sensory issues

December2012/January2013Vol7No10British Journal of School Nursing

Special Needs
Although there are specific characteristics, each child is different in their levels of functioning. The school nurse can play a part working with other professionals to support young people with autism to reach their full potential as they approach adulthood. The importance of understanding individual needs is fundamental and enables individuals to cope with life changes such as puberty. Working collaboratively is beneficial and provides continuity. Holistic needs must be addressed to promote independence skills and preparation for adult life. Clinical multidisciplinary working together addressing behaviour strategies, health needs and communication has an impact on the young persons ability to manage everyday life. Working with staff to implement NHSP at Higford School has resulted in positive outcomes for BJSN the children.
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text revision. Autistic Disorder. APA, VA Department for Children Schools and Families (2004) Every Child Matters: Change for Children. DCSF, London Department for Education and Skills, Department of Health (2006) School Nurse: Practice Development Resource Pack, Delivering on Health Priorities. The Stationery Office, London Department of Health (2011) The eatwell plate resources. www.dh.gov.uk/en/ Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_126472 (accessed 5 December 2012) Jackson L (1988) Freaks, Geeks & Asperger Syndrome. A User Guide to Adolescence. Jessica Kingsley Publishers, London Janzen E (1996) Understanding the Nature of Autism, A Practical Guide. Therapy Skill Builders, Texas Mental Health Commission (2006) Multidisciplinary Team Work, From Theory to Practice, Discussion Paper. MHC, Dublin National Autistic Society (2012) Making a Difference for 50 years: The way we are Autism in 2012. NAS, London National Autistic Society (2003) Visual Supports. NAS, London National Autistic Society (2011) What are the causes and is there a cure? NAS, London National Institute for Health and Clinical Excellence (2006) Obesity, guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline 43. NICE, London National Institute for Neurological Disorders and Stroke (2009) Autism Fact Sheet. Bethesda,US Phelps J (2007) Weight Gain and Bipolar Disorder Treatment. www.psycheducation.org/hormones/ Insulin/weightgain.htm (accessed 5 December 2012) The Childrens Learning Disability Nursing Team, Leeds (2009) Puberty & Sexuality for children and young people with learning disability, a supporting document for National Curriculum Objectives. White SW, Oswald D, Ollendick T, Scahill L (2009) Clinical Psychology Review. Anxiety in children and adolescents with autism spectrum disorders. Clin Psychol Rev 29(3): 21629

Key Points
Nurses need to provide a service to meet individual needs, considering the functioninglevelsofeachyoungperson. Support is needed for young people to attain good physical, mental and sexual healthtoenablethemtomakepositivehealthchoices. Stafftrainingisvitallyimportanttoenableaproactiveapproachandcontinuity. Collaborativeworkingsupportstheyoungpersontoachievehisorherfullpotential, helpingmakeadifferencetohisorherlife.

success as our analysis shows improvements such as fat reduction in diets and higher percentages of fruit and vegetable portions being eaten. Along with evidence of weight loss for individuals on weight management plans since introduction of healthy schools criteria plan. This is an area in which a whole-school approach can make an important difference. Our deputy headteacher leads for PE and supports education staff to encourage childrens participation in sporting activities. This is dependent on the level of functioning of each child; for instance, it may be basic support such as hand-over-hand to help the child feel movement and follow technique. We work together and have provided joint training for staff around physical activity and support in meeting healthy school criteria. Physical activity is very much encouraged by the nursing staff and forms part of weight management programmes. The School Nurse: Practice Development Resource Pack (DfES and DH, 2006) addresses the benefits of physical activity such as improving health and enhancing academic performance. Participating in physical activity can be particularly beneficial as it improves energy, releases tensions, produces endorphins for a feel good factor, helping with self-confidence and self-esteem. Students are encouraged to take part in events that have a fun aspect, such as the sponsored run or walk for Sports Relief organised within the school and supported by nurses and other staff members. Teachers report that physical exercise as part of the curriculum is helping students settle into group activities.

Physical activity

already identified as being a vulnerable group. We are able to support them and their families in many ways. Anxiety in children with autism can worsen with adolescence (White et al, 2009). Many children with autism experience high levels of anxiety. It is important that the activities offered and the approaches used decrease students anxiety levels. Our educational psychologist assesses and prepares behaviour support plans for each individual young person here. Higford staff will attend home visits to support behaviour if required. Parents are invited to attend clinics held at Higford and have the opportunity to speak to members of the multidisciplinary team on site. They also have telephone contact with the nursing and/or care teams whenever required. From a nursing perspective we provide support such as building self-esteem for the young people. This is included in PSHE as part of the sex education programme by looking at self and identifying likes and dislikes. Encouragement is given to students to participate in activities within the school setting and extracurricular ones (e.g. attending youth clubs, swimming sessions and other offsite activities) helping to promote social inclusion.

Conclusions

Autism stays with a child for life. But a great deal can be done to support children with autism to develop skills and independence.

Emotional health and wellbeing

The young people who attend Higford are

450

The school nurse can play an important part ... to support young people with autism to reach their full potential

British Journal of School NursingDecember2012/January2013Vol7No10