The Anxiety Bucket A model and framework to support anxiety related presentations in Autism and ID

1. The Anxiety BucketA model and framework to support anxiety related presentations in Autism and ID Hana Holden Consultant/ Professional Lead Speech and Language Therapy Sue Marsden Specialist Community Matron 2nd April 2019

2. The Anxiety Bucket

3. The Anxiety Bucket • Evolved from clinical practice in approx. 2011. • Use of Anxiety/ Stress bucket common in Mental Health. • Feedback from teams and families regarding lack of clear understanding about behaviours. • Understanding that presentation fits neither a challenging behaviour nor mental ill health construct. • Recognition of trends, themes and similarities across multiple people. • QI Methodology used to develop and refine.

4. The Anxiety Bucket - Origins • This model is not unique to either Autism or Learning Disability but has a place for us all – in understanding our own stress responses. • It can be used to support staff team reflective practice • Similar work around country in Autism Services – Kevin Baskerville (National Team TEACH Conference March 2013) • Dr Melanie Bruce and Sharon Jeffreys (RNLD) – Norfolk – Video Interview re “Anxiety Bucket” on NAS website • Temple Grandin - describes the “overflowing glass” • “Me and my PDA” – GlòriaDurà-Vilà and Tamar Levi

5. The Anxiety Bucket – clinical rationale • Hypothesis that anxiety is the primary driver for behavioural and communication changes in someone with Autism and IDD • Cumulative effect of build up of stressors over time • Presentation will fluctuate • There will be days when the bucket “overflows” • Theory accounts for why stressors do not always elicit a behavioural response • Clearly shows communication changes as bucket fills • Can explain some of the complex diagnostics - unusual communication that sounds like psychosis.

6. Understanding Behaviour and Communication

7. The Anxiety Bucket • We’d like you to think about your own buckets. • For the next 5 minutes spend some time thinking about the things that cause you stress, your own stress behaviours, and the ways in which you empty your bucket. • We recognise that people here may be managing different levels of stress – so be kind to each other, but also be kind to yourself. If you don’t feel you can do this exercise it’s fine. • If you are then happy to – please share some of this with us • Please take your Bucket home with you – and consider using it in Supervision sessions to help your manager know and support you better.

8. The Anxiety Bucket andMaslow’s Hierarchy of Needs

9. Recovery Framework in Practice • Focussed discussion on the person –

10. Green Boundaries – are the least restrictive and offer the widest community access, representing the highest level of ability and choice the person can cope with Yellow Boundaries are low level interventions, or restrictions that might keep someone safe and recognise that they need additional support Circles of support Red Boundaries are the most restrictive – restraint, locked doors, possibly the police, or CJS Amber Boundaries are increasingly restrictive, and choice, and freedom are likely to be limited, as is community access

11. Circles of support

12. Case study No formal ASD diagnosis Varying level of assessed ability History of Admissions under Significant physical MHA challenges – aggression and property damage Altered Communication Responses – resembling Clear behavioural Psychosis progression when anxious Complex Physical Health Strong MDT working to problems reduce risk of future admissions/ placement High Anxiety breakdown • This Photo by Unknown Author is licensed under CC BY-SA

14. In Summary • Anxiety is proposed as the driving factor for behaviour in people with autism. • Recognition of this as a humanist perspective – holistic, multiprofessional, and multi faceted – it is still a PBS approach • Cumulative nature of stressors adding to behaviour and importance of swapping the “last stressor” around. • Changes in communication as stresses increase – “she understands everything” – and understanding receptive and communicative changes. • Interplay between carer stress and service user – highlight to staff that they go away and complete their own bucket. • Fluttering/ skipping stages/ notion of “bad day” recognition that it isn’t always within one’s gift to change things – so change the things you can!

15. Feedback “ Life changing ” “ Genius ”, “ I love this bucket ” “ easy to relate to ” “ love the visual” “ I think it’s brilliant ” “ it’s changed the way we understand G’s behaviour” “ I found the course extremely helpful and has given me personally a greater understanding of challenging behaviour ” “ Very good techniques ” “ very interesting and eye opening ”