CASE STUDY
Malek, a 9-year-old Romanian boy came to the UK 6 months ago and was at home with his family until starting special school 4 weeks ago. He has severe developmental delay and is awaiting an assessment for autism. He is a very quiet boy who occasionally seeks out attention from adults and unless directed to equipment or activities will remain alone holding the first item of interest as he comes into the classroom.
In Romania he attended a small unit in a very large psychiatric hospital where he regularly came home upset having been bitten and/or scratched that day. Over the 9 months he attended he became more and more reluctant to leave his mum in the mornings and was getting more upset and distressed at other times they were together. When she spoke to the senior staff at the unit, they were dismissive, and nothing changed. As a result, mum decided to bring Malek to the UK where she hoped he would attend school and be safer and happier.
In school
On arrival in class Malek always moves straight to the far corner where everyone is in full view. Throughout the day he is quiet and withdrawn. He will not take off his coat until everyone is seated for the morning circle. He will join the circle but only if he sits with a member of staff between him and his classmates. It takes time to coax him into participating, but he does relax and enjoy when he is involved, particularly in singing and action songs.
The classroom is a total communication environment with pictures, symbols and words available around the room and a visual timetable is used to communicate the daily routine and curriculum activities. Mum has also helped the class team create a list of familiar words in Romanian that Mum uses with him at home.
Malek is becoming more familiar with the class routines, but transitions are still a challenging time for him. When he has to leave the classroom to move to other areas of the school, he has to be last to leave, with his coat on and fully buttoned up. When he enters another room, e.g., the cookery room, he will again go and stand in the far corner. Once the activity starts and the ingredients are being passed around, he will join the group as long as a member of staff sits between him and his classmates.
Outside the classroom
In the playground Malek will spend most of his time standing by the door with his back to the wall. If staff encourage him to move away, he will walk with them for a few minutes then when they are distracted, he will make his way quickly back to the door into school.
Malek eats well at lunchtime but very slowly. He needs to be coaxed to stay focussed and not take as long as he would if left alone.
At the end of the school day the bus escort collects Malek from class as his bus is always first. She greets him warmly and if he has taken his coat off, she takes it from his hook and warmly invites him to put his coat on and go see ‘Moo-mee-ay’ (mummy in Romanian). He moves quickly to put on his coat and leave.
How do we begin to help Malek feel safe in school?
Q.1 What do we know?
From the information above we can assume that Malek feels high levels of stress and anxiety, suggesting Malek sees significant levels of danger and risk in school.
He responds by withdrawing or isolating himself to try to cope with his feelings, indicating he may be feeling too overwhelmed by them to be able to connect with others.
Malek does not behave in ways that present any physical or emotional threat to others.
He appears anxious at certain times more than others and these appear to be times of transition. For example, entering the classroom in the morning.
There are times his anxiety is reduced, and he enjoys participating in activities when supported by an adult. For example, he will only sit when an adult is between him and his classmates.
Q.2 What can we do differently to reduce his levels of stress and anxiety?
To address Malek’s stress and anxiety we need to help him in order that his social engagement system, as outlined in blog 2, becomes the way of responding and interacting with others to regulate his level of arousal.
His social engagement system will rely on:
| ATTACHMENT THEORY | POLYVAGAL THEORY |
| The positive experience of Attunement, Empathy and the degree of self-regulation achieved through Co-regulation
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Access to the higher cognitive functions achieved by the interactions of Neuroception and the Face-Heart system in moderating the physiological response and enabling him to consciously use previous memories and experience in order to benefit from Co-regulation |
For Malek to be able to self-regulate he needs to be supported through the co-regulation of an attuned and empathic adult who recognises his needs and responds to Malek helping him feel connected and able to cope. Their co-regulation helps to regulate his physiological arousal preventing him feeling overwhelmed in anxious and stressful situations.
Therefore, class staff need to identify how to be more attuned and empathetic.
Q.3 What do we need to consider first?
To enable Malek to use his social engagement system effectively, staff must help him to reduce his heightened state of arousal.
This begins by class staff observing Malek’s behaviour, his posture, body language and importantly his facial expressions as they begin to interact with him. As described in blog 2, a great deal of sensory and motor information moves back and forth about Malek’s surroundings and is processed by him to assess the level of risk and danger he feels. His behaviour will reflect his level of stress and anxiety and how well he is currently able to cope with the situation.
We know that when Malek is stressed and anxious, he is quiet and withdrawn. From this we could assume:
| ATTACHMENT THEORY | POLYVAGAL THEORY |
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Malek is not yet feeling connected to or experiencing Attunement with any of the adults.
Malek is not experiencing staff awareness of how he is feeling which prevents Empathy
Without connection and awareness of Malek’s feelings by the adults, Co-regulation will not happen and he is at risk of being emotionally overwhelmed causing him to shutdown access to previous supportive knowledge and understanding that would help him to cope and identify how safe or not he is.
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Malek has a growing ‘sense of unease’ and his Neuroception is signalling ‘be alert and prepare’.
His Face-Heart System is constantly scanning sensory information and limiting movement to avoid drawing attention to himself. His system shifts from seeking cues for connection and adapts to the detection of danger. His facial expressions along with the muscles of his neck adapt to an increasing heart rate preparing to respond to his levels of stress and anxiety.
Without Co-regulation Malek is at risk of being physiologically overwhelmed by his bodily responses which will limit his ability to cope with the situation. The greater his sense of being overwhelmed, the less he is able to rationalise and interpret what is happening and can cause a fight, flight or freeze response. |
Q.4 How can we engage with Attunement and Empathy?
Our starting point in building a relationship is by observing eye contact, facial expression and body language as we interact. For just as Malek is being observed he too is observing as he looks for signs of safety or danger.
In order to help him feel safer we must have a sense of what that feels like for him. We must attune and empathise with his feelings. By observing him you can begin to sense how Malek is feeling, when he is anxious and stressed, and begin to focus not upon how he ‘should´ behave but how he ‘is’ behaving.
These are abilities we all have and use daily, and they are skills we can further develop in the classroom. As you approach and interact with Malek you can begin to ask yourself:
| Attachment Theory | Polyvagal Theory | |
| From the way you appear Malek I imagine you must be feeling………
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When you begin to recognise and connect with the emotions of Malek- that is ATTUNEMENT | As you begin to connect with Malek your positive response can trigger a NEUROCEPTION of safety that reduces his perception of risk |
| Now imagine you are Malek and you were feeling his anxiety and stress –
What would it feel like? |
When you can imagine and begin to understand the world through Malek’s eyes – that is EMPATHY
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When you are aware of how Malek feels, your FACE-HEART SYSTEM detects cues of safety/accessibility. Therefore, your own social engagement system begins to respond. |
| What would help you to feel less stressed and anxious?
What can you do differently that can begin to help Malek feel differently?
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When you respond to Malek’s emotional and physiological cues to help regulate his behaviour and emotions – that is CO-REGULATION
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As you begin to respond and calm your own face-heart response you become part of a shared system of CO-REGULATION which makes Malek’s social engagement system respond more positively to yours. |
By being able to better understand when and how Malek’s anxiety and stress begins, we can better connect and help Malek to feel safe in situations where his own resources are feeling overwhelmed.
Examples of Theory into Practice
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A generalised welcome
This strategy will communicate that he is welcome into his new class.
It can begin simply with positive eye contact and a genuine ‘warm’ expression, as you observe and interact with him.
From the information we can assume that when Malek is quiet and withdrawn he is stressed and anxious and finds it difficult to connect with others using eye contact, facial expressions or body language, so any response from him is likely to be very short as he will likely avert his gaze or turn away.
This does not mean Malek does not want to connect but that he can only tolerate it for very short periods at present.
Malek can appear cut off as awareness of his wider environment is more important to Malek at this point, while dealing with the risk and threat he feels. He will want to know that he is not at risk of being bitten/scratched (as happened previously in Romania) and may feel it is in his best interests to assume this is still a real threat for him.
The adult’s response to Malek is increasingly important as a bridge between his current coping strategies and the benefits of connecting with each other’s social engagement systems. Positive eye contact and a warm expression are unlikely to be what he expects but offer potential for a positive change in his perception of how safe he is and therefore more able to access new learning opportunities.
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Transition from the bus into the classroom
In some settings it can be a staff expectation that children remove their coats when they enter the classroom. However, in Malek’s case the transition into class is a stressful and anxious time that needs to be acknowledged by staff:
| ATTACHMENT THEORY | POLYVAGAL THEORY | |
| Coming into class is an anxious and stressful time for Malek and to remove his coat would increase this. | Malek’s response suggests that he believes from past experience that nobody can keep him safe.
His strategy for regulating his emotions to prevent him from feeling overwhelmed is to control his environment by: · keeping his coat on and limiting his movement · Isolating himself from all others. |
Possibly even before Malek has arrived at school his unconscious awareness of the situation will put him on ‘alert’.
His NEUROCEPTION will be actively scanning internally and externally as his level of arousal will be increasing in anticipation of a need to protect himself from what is about to happen.
His FACE-HEART SYSTEM would be ‘on alert’ with his social engagement system activity limited as more attention is directed to scanning for danger.
When Malek responds in this way he will have limited success in regulating himself and not have had the opportunity to experience CO-REGULATION
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| Supportive response – Doing things differently | ||
| As Malek enters, the adult should interact with Malek to acknowledge the experience for him and use it as an opportunity to offer support.
Once inside staff could: · Allow Malek to keep his coat on · Help Malek to select a toy or object he wants to take with him · Go with him to the far corner of the classroom. |
At this transition point take time to connect with Malek:
· Talk to him about what is happening using a gentle voice and soothing tone · Try to make eye contact and observe his facial expressions, body language and movement to connect with him.
Give yourself time to ATTUNE to Malek’s feelings and move on when you think he feels ready.
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On entering Malek will be shifting attention as his NEUROCEPTION responds to what he sees as a potential threat, trying to prevent himself from becoming overwhelmed. He will rely upon his sensory information for clues and cues as to how to respond.
The adult needs to be sensitive to their reactions to Malek’s facial expressions, vocalisations and body language to ensure his reactions do not drive your response.
Your response should use eye contact, facial expression and tone of voice to stimulate a different response from Malek.
One that signals to Malek that you understand what he is feeling but he is safe, and you are there to help. |
| As you observe Malek’s reactions:
· Try to imagine how he must be feeling, e.g., is he happy, scared, fearful, etc. · What would it mean to you to feel the way Malek does.
When you understand how Malek feels each day he comes into school you can EMPATHISE with the emotional challenge he feels.
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As you connect through the FACE-HEART SYSTEM there is a dynamic process of action and reaction between the social engagement systems of you both.
A consistent, calm and patient response from you based on an understanding of what it would be like to feel as Malek does and what would help you to feel ‘better’ will affect this dynamic.
Malek’s social engagement system response to your eye contact, facial expressions and vocal tone will help you connect with Malek and allow him to know that his feelings are recognised and ‘felt’ by another. |
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| To support Malek in managing his ‘challenge’ develop a routine with him from the moment you meet him on the bus until he is in the corner of the classroom.
Use the routine to help Malek feel more at ease. Be aware of: · Your facial expression and tone of voice in the words, signs or symbols you use · The timing of how you are doing things as you move along, not too fast and not too slow · Each change being acknowledged to Malek · When you arrive in class help him to find the toy or object he wants to hold with him · How Malek feels as you move away once he is in his favoured corner of the room.
Each of these changes is an opportunity to support Malek to regulate himself by identifying how he is feeling and understanding how difficult that must be for him. Your response should offer reassurance that Malek can manage the risk and you can help by CO-REGULATING his emotions with him. |
By using a routine, you help Malek begin to regulate physiologically in response to what is happening in the situation.
Staff can observe any key moments of change In Malek during the routine through eye contact, facial expression or vocal tone.
Each of these moments can be used to change Malek’s sense of safety and physiological responses through a calm, consistent approach within your social engagement system.
This will stimulate Malek’s Face-Heart system and help him to be more receptive to connecting with you as you have enabled him to feel calmer and safer.
Each time you do this establishes a positive way of responding. It enables the shared psychological and physiological CO-REGULATION by one calmed nervous system (YOU) on the nervous system of another (MALEK).
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Once again, the repetition of the routine described above becomes a bridge between Malek’s anxiety in anticipation of the risk that coming into the classroom poses and the potential for experiencing the classroom as a safe and nurturing learning environment.
In summary
By using these two theoretical approaches to create a framework for supporting the emotional well-being and mental health of CYP with severe and profound learning difficulties we can be sensitive to the importance of both psychological and physiological needs and their connectedness. Strategies can begin from the most informal to the more structured and prescriptive in more challenging situations.
Within any supportive framework it is important that we recognise the fundamental human need of all children and young people to feel safe, cared about and care for others. By using the key principles within these two theories we can begin to recognise their capacity to cope with a situation and respond to their needs no matter the degree of learning difficulty and irrespective of the limits it places upon them to interact with others in order to feel safe and free from threat.
With many thanks to Tom Laverty for this series of blogs.
Tom started work as a residential social worker in a respite centre for children with complex learning needs and their families. He then worked as a teacher for 27 years in a school for children with severe learning difficulties, Profound and Multiple Learning Difficulties and autistic spectrum disorders.
Tom is now a member of the Emotionally Able team supporting and training practitioners within specialist settings across London and nationally.
