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Introduction
Guiding principle in therapeutic work
Input from other professionals and organisations
Adapting procedures to needs and circumstances
Tactile solutions
The therapeutic work
Reviewing and evaluating progress
Ensuring continued support
Footnotes
Further reading
This practice note is based on a practitioners’ therapeutic work with David, 1 a blind child who was referred to the NSPCC. It is not intended to be a comprehensive account of the therapeutic work with David, or of the assessments involved in developing the work, but rather to highlight the specific issues that had to be dealt with in providing a service to a blind child within the context of normal NSPCC and government guidance.
David came to the NSPCC when he was six years old due to concerns from both his school and his mother over his emotional wellbeing. He had been subjected to alleged physical abuse from his stepfather, and had also been present during domestic violence incidents between his mother and stepfather. David was described as a very traumatised boy, who would sob for prolonged periods of time for no apparent reason. He would get angry very quickly, and go as far as saying that he would kill himself or others. His aggressive behaviour and emotional distress were obviously very worrying to those around him. David had not yet begun to read Braille. His school had identified him as having additional needs and “global developmental delay”. The practitioner felt that this could be due to a number of factors: being born prematurely; having a visual impairment; the traumatic events in his home life; and the effect of all or any of these factors on his relationship with his mother.
The practitioner worked with David over a period of a year and a half (2007-2009), involving 60 one-to-one sessions, lasting one hour each. As the therapeutic work progressed, the impact of the trauma on David’s developmental delay became increasingly apparent to both the practitioner and David’s mother. When David first came to the NSPCC, his mother talked to the practitioner about the challenges she and David faced every step of the way, as it is very rare for a child to be completely blind. Most of the professionals they had come into contact with had never worked with such children, and services were not always easily accessible for David.
When a child is referred to an NSPCC service for therapeutic work, the guiding principle is always for it to be child-centred, allowing the child to be involved in the process of the work and empowering them to go at their own pace, with the practitioner guiding the child.
As part of this process, a holistic assessment is carried out using the principles of the Framework for the assessment of children in need and their families (2000) 2 and adapting these to assess therapeutic need. This involves looking at such things as the family and home environment; parenting capacity; the child’s development, including any additional needs the child may have; and in particular the child’s emotional wellbeing and the impact of the trauma they have experienced.
In David’s case, the practitioner also needed to find out more about his visual impairment, not only in terms of how it affected his communication, but also to understand how it influenced his perceptions and experiences of the world around him and the people in it. It was also important to understand how the traumatic events in his life had shaped his perceptions, and prompted the behaviours that were clearly upsetting to himself and others.
Understanding all these aspects of his background formed the basis of developing a therapeutic approach appropriate to his particular needs and suited to his particular circumstances. Much of the information the practitioner needed was gathered from speaking to his mother, his vision support teacher, teaching assistant, social worker, and from observing David’s play.
The practitioner also contacted support organisations such as the National Blind Children’s Society 3 , who were able to give valuable practical advice and provide background information that was key to understanding how a blind child thinks and reacts to situations, and what are ‘common’ behaviours for them. For instance, David would throw objects around the room, which for young children can be a way of expressing anger or frustration. For David, however, it was a way of simply gauging the dimensions of the space around him as well as expressing his feelings.
Guidance or other resources relating to the provision of therapeutic work with visually impaired children turned out to be mostly limited to information about communication methods and understanding behaviours. However, the practitioner was able to use Axline’s principles of play therapy 4 to shape her work with David, allowing him to lead the sessions, not hurrying him along, and giving him the space to express his feelings. The therapeutic work had to evolve over time, with the practitioner using her own judgement as she developed a relationship of trust between David and herself.
The practitioner soon realised that, in order to work successfully with a child that can only explore and interpret his world through sound, touch, smell and taste, some of the ‘standard’ approaches would have to be adapted to suit the situation. For instance, it was particularly important that the same room was used each week for David’s sessions, and that the room was laid out the same way each week. One of the first things the practitioner did was to familiarise David with this room by leading him around it, letting him explore and touch all the things in it, and when necessary explaining what things were. In time this became more of a routine, which gave him a sense of comfort and independence as he became accustomed to finding his way around.
The boundaries that normally apply to physical contact with children who come in for therapeutic work had to be relaxed to some degree. With a blind child, communication has to be more ‘hands-on’: for example, when David needed to be ‘shown’ things, the practitioner would need to guide his hands to them by putting her hand(s) on his -although she also encouraged David to find things for himself and was able to guide him to things using verbal cues as well.
NSPCC guidance requires that the service user and/or their parents or carers are informed about the service they are accessing, and what they can expect to get out of it. Generally, when working with a child, they will be given information leaflets that explain how they can expect to be treated; how to comment or complain; how everything is recorded; how they can access these records; and how they can have an input in the whole process. However, these leaflets were clearly not suitable for David.
To enable him to access the service in the same way as other children, the practitioner devised a tailor-made tactile ‘book’ of information, which David could take home and discuss with his family. The book was made up of objects that related to the information that David was entitled to, and would prompt him in remembering what the practitioner had told him about it: for instance, a few keys of a computer keyboard signified that his details would be stored on the computer; a pen that the worker would make notes about their sessions; and a toy mobile phone reminded him that if he was unhappy with the service, he or his carer could talk to someone on the telephone about it. These were attached to the pages with Velcro, so that they could be pulled out, explored and then put back in the book.
The practitioner also used this approach in reviewing her work with David, for instance by using a toy car so that David would remember that they had used the cars in some stories they had made up, or some sand stuck to the page, to remind him that they had used the sand tray.
Throughout the course of weekly therapeutic sessions, the practitioner used toys, shapes, figures, sand, and even music as prompts to stimulate David’s story-telling and to help him explore his feelings. Telling stories was David’s favourite way of exploring different feelings and the traumatic events of his past. They would come to him quite naturally, and by ‘playing’ the different characters in the stories (a Mr Fierce with a very gruff voice featured regularly), he was able to express his feelings about these experiences.
In the earlier stages, he would whine and cry a lot as well. Many of the stories featured things being broken, and no one being there to fix them, or people being left alone, being upset and hurt. Most of the stories did not have happy endings, which was probably indicative of the fact that in David’s world, happy endings were few and far between.
The sessions at the NSPCC gave David the safe space in which to engage in play, storytelling and other creative activities, expressing his worries and feelings without being judged. Eventually, he started to recognise and describe his own feelings rather than acting them out, and started to talk about why he felt the way he did. The stories, plays and music still served to explore his emotions, but he became calmer and was better able to express himself verbally rather than physically. The stories themselves also became more positive: they were not always about things being broken and no one being around to fix them. They started to have happy endings, with things being repaired.
The games and play became more developmentally appropriate and David moved from needing his sessions for therapeutic purposes to using them to have one-to-one attention from the worker, allowing him to play and have fun. David had got to a point where he said that he felt happier, and that his troubles and worries had “all gone”.
The practitioner regularly reviewed her work with David. She would also meet with his mother to share information about what had happened during sessions, and to elicit her views on how the work was progressing, in terms of her experiences with David at home.
In order to evaluate children and young people’s progress, the practitioner used Briere’s Trauma symptom checklist for young children 5 as a measurement tool both at the start and end of the therapeutic work. There are no dedicated tools specifically for children with disabilities, but Briere’s checklist provides some guidance towards how the child may be feeling. It involves the parent/carer giving a rating of how often (“not at all”, “sometimes”, “often”, “very often”) they feel their child experiences certain fears or other feelings or demonstrates certain behaviours, and this was completed by David’s mother.
The responses - to a total of 90 statements - were then scored by the practitioner. The mother left out those statements that were not relevant to David’s particular situation: for instance “being afraid of the dark”, as “dark” had little meaning to David - although this should not be assumed of a visually impaired child, as there are many variations of visual impairment. It is always best to ask the child of their understanding of a word.
Having involved David’s mother throughout the process, towards the end the practitioner started to involve David’s mother and stepfather (not the abuser) more actively in some of the sessions. This showed them what she and David were working on so that they could carry on with some of the positive ways in which David had learnt to explore his feelings. This encouraged them to develop a better relationship with him, and to help David to discuss his feelings with them.
Throughout the work the practitioner attended meetings with the school and social services to ensure that support would be provided to David and his parents, in line with Working together (2006) 6 , so as to achieve the best outcomes for David and also to ensure that David and his family would remain supported once the NSPCC work ended.
David’s mother also continued to remain involved with the National Blind Children’s Society 3 . Not only did this give her an opportunity to meet with other parents of visually impaired children, but she even took David on some activities arranged by the charity.
1. The child’s name has been changed to ensure confidentiality.
2. Department of Health, Department for Education and Employment (DfEE) and Home Office (2000) Framework for the assessment of children in need and their families (PDF). London: The Stationery Office (TSO).
3. National Blind Children’s Society
4. Axline is recognised as the originator of non-directive play therapy. For the principles of this approach see:
Axline, Virginia M. (1989) Play therapy. New ed. Edinburgh: Churchill Livingstone. Alternatively, access the principles online from Play Therapy UK.
5. Briere, John N. (1996) Trauma symptom checklist for young children (TSCYC): professional manual. Odessa, Fla.: Psychological Assessment Resources, Inc.
6. Her Majesty's Government (2006) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). Norwich: The Stationary Office.
Please note this guidance has since been updated with: Her Majesty's Government (2010) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). Nottingham: DCSF (Department for Children, Schools and Families) Publications.
Gordon, Ro et al. (2001) Two way street: communicating with disabled children and young people. Leicester: NSPCC.
Marchant, Ruth, Julyan, Antony and Jones, Mary (2009) Three way street: putting children at the centre of three way communication. Brighton: Triangle.
Towers, Anne (2008) When only an eyelid moves (PDF). Counselling Children and Young People, June 2008. pp.25-9.
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