13 Learning difficulties and autism
Although the term learning disability is widely used, people who are themselves affected prefer the term ‘learning difficulty’ (Northfield 2004, DoH 2001), but this change in terminology has yet to be widely adopted, as can be seen from the quotes and references used throughout this chapter.
Currently there are over 1.5 million people in the UK with diagnosis of a learning disability (Mencap 2010a). Statistically it is difficult to ascertain the number of people affected by autistic spectrum disorder (ASD) in the UK due to lack of data, but it is thought to be about 1% of the population, both children and adults (Brugha et al. 2009, Green et al. 2005). Comparable figures for the USA estimate that 1 in 110 children have a diagnosis of ASD, a prevalence of 1% (Centers for Disease Control Prevention, 2007).
Learning disability is not a mental illness (Mencap 2010b). This term can cover a broad range of disabilities or difficulties with which a person may present (BILD 2007). Founded on the belief that people with learning difficulties are people first, learning difficulty can be defined as a significantly reduced ability to understand new or complex information or to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning) and which started before adulthood with a lasting effect on development (Department of Health (DH) DoH 2001).
People with learning difficulties have poorer health and are more likely to die prematurely than the rest of the population (DH DoH 2008). Health-related conditions that may coexist with the diagnosis of learning disability include Down’s syndrome (a lifelong genetic disorder that causes delays in development and learning (Mills 2007)), cerebral palsy, epilepsy, autism and Asperger syndrome (Mencap 2010c).
The National Autistic Society (NAS) 2009a explains Asperger syndrome (AS) as a form of autism (see below). Although there are similarities with autism, people with Asperger syndrome have fewer problems with speaking and are often of average, or above average, intelligence. They do not usually have the accompanying learning disabilities associated with autism, but may have specific learning difficulties including dyslexia and dyspraxia, or other conditions such as attention deficit hyperactivity disorder (ADHD) and epilepsy. People with AS can find it harder to read signals such as facial expressions and body language which most of us take for granted. Thus they find it more difficult to communicate and interact with others, which can lead to high levels of anxiety and confusion, frustration, anger, depression and a lack of self-esteem.
Autism is a lifelong developmental disorder characterized by impaired social interaction and communication, severely restricted interests and highly repetitive behaviour (Brugha et al. 2009). ‘Spectrum disorders’ is the collective term used, as the symptoms can present with varying degrees of severity (Autism Society of America 2006). Further classifications used are high-functioning autism, low-functioning autism, mild, moderate, severe and autistic traits or tendencies (Bogdashina 2006).
Autism can also occur in association with other conditions such as metabolic disturbances, epilepsy, visual or hearing impairments, Down’s syndrome, dyslexia, cerebral palsy, attention deficient disorder and ADHD (Bogdashina 2006). Other health problems that may be experienced by children with autism include sleep problems, eating difficulties, bowel problems, and difficulties developing motor skills such as holding a pencil (NAS 2009b).
Some people with autism have severe learning disabilities, and some are non-verbal. They may also have abnormal sensory perceptions, for example being hypo- or hypersensitive to tastes, smells and sounds (NAS 2009c, Royal College of Psychiatrists 2004), each altered perception possibly fluctuating between hypo- and hypersensitivity (Autism & Practice Group (APG) 2007).
However, some people with autistic tendencies are very high achievers and their oddness may show up only in their preference for being alone, lack of empathy and single-minded pursuit of their own interests (Wing 1997). Many very successful academics are thought to fall into this category (Carter 1998).
Case 13.1 Introducing touch
Michael, aged 60, is non-verbal with mild to moderate learning difficulties and challenging behaviour which could involve attacking other people and throwing things and furniture. He was learning to adapt from having spent 30 years in an institution before coming to the group home.
The first month of meeting was spent walking outside together for him to get used to the therapist. Initial sessions were only 15 minutes long, with limited eye contact, as he did not like this. Gentle, relaxing strokes were used on his feet, avoiding any sudden movements. Gradually his hands were touched to introduce closer contact. After another month, sessions up to 30 minutes and occasional eye contact were possible.
Touching, tasting and smelling – everyday experiences – inform us about the world we live in, each experience leading on to the next, assisting in learning and development. Those with autism may not be able to process the information in the same way, leading to ‘abnormal’ behaviour as the affected individual struggles to cope with altered perceptions (Table 13.1).
(Autism and Practice Group 2007, Sensory Issues in Autism, p. 8)
People with autism might display what are known as autistic traits, e.g. rocking, flapping hands, or pressing fists into their eyes when experiencing a hypersensitive reaction to a sensory stimulus. This is because they are trying to induce different sensations in an attempt to block out the pain or calm themselves down. When autism causes hyposensitive sensory perception, the affected individual might bang objects/doors, seek out noises such as the vacuum cleaner, prefer tight clothing or self-injure in an attempt to cause sensations to help their brain get more information from the outside world. Aromas can be overpowering, so can background noise, and touch can be excruciating;
Contending with smell, noise and touch can cause a person to go into hypersensitive overload, leading to sensory shutdown (APG 2007). Although aromatherapy might not seem to be the obvious therapy choice for anyone with ASD, when used with discernment and care by a responsible, professional therapist, it can provide valuable support.
The Disability Discrimination Act (2005) and Mental Capacity Act (2005) highlighted the health requirements of people with a learning disability or autism. It should never be assumed that people cannot make their own decisions, simply because of their problem (DoH 2003), and consent – where the person is able to give it – should be sought before commencing an aromatherapy intervention.
Children 16 years or older and competent to do so, or under 16 years and deemed ‘Gillick’ competent, can legally consent to their own treatment (DoH 2009). Gillick competence is a term used in medical law to decide whether children under 16 are able to consent to their own medical treatment without parental permission or knowledge (Wikipedia 2010). Those with parental responsibility may consent to treatment for those under 16 (DoH 2009). Written consent is not always necessary, but the therapist should always record what consent was given and by whom.
Particular care should be taken to ensure that children and adults with learning difficulties or autism are given every opportunity to communicate their needs, wishes and feelings regarding care and treatment.
If an adult is not competent to consent, then the relatives/carer/key worker should be involved in the decision – when the treatment is in the client’s best interest, it is lawfully possible to provide it (DoH 2009).
Although there is little research evidence, there is a consensus of opinion that aromatherapy has a positive effect. The individual parts of an aromatherapy treatment – the relationship between client and therapist, touch/massage, essential/carrier oils and olfaction – can each provide support, and the synergistic effect of the whole package can produce significant physical and psychological benefits. Research has revealed that aromatherapy can have profound effects on the mind by affecting the autonomic level of the cognitive part of the brain (see Ch. 7); this can be seen in a study with older adults, linking postural stability to the olfactory system, where some changes in stability were noted (Freeman et al. 2009 (see Box 13.1, Broughan 2005; also Ch. 7).
This study tested the effect of olfactory stimuli on the postural stability of 17 older adults. The subjects were randomly exposed to the odour of Lavandula angustifolia [lavender] or Piper nigrum [black pepper] or the sham (distilled water) while standing with feet slightly apart on a force plate which measured movement of the body’s centre of pressure. The odour was presented to the subject on a spill which had been dipped in one of the oils or the water and held a few centimetres from, but not touching, the right nostril. They stood for 1 minute with eyes open, looking straight ahead with the odour stimulus, then a 2-minute break during which they sat and relaxed. The spill was re-dipped in the oil or water and presented again for 1 minute, during which time the subjects were asked to stand on the force plate with eyes closed. Subjects also underwent the same protocol with no odour exposure. The study found that with eyes closed, olfactory stimulation with either Lavandula angustifolia or Piper nigrum significantly reduced the velocity of postural adjustment, suggesting that olfactory stimulation may improve postural stability in older adults.