Carly had always found the world a strange, bewildering and frightening place. Her parents had tried their best to protect her from the cruelties and confusions her day-to-day life seemed full of; but in doing so simply encouraged her to retreat into her bedroom and further and further into her head. Eventually, even they became a threat to her rituals, and they found themselves wholly ill equipped to cope with Carly's aggression and her frequent display of bizarre behaviour.

Carly has moderate learning disabilities and profound autism. For her, most of what people say to her makes little sense. She is very easily upset, turning to tears, rage or both at the slightest, usually accidental provocation; changes in routine and unpredictable sets of events tends to send her reeling. Carly is a difficult young woman and for 14 years her parents, both who have mild learning difficulties themselves, tried to cope with her by avoid provoking her in anyway. As a consequence Carly learnt virtually nothing, other than to scream, throw and break things or even hit people; all of which would usually result in others acquiescing to her demands, however unreasonable those demands were. In such circumstances it was hardly surprising to find that Carly could not function at all in the world in any productive or meaningful way. What's more, at 14 her increased size and strength terrified both her parent's and siblings. There was little choice but for her to come into care.

The level of Carly's multiple disabilities and delayed development initially shocked even the Marlowe's experienced staff. She had no idea of safety in the home or on the road, she was disinhibited in public and apparently impervious to embarrassment; she struggled to dress herself and she couldn't even use a knife and fork properly; nor did she have any idea how to manage her own personal hygiene. Further, Carly had so rarely attended school that, even taking into account her learning disabilities, she was way behind her peers in terms of reading and writing.

Because of the extremes of Carly's behaviour, especially when frustrated or upset, the process of developing a detailed assessment and a structured programme within which she could function needed to be put into place quickly and concurrently. In order to mitigate the worse of Carly's unmanageable anxieties she needed maximum predictability in her life. This programme, worked out with her for the most part, helped Carly and the staff team avoid the worst of her aggressive outbursts. Carefully worked out diffusion techniques managed to quell most of the others.

Consistency of staffing, and the clearest possible communication allowed Carly to feel a little safer almost immediately. By constantly checking with Carly that she understood, and allowing her to say ‘I don't know what you mean’ without feeling humiliated was key to establishing the beginnings of trust. Further, also built in as part of the programme was the time set aside each day in which she could indulge in some rituals in her bedroom - usually organising 100's of pens and crayons into ‘order’, or adjusting the position of her soft toys to ensure they remained in the ‘perfect place’. These ‘rituals’ were Carly's safety valve, and although strange to the rest of the world, properly boundarised, were essential to her sense of well-being. It was therefore important to allow her this small ‘safety valve’.

In terms of bringing Carly forward, the programme initially focused on the most basic things. She learnt slowly and with some difficulty, how to use a knife and fork, how to clean her teeth, to shower and to manage her periods herself. Although, she was initially poorly motivated to these things (and even actively resistant), the combination of precise positive reinforcers built into her programme, along with patient encouragement were the key to successfully overcoming her resistance.

At school, backed up by work at the unit, her reading and writing skills improved. Again, success was rewarded; this time by staff reading out loud a chapter or two of ‘Harry Potter’ before bedtime, over a hot chocolate with cream!

Relationships with peers had never previously played a significant part in Carly's life. However, superficially at least, at her best, she began to get something from their company. While jealousy between them over staff time was often a potential source of conflict, by sticking rigidly to the programme staff managed to help Carly to internalise some increased patience with others around her. She learnt that she could not always have what or whom she wanted ‘now’, and that actually she could manage to wait (once she was sure she would get what she needed eventually).

So many positive changes for Carly did not come without a cost. Her caring, well-meaning but inadequate parents struggled to cope with the meaning of Carly's growth and increased abilities. For Mum and Dad every success seemed to reinforce their own self-perceived failures. As a consequence, they were not above, consciously and un-consciously, sabotaging the work that was being done. Addressing this with them was a difficult and delicate task, and required close co-operation between agencies. For Carly, her parents remained the most important adults in her life. It was therefore essential she experienced them and the various professionals in her life working with her to the same agenda. To achieve this, her parents needed to feel they were contributing and their contribution was valued. Much time and effort was spent by both Marlowe staff and her Social Worker, ensuring Carly's parents felt they were ‘part of the team’.

Within nine months of her placement Carly was able to begin a college course. Even within groups of students, all of whom also had special needs, Carly needed more support than most - one of her care team with her all the time at college. This was, after all, a huge step forward. The level of support given worked. Not only did she continue to develop academically, but also socially she blossomed. The social benefits of learning to control her impulsive and aggressive behaviour began to have real meaning. As a consequence she was able to join in college social activities such as cinema trips, ten-pin bowling and even a short adventure holiday. Winning her course's ‘Most Improved Student’ was the highlight of an enormously successful first year.

For Carly the world remains a difficult place; the expectations of others are still often confusing for her. She still feels safest in her bedroom sorting out blue crayons from red ones, green crayons from yellow ones. However, she also now sees that life has things to offer that she enjoys. For the first time in her life she now has choices.

For reasons of confidentiality, and out of respect for the privacy and dignity of the children and young people concerned, names and other incidental details have been changed to obscure their identity. However, in all of the important details, these case studies are an actual summary of what happened. All imagery used has been created purely for artistic effect by Marlowe Child & Family Services Limited and is ©copyrighted by the owner.