Cara Outreach Service

Conceptual Framework


Rehab Group

Target Group    18+
Description  The CARA Outreach support service is part of the National Learning Network located in Waterford City, County Waterford.  The CARA Outreach Support Service provides specialised support for individuals with a diagnosis of Autism spectrum Disorder (ASD). This is a highly proactive, structured and holistic service providing Person Centred outreach support. The service is designed to support the individual to recognise and to attain their future aspirations and potential. 

This non-residential service provides home and community based support which focuses on continued life and social skills development. This programme aims to work in partnership with other people relevant to the individual’s life, including parents and carers, Social Workers, Occupational Therapists and Psychologists.  This approach ensures a multidisciplinary and holistic structure, which aims to have the maximum potential affording a positive impact in the individual’s life.

All individuals accessing this service are subject to an in-depth pre-admission assessment which forms a structured baseline for future care and support.  Assessment tools include NLN Needs Analysis and Social Skills Assessment (Alex Kelly), where appropriate and any relevant Psychological Reports or other relevant professional reports.
Assessment of Need
The exact nature of the support delivered to the individual who accesses this service is dependent on individual needs, as determined by the structure of assessment. Based on its individualized approach, interventions are incremental in nature, focusing around achievable mid and long term goals in overcoming the challenges frequently presented by living in society and having ASD.

Outreach workers engage individuals identified for this service and develop a relationship of trust with those people who are not able to come to a service. This outreach approach is often necessary for people who are wary of services, dubious about the benefits of support, or just low in ‘motivation’. The outreach worker may need to consider using a series of short visits to build up contact or visit the parents/family for a time, until the person is ready to interact openly with the outreach worker.

Target Group
This service targets people between above the age of 18 years of age who have been diagnosed as having Asperger syndrome or Autism Spectrum Disorder and who are not in fulltime education, training or employment or whose current placement in same is at risk. This service design is focused on individuals who by virtue of their inability to self-manage, interact and communicate within society, has resulted in them becoming isolated or disconnected from society. This service aims to provide a service to those without any service, many who are fulltime residents in their family home.

The target group of eligible candidates for this service are resident in the HSE administrative areas of County Waterford. It is envisioned that this programme provide consistency and continuity of service for individuals who have previously been supported by the Autism Services in Waterford. Those individuals with a diagnosis of Asperger syndrome/ ASD, who have come through the main-stream school system and have had contact with the Autism Services in Waterford, form part of the cohort of service users. 

Referrals to this service are made through the Disability Guidance Officer, who in consultation with the HSE Disability Guidance Authority assess and advise the candidate as to their suitability for participation on this service. The Disability Guidance Officer, as a member of the Admissions Committee, ordinarily initiates the assessment process in consultation with the Admissions Committee.

Persons who are currently participating on RT/Foundation training programmes and who are making progress on same are not included in this service.

A diagnosis of Asperger syndrome/ ASD does not mean that someone will meet eligibility criteria for this service. However, an assessment of need will always be required to establish whether the individual’s particular difficulties meet eligibility for service. The CARA outreach Service welcomes enquiries from all professionals, families, carers, organisations and prospective clients.

Whilst the ‘triad of impairments’ (Wing, 1981) is considered to be the common factor
Among all those with the diagnosis, it is important to take into consideration that people with Asperger syndrome/ASD are individuals and everyone affected is different. People vary in personality, life experience, intellectual ability and genetic inheritance, which make it crucial that strategies are not developed on the basis of limited understanding. The individualized design of this outreach service addresses this reality

This outreach service aims to meet the varying and sometimes complex needs of the individual while acknowledging the unique character of each person. However, this service is cognisant of the natural limitations within the available recourses allocated. Recognising that each individual’s needs will be assessed prior to initiating any intervention, the following construct of delivery are utilized. The level of support contact that the individual receives is determined by the assessment process and approval of the Admissions Committee and the Manager at NLN.

Outreach Service placement is offered to the individual once funding is confirmed in writing from the funding authority. Service interventions commence after the appropriate resources are in place as determined by the Admissions Committee and area manager.

Construct of Delivery of Service
Level 1)   This is a high level of intervention, where the Outreach support worker works directly with the individual on a regular basis/interval.  Interventions are determined by the individual’s needs, the multi-disciplinary team and other professionals as deemed necessary. Approximately four to six hours a week are generally considered appropriate.

Level 2)   This is a medium level of intervention as determined by the individual’s needs and consultation with the multi-disciplinary team and other appropriate professionals. Approximately one to four hours a week is considered appropriate hours of contact.

Level 3)   This is a low level of intervention based on the individual’s needs and in consultation with the multi-disciplinary team and other professionals. Periodic consultation with the individual is considered appropriate.

Need for Individual Service Design
Many individuals with a diagnosis of Asperger syndrome do not ‘fit’ into the Intellectual Disability or Mental Health category and thus continue to be excluded from services; they feel isolated and singled out as people whose disability is deemed unworthy of assistance (Powell, 2002). This service aims to provide an appropriate and professional outreach service which meets the unique needs of these individuals. Since the addition of Asperger syndrome into the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in 1994, the prevalence of the diagnosis continues to increase.

As a result of trying to ‘fit in’, many adults experience significant levels of anxiety (Attwood, 1998) and often develop other mental health difficulties, most commonly depression (Howlin, 1997, Tatam, 1991). The CARA service endeavours through professional and competent support service to provide a structure in which individuals with Asperger syndrome will become healthy and productive members of society. 

Unless we understand that people with this diagnosis have a unique cognitive style and a different view of the world, our efforts to address their needs are likely to be ineffective and even counterproductive (Powell, 2001). This service acknowledges the fundamental reality that no matter how comprehensive or thorough the assessment process might be, manifestation and presentation of complex needs are diverse and multi-faceted. Subsequently, each individual participates in the service for an initial period of three months. At the conclusion of the initial three month trial period the individual placement is confirmed or extended as determined by the operational committee area manager.  The rationality of this process is essentially an acknowledgment of the diversity of needs and the unique profile of individuals with a diagnosis of Asperger syndrome/ASD.

Post-diagnostic support (Outcomes)
Adults recently diagnosed with Asperger syndrome/ASD require post-diagnostic counselling support over several months (Attwood, 2006).  Although diagnosis usually seems to bring a sense of relief, for those old enough to understand what it means, there will be a number of reactions to having Asperger syndrome/ASD on a day to day basis.

One thing that can assist most people to adjust and ‘come to terms’ with the diagnosis is information and the opportunity to talk. The exception to this may be people who are diagnosed but denied having any difficulties before. These people may not wish to discuss Asperger syndrome/ASD at all following diagnosis.

For adults who were not diagnosed until their teenage years, or later, there can be anger about how much time has been ‘wasted’, how badly they were treated at school, and about professionals who misdiagnosed them. People may also perceive the diagnosis as the end of being able to aspire to ‘normal’ lifestyles and this may take time to consider and come to terms with (Powell, 2001).

Therefore post-diagnostic support is an important part of the therapeutic process and should not be rushed. Individually or in a group, post-diagnostic support should include discussion and information on the following elements:

-  diagnosis explained again in more detail
-  Possible emotional reactions
-  Examining past events in light of new diagnosis
-  disability awareness: strengths and abilities
-  disability awareness: differences and challenges
-  Disability awareness: what is Asperger syndrome?
-  being in control; self-advocacy; being positive
-  how to explain Asperger syndrome to people outside the family
-  implications for family members and friends
-  facing the future; independent living options
-  social welfare benefits – how to request support
-  ensuring the person is linked into information dissemination, with professionals
-  opportunities to meet others with Asperger syndrome
-  opportunities to attend ongoing social support groups

Ultimately the overall aim is to give people a better self-understanding and a positive view of diagnosis. It is also about identifying needs and securing any necessary ongoing support

Practical support
Support may be in a group or undertaken as individual work, and may vary from intensive intervention to occasional visits. Often an independent living skill will need to be taught in the actual place where the person lives or works and will be using that skill, because people with Asperger syndrome may find it hard to generalise a newly learnt skill even across similar settings. This ability varies and will be considered when offering practical support and guidance.

Some people with Asperger syndrome/ASD will require lifelong support to acquire some of the following ‘skills’; others will often require a prompt; many others can achieve these with minimum support and become independent.

The following are practical supports, some or all may need to be addressed to achieve independent living. It is the responsibility of the outreach worker under the direction of the programme coordinator and in consultation with the Admissions Committee/area manger to implement these supports.

-  Financial (for example, budgeting, paying bills, assessing values, dealing with door salesmen, saving money).

-  Morning routines (for example, early morning call, waking and getting up, washing, choosing appropriate clothing, grooming, personal hygiene, self-presentation).

-  Organisation and reminder systems (for example, weekly timetables, note keeping, maps, using a mobile phone, useful telephone numbers book, keeping appointments, calendar).

-  Food hygiene (for example, cleaning the fridge, checking sell-by-dates, cooking at the right temperature).

-  Diet (for example, understanding of a balanced diet, remembering to eat and drink enough and to exercise).

-  Avoiding loss of personal possessions, (for example, crime prevention awareness, not leaving possessions unattended, not lending items to strangers).

-  Home safety (for example, locking up at night, not leaving the gas on, shutting windows, when to ask for assistance).

-  Home skills and maintenance (for example, cooking, dealing with uninvited guests, changing a plug, ironing, washing up, adjusting to seasonal changes, unblocking a sink, heating, doing the laundry, putting the bins out, when to ask for assistance).

-  Personal care (for example, reporting illness, medication, hygiene, sexual health, getting enough sleep, how to relax).

-  Community skills (for example, going to the pub, cafes, clubs, taxis, letting someone know your whereabouts, using public transport, using libraries, driving lessons, basic manners, avoiding risk situations, how to explain Asperger syndrome to others, how to say ‘no’, awareness of own behaviour, reporting incidents, dealing with neighbours, useful conversation topics, personal disclosure, not ‘staring’.

-  Understanding and applying for Social Welfare (for example, Job Seekers Allowance, disability benefit, rent allowance, accessing FAS, assistance with form completion.

Progression Individual clients who participate in this service are encouraged to develop progression routes for their future. An essential element of the support service is the participant setting realistic goals for themselves.  Clients are encouraged and assisted in developing short and long term goals in their particular area of interest. Vocational and educational options are explored with each client. Because this service is operated from the National Learning Network, the client will have various other options available to him/her such as Employer Based Training, IT and Office Skill Courses. The Coordinator of the service will work closely with each individual in terms of setting realistic progression routes to a successful and healthy life.

Steering Committee and Admissions Committee Steering Committee
A Steering Committee (Appendix A) composed of a group of individuals who are responsible for general operating policy, procedures, and related matters affecting the CARA Outreach Programme. Representatives of the primary stakeholders address system issues, enhance service delivery and develop or provide training. Various professionals operating locally in the field of Autism form the membership of the Steering Committee. The Steering Committee convenes on a bi annual schedule. The following individuals form the core membership of the Steering Committee:
The Coordinator of Disability Services, The Occupational Guidance Officer, National Learning Network Area Manager, The Coordinator of the CARA Programme, A member of the Autism Services in Waterford and any other professionals as deemed appropriate by the Steering Committee.

Admissions Committee
An Admissions Committee (Appendix A) composed of individuals responsible for service interventions and delivery of the programme. The Admissions Committee convenes quarterly with the objective of reviewing and evaluating the programme objectives. The Admissions Committee evaluates each of the programme participants’ progress in terms of goals and objectives and relative outcomes. The members of the Admissions Committee work in collaboration to design appropriate interventions. Service interventions are re-evaluated as necessary for their strengths and weaknesses. The Admissions Committee contribute constructive feedback and recommendations to the Outreach Coordinator with a view to ongoing effective development and delivery of service. The period of service intervention is determined by the multi-disciplinary assessment process.  The following individuals form the core membership of the Admissions Committee:
Occupational Guidance Officer, National Learning Network Area Manager, Coordinator of the CARA Programme, Occupational Therapist, Psychologist and a member of the Autism Services in Waterford.

The Cara Outreach Service has as part of its normal operation a series of documentation that is collated if the individual confidential file. They include:

Administration File:
Application Form
Referral Form
Psychological Reports (Sealed envelopes)
Consent Form

Service Files:
- Needs Analysis
- Goals or area of support
-  Progress Notes
-  Miscellaneous documentation

Support Framework It is imperative that the Cara Outreach Service have as an inclusion a provision of supervision both clinical and process focused. This specialised form of mentoring provided for practitioners responsible for undertaking the challenging work of the Cara Outreach forms an essential element of professional practice.  It is envisioned, that when in place professional supervision is provided to ensure standards, enhance quality, advance learning, stimulate creativity, and support the sustainability and resilience of the work being undertaken.

It is recommended by this author, John McCraith, that supervisors should be sufficiently experienced in the field of autism services or a closely related field. Accurate records of supervision should also be available to the appropriate authority in National Learning Network.

Currently the staff members who work in the Cara Outreach as part of their professional obligations to professional bodies, (British Association of Counselling and Psychotherapy) privately engage with supervision external to the organization.

Currently local management function as managerial supervision directly to staff members working in the Cara Outreach.  

Continuing Professional Development  
CPD is currently available to staff working on the Cara Outreach. These opportunities for training and development are ordinarily available only external to the organization by ASD specific entities. CPD is envisioned as any learning experienced that can be used for the systematic maintenance, improvement and broadening of competence, knowledge and skills to ensure that the practitioner has the capacity to practise safely, effectively and legally within their evolving scope of practice. It should include both personal and professional development. The elements of reflective practice are highly recommended to promote evaluation and guide future delivery of services.   

Aspect Cork Ireland
Staff and Resources 3 Full time
Duration Ongoing
Budget HSE Public
Contact /more
John McCraith: