NDIS Psychology Session Progress Note

Liam Vance

14/05/2024

Liam Vance (Client), Sarah Vance (Mother - first 10 mins)

Face-to-face

Clinic

Current Presentation

Session focused on heightened sensory overload and social anxiety experienced during recent transition to a new community art group.

These symptoms have resulted in avoidance of community outings and increased emotional dysregulation at home, reducing independent community participation by approximately 50%.

NDIS Goals Addressed

Addressed NDIS Goal 1 (increase community participation and social independence) and Goal 2 (develop emotional regulation strategies to manage daily stressors).

Liam actively engaged in role-play scenarios and collaboratively updated his sensory safety plan.

Liam demonstrated intact expressive language when calm and adequate cognitive flexibility during structured problem-solving tasks.

Progress Toward Goals

• Goal 1: Achieved 40% progress; Liam attended 1 community session for 30 minutes before requesting to leave, which is an improvement from prior total avoidance.
• Goal 2: Achieved 60% progress; Liam independently identified 2 early warning signs of dysregulation during the past week, though unexpected schedule changes remain a significant barrier.

NDIS Therapeutic Approach

Cognitive Behavioural Therapy (CBT) adapted for Autism Spectrum Disorder (ASD) and Acceptance and Commitment Therapy (ACT) frameworks were applied during this 50-minute session.

Interventions

• Cognitive restructuring and interoceptive awareness training to link physical sensations with rising anxiety levels.
• Graded exposure planning and behavioural rehearsal to build tolerance for unstructured social environments.

Key Activities

• Completed a functional behaviour assessment chain analysis of the recent community art group overwhelm.
• Utilised the 'Zones of Regulation' visual chart and a customised CBT thought record worksheet.
• Addressed emotional regulation, distress tolerance, and assertive communication skills.

Session Content

• Sensory triggers in crowded spaces, cognitive distortions regarding peer judgment, and proactive coping mechanisms.
• Liam reflected that he waits until his distress is at an 8/10 before using his noise-cancelling headphones because he worries about "looking different" in front of peers. He recognised that intervening at a 4/10 would prevent a meltdown and allow him to stay at the activity longer.
• Discussed the layout of the local community centre and agreed on a designated quiet zone with his support worker prior to entering the main room next week.

Progress and Barriers

• Liam successfully utilised box breathing in session to reduce his self-reported anxiety from 6/10 to 3/10, and demonstrated improved insight into his internal sensory cues.
• High ambient noise levels at the community venue and internalised social stigma regarding the use of sensory aids continue to act as primary environmental and psychological barriers.

Client Response

Liam participated cooperatively and remained calm throughout the 50-minute session, despite initial hesitancy when discussing the art group.

He displayed mild frustration when recounting the sensory overload incident, which quickly resolved following validation and redirection to problem-solving.

Observed intermittent eye contact, fidgeting with a stress ball during difficult topics, and relaxed posture during the final 15 minutes of the session.

Caregiver Involvement

Yes

Sarah attended the initial 10 minutes and reported 2 episodes of post-outing exhaustion and verbal outbursts over the past fortnight. She expressed concern regarding Liam's reluctance to communicate his needs to his support worker in real-time and requested strategies to share with the support team.

Risk Assessment and Management

• Suicidal ideation: Nil reported or indicated.
• Homicidal ideation: Nil reported or indicated.
• Self-harm: History of head-hitting during severe sensory meltdowns; 0 incidents reported in the past 4 weeks.
• Violence or aggression: Occasional verbal aggression (shouting) toward family members when overwhelmed; no physical aggression toward others.
• Addictive behaviours: Nil reported.
• Risk-taking/impulsivity: Mild risk of absconding from loud community environments when dysregulated without warning support staff.
• Management plan: Updated Green-Amber-Red behavioural response plan; implemented a non-verbal signal card for Liam to hand to his support worker before exiting a room to mitigate absconding risk.

Risks or Alerts

Risk of impulsive absconding from unfamiliar community settings during acute sensory overload.

Introduced a visual 'break card' system, rehearsed the exit protocol in session, and emailed the updated safety protocol to his mother and disability support coordinator.

Session Outcomes

Liam gained clear insight into the threshold at which he needs to deploy sensory accommodations. We successfully established a concrete, 3-step graded exposure plan for next week's community outing, and Liam reported feeling confident (7/10) in using his new non-verbal break card with his support worker.

Next Steps

Review the outcome of the graded exposure task at the community art group and introduce social scripts for initiating peer conversations.

Liam to practice using his noise-cancelling headphones for 15 minutes in a moderately busy environment (local cafe) and log his distress levels pre- and post-activity.

Send a brief summary of the visual break card protocol and sensory accommodations to Liam's NDIS support worker (with consent) prior to Tuesday's outing.

Reporting Summary

NDIS goals targeted: Goal 1 (Community participation) and Goal 2 (Emotional regulation).

Presenting issues: ASD-related sensory overload and social anxiety limiting independent engagement in community group activities.

Interventions: Psychoeducation, interoceptive mapping, cognitive restructuring, and graded exposure planning.

Therapy models: CBT and ACT.

Therapeutic support provided: Provided targeted psychological intervention to build psychosocial functioning, self-advocacy, and emotional regulation capacity, directly supporting safe and sustainable community participation.

How supports helped: By equipping Liam with proactive sensory management strategies and a non-verbal communication tool, the support increased his self-efficacy to manage distress independently, reducing the likelihood of behavioural crises and decreasing long-term reliance on 1:1 crisis support in the community.

Client engagement: Cooperative, insightful, and responsive to visual scaffolding.

Barriers: Sensory-unfriendly community environments and fear of negative peer evaluation.

Functional capacity observed: Demonstrated capacity for self-reflection, ability to co-develop safety plans, and effective use of somatic calming techniques when prompted.

Progress made: Acquired ability to map early physiological warning signs of overload and established a functional, non-verbal self-advocacy strategy for community settings.