Jane, who is 5, is capable of playing alone in her room with the door closed, despite displaying some behavioural difficulties.

The case manager determines that Jane does not meet the severe behavioural difficulties test as from the information available, her behaviour does not appear to be extreme, her carer is not regularly required to intervene in order to prevent or reduce the likelihood of physical injury to Jane or others, and her carer is not required to be present and watching over Jane whenever she is awake.

John is 9 years old, has autism and is not able to speak. He lives at home with his family and attends a school for children with extra support needs 5 days per week.

The case manager has already determined that he is entitled to the higher rate care component of CDP. John is never left alone at home as he often has random violent outbursts. He can become violent towards his family, hurts himself and destroy household objects. In general, John has no understanding of the impact of his behaviour.

His parents take actions that are set out in John’s positive behaviour support plan to prevent harm to anyone or damage to their home. His parents take turns sleeping in John’s room to ensure his immediate safety if he wakens at night.

His school has provided a report about his behaviour. While at school, he has unpredictable violent episodes, can attack anyone nearby, throws chairs and injures himself.

Two members of staff are present at all times to supervise him and take action if necessary. This is due to John’s unpredictable and destructive behaviour. He requires the constant presence of another person to watch over him and take action.

This action is set out in John’s positive behaviour plan. This meets the severe mental impairment and severe behavioural difficulties test and the case manager makes an award of the higher rate of the mobility component.

Dylan is 9 years old and has:

• global developmental delay
• poor communication skills
• behavioural difficulties that include eating non-food objects
• not been toilet trained
• a tendency to show extreme disruptive behaviour.

His social worker and teacher have supplied supporting information indicating that Dylan:

• is restricted to basic gesturing when communicating his needs
• cannot co-operate in play
• has no insight into the effect of his challenging behaviour on others.

The case manager accepts that Dylan:

• requires attention throughout the day and at night
• has an arrested development of the brain, or a deficiency in the functionality of the brain as a result of its incomplete physical development
• has a severe impairment of intelligence and social functioning.

The case manager awards Dylan the highest rate of the care component and the higher mobility component of CDP.

Adam is 7 years old. He has severe autism and a learning disability. Adam’s ability to communicate is limited to making sounds. He also does not seem to understand speech at times and simple requests made of him.

He expresses his emotions through behaviour. He:

• lashes out when he is upset
• is destructive
• can hurt others and himself
• is unpredictable in his mood swings, which can be triggered by minor issues
• does not have an understanding of the impact of his behaviour.

His parents:

• need to supervise Adam constantly and watch over him during the day and at night
• have had to remove all furniture from his bedroom apart from a mattress.

This is to ensure his safety and prevent him from destroying objects or being a danger to himself and others. As he gets older, it is getting more difficult to manage his behaviour due to his strength increasing.

The case manager has decided that Adam meets the criteria for the higher rate care component. They also decide that Adam has:

• a condition which has resulted in arrested development of the brain
• unpredictable behaviour
• a severe impairment of intelligence and social functioning.

The case manager awards Adam the highest rate of the care component and the higher rate mobility component of CDP.

Jamie is 13. His behaviour is extremely challenging and he is no longer attending school. His foster parents apply for CDP on his behalf.

The case manager reviews Jamie’s application form. They establish that Jamie:

• experienced several adverse childhood experiences (ACEs) at a young age and over a prolonged period
• is awaiting a diagnosis of Complex Post-Traumatic Stress Disorder
• is unable to understand the consequences of his actions and has been detained by the police on multiple occasions when outdoors without adult supervision
• often runs away from adults in his support circle and community who are trying to keep him safe
• does not understand the impact of his behaviour
• is unable to assess risk or be aware of his environment.

Jamie’s foster parents explain in the application form that they feel overwhelmed and unable to supervise Jamie’s extremely challenging behaviour at all times, although they make every attempt to try and keep him indoors.

The supporting information tells the case manager that Jamie and his family are supported:

• in the community by a support worker through an organisation which provides intensive support service
• by CAHMS. However, Jamie can struggle to engage at times.

The case manager requests a clinical case discussion to better understand Jamie’s potential condition as well as his needs. The practitioner advises the case manager that:

• it is unlikely Jamie will receive a brain scan. However, it is recognised that in people living with PTSD, parts of their brain will appear different in scans.
• These changes can lead to flashbacks, nightmares and prolonged anxiety
• Jamie appears very vulnerable, based on information in the application form which describe that he is unable to identify positive or negative relationships, is actively seeking relationships which put him in danger and is using alcohol and recreational drugs
• Jamie experiences frequent nightmares and can bed wet during and after these. Jamie requires frequent and prolonged comfort, support and physical assistance (wash, change and clean bedding) during the night, which would be consistent with the conditions noted within his application
• at Jamie’s age, children would be expected to develop skills related to growing independence. Jamie appears to manage dressing and washing independently but requires encouragement. This would indicate delay in this skill, but may also indicate low self-worth. Jamie also shows several behaviours which would indicate he has not yet developed an awareness of risk or danger.

The case manager makes a determination to award the highest rate of the care component.

Based on the application form, the supporting information and the case discussion, the case manager establishes that Jamie:

• has severe impairment of intelligence and social functioning which is caused by Complex PTSD and ACEs
• has severe behavioural difficulties
• meets the criteria for the highest rate of the CDP care component.

The case manager therefore establishes that Jamie meets the severe mental impairment and severe behavioural difficulties test. They award Jamie the higher rate of the mobility component, in addition to the highest rate of the care component for CDP.