Thoughtful response…



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“THOUGHTFUL RESPONSE…”

This paper based on a popular training by the same title


Thoughtful Response to Agitation, Escalation and Meltdowns

in Children with AutisM Spectrum Disorders


Part I: Understanding Inflexible-Explosive Children
Part II: Understanding the Stages of Crisis, Leading to Meltdown
Part III: Reacting to Agitation, Escalation and Meltdown
In the literature about working with individuals with Autism Spectrum Disorders, attention is routinely given to proactive or preventive strategies for helping children manage their lives smoothly. These strategies are based on insight into a child’s particular challenges, recognition of their particular strengths, and acknowledgement of their particular communication style and skill level. The strategies that all of us know, and use, are also based on the understanding of sensory differences and the child’s often pervasive need for sameness and routine.

For example, every time you go over a schedule with a child, you are using a proactive strategy for managing potentially challenging behaviors. You understand that this child needs predictability and/or rehearsal, delivered in a visual form, in order to comply with general expectations.

As parents or professionals, we are skilled in our delivery of front-end strategies because these strategies give us our peaceful and focused moments that optimize both functioning and learning.


But there are times that no matter how prepared we are for the anticipated challenge of our students, how diligent we are with rearranging the environment, with communicating appropriately and with fulfilling sensory needs, our students get agitated, this agitation escalates and they have a meltdown.
That is the topic of this paper.

Part I: UNDERSTANDING The Inflexible-Explosive Child1

It is always tempting to go right to the “How To…” section of any clinical paper. We all want to read that when so-and-so happens, this is what we need to do. However, there should be a high premium on understanding why children behave in certain ways because if you have insight into the roots of behavior, you are more likely to respond with compassion and intelligence and you are more likely to be effective in addressing challenging behaviors. There is no formula I can give you that guides your therapeutic actions during meltdown or crisis. There is no recipe for the perfectly managed outburst. What I can give you is knowledge and tools. It is up to you to use that knowledge to select the right tool for the job or to invent a new tool that fits the child and the situation best.

So we are going to spend time learning about the characteristics of children who tend to have outbursts and how their biology leads them down the path to explosiveness. Hopefully this will enhance your understanding of the children with whom you work and give you the background you need in order to respond not with annoyance and not with a rote formula, but with understanding.


Common Characteristics of Meltdown-Prone Children


  • Inflexible and explosive children have difficulty managing and controlling emotions associated with frustration. They also have difficulty “thinking through” ways of resolving frustrating situations. In these children, frustration (usually caused by a demand to shift gears) often leads to a state of cognitive debilitation in which the child:

      • Has difficulty remembering how to stay calm and problem-solve;

      • Has difficulty recalling the consequences of previous episodes;

      • May not be responsive to reasoned attempts to restore coherence; and
      • May deteriorate even further in response to limit setting and punishment.





  • Inflexible and explosive children have an extremely low frustration threshold. They become frustrated more easily and for seemingly trivial things (we know in autism, however, that what may seem trivial to us is often anything but trivial to our students!)




  • Inflexible and explosive children also have an extremely low tolerance for frustration. So not only are they more easily frustrated, but also the experience of being frustrated itself can be very intense, disorganizing and sometimes overwhelming.




  • Inflexible and explosive children have a tendency to think in a concrete, rigid and black-and-white manner.




  • Inflexible and explosive children persist in their inflexibility and poor response even in the face of meaningful consequences.




  • Explosive episodes can appear to have an out-of-the-blue quality.




  • The inflexible and explosive child may have one or more issues about which he/she is particularly and repeatedly inflexible (i.e. what to eat, what to wear)




  • Even though all children grow more easily frustrated when tired, ill or hungry, the inflexible and explosive child may have even fewer coping mechanisms when already stressed by internal factors.

So now we have a picture of a meltdown-prone child (which sounds very much like most or all of our children with autism). But how does this happen? What creates this cluster of symptoms?


There are many neurologically determined pathways that lead to explosive behavior. Please refer to the chart below.

Sensory Integration Dysfunction

ADHD and executive function deficits

Social Skills Deficits








The inflexible-explosive child

Anxiety



Language processing difficulties




MOOD

Difficult Temperament



The Pathways to Inflexibility and Explosiveness – A Few Elaborated


Deficits in executive function are commonly associated with Autism and ADHD. The areas of compromise for our children include the following:



Shifting cognitive set: the ability to shift efficiently from one mind-set to another

Organization and planning: organizing a coherent plan of action to deal with multiple thinking tasks simultaneously

Working memory: performing multiple thinking tasks simultaneously

Separation of affect: the ability to separate your emotional response to a problem from the thinking you need to solve the problem.

All of these skills are needed for both flexibility and problem solving. They are often impaired in children with autism. If you can’t shift your attention, organize your thoughts, or keep your emotions from overwhelming your ability to think logically, it is quite possible for even simple requests to trigger an explosion.

Deficits in social skills, a problem for every child who has been diagnosed with autism, affect the flexibility, complex thinking and rapid processing required for social interactions. Most meltdowns occur when a child with autism is asked by another person to stop what they are doing and do something else. We often assume that the child will be able to do this, with minimal frustration. We also often assume that the child will want to comply because of their wish to please a social partner. This, however, is not always true for children with autism.

Sensory integration dysfunction is another contributing factor to inflexibility and explosiveness. Many of our students cannot consistently sort through incoming sensations. There may be times when they feel overwhelmed by noise and hubbub and cannot tolerate the addition of frustration. There may be times when their bodies feel out-of-sort and they react more emotionally and less adaptively to requests or expectations. If a large part of their brain is coping with uncomfortable sensation, they may have little energy left to adapt to a request to shift gears.
Language processing difficulties are common in autism and this deficit, too, can affect how the child tolerates and/or manages frustration. Children who are less efficient at understanding language, categorizing and storing current and previous experiences (in language), thinking things through (in language) and retrieving language in a timely manner to express themselves, are at great risk for frustration. And when you add the difficulty of understanding and using the language of emotions (a characteristic of autism), your risk of frustration increases.
Conclusion to Part I:

So now we know the characteristics that increase the likelihood of meltdowns. We also know what parts of the child’s neuropsychological profile contribute to these characteristics. Why is this important? Because we cannot figure out how to respond to moments of escalation in our students without knowledge and understanding about what it is that makes a child susceptible to rages or rapid escalations. If you don’t understand the basic characteristics that can cause distress in a child with autism, you might think they are just “being bad”, or “manipulative”, or “controlling”. You might also choose inappropriate techniques to manage these crises, thinking that if you just keep piling on consequences, you will win the battle. But when you understand the characteristics of the inflexible, explosive and autistic child and how these characteristics are determined by neurological difference, you realize that it is never a battle where someone wins and someone loses. Becoming so frustrated that you lose control of your body and of your rational mind is distressing - for the frustrated child and for you. No one ever, ever wins.

Part II: Understanding the Stages of Crisis, Leading to Meltdown



MELTDOWN





ESCALATION


AGITATION



Agitation/Escalation:
Many things can trigger agitation in children with autism:

  • Not getting what he/she wants

  • Not doing what he/she wants to do

  • Not being able to regulate to environmental stimuli

  • Not being able to regulate to internal stimuli

All of these triggers represent a demand to shift gears: shifting to a new activity; shifting away from a routine; shifting attention away from something uncomfortable externally; and, shifting attention away from something uncomfortable internally. Why is this shifting so hard for children with autism? This is a complicated question for which the answer is only emerging through research.




A research tidbit

The ability to shift attention was explored by Susan Bryson and Reginald Landry from York University and Hospital for Sick Children in Toronto. They have discovered that in children with autism, there is a universal problem with visual orienting. This is the most basic form of attention. It describes the ability to move one’s attention in space. It is critical for survival.


Children with autism, even children with normal or above normal IQs, have marked difficulty in disengaging attention when shown first one visual stimulus and then another one simultaneously. Although non-autistic children were able to instantly shift to the novel stimuli (something most of us are hardwired to do), children with autism took an average of 8 seconds to disengage from the first stimulus in order to look at the newer (and equally eye-catching) stimulus. During that long 8 seconds most of the children appeared distressed.



Conclusion: It is neurologically difficult to shift attention if you are an individual with autism. Children with autism aren’t being bad or non-compliant. They are being autistic. This problem is not just a problem for us. It seems to be a problem for the children as well.

What happens when you do ask a child with autism to shift gears? Sometimes nothing – they simply comply. Sometimes, however, this simple request can be a trigger for increased agitation and escalation. Because we are working with children who are inflexible and have significant problems with the management of frustration, these early phases of a potential meltdown are aptly described by Dr. Greene as “vapor lock”.2 In cars, vapor lock is caused by excessive heat that creates a bubble in the gas line. This prevents gas from flowing to the engine and causes the engine to stall. No matter how many times the driver pushes the pedal or turns the ignition, the car won’t start again until it cools down. Similarly, Dr. Greene suggests, frustration causes breakdown in our student’s capacity to think clearly, causing him/her to become overwhelmed and less rational. No matter how many times the adult reasons, insists, rewards, punishes, or whatever, the child can’t start thinking clearly until someone helps him/her cool down.

You might think of it as brain-lock.
Meltdown:
Dr. Daniel Goleman, the author of Emotional Intelligence, refers to the meltdown phase, in which the child seems to be “out of control”, irrational, incoherent, destructive and sometimes abusive, as “neural high jacking”. What does this mean? It means all coherent, rational thought has been stolen and what is left is a debilitated state of incoherence. What the child does and says during meltdown is simply mental debris (a phrase used by a number of professionals in the field) and all attempts to teach, reason or reconcile are lost.
An escalating and deteriorating inflexible-explosive child is not a pretty sight. Not for you, not for the others around you and certainly not for the distressed child.
As parents, teachers, therapists and consultants, we need to find the crossroads of every potential meltdown and intervene at that critical moment with strategies that calm and focus the child so that he/she can slowly learn to adapt to whatever is causing the frustration.

Part III: Reacting to Agitation, Escalation and Outburst



Before we begin… a word about consequences
Children who are developmentally compromised in the areas of flexibility and frustration management usually:

  • Lack the capacity to manage emotions associated with frustration well enough to think clearly in the midst of crisis; and

  • Lack the ability to shift their thoughts from their agenda to your agenda even when faced with very meaningful consequences.

So, think about these quotes from Dr. Greene:


For a consequence to achieve its desired effect – that is, for a consequence to make it less likely that a child will explode the next time he’s frustrated – you have to have faith that the consequence you administered on the back end the last time (i.e., following the last explosion) is going to be accessible and meaningful to the child on the front end the next time he becomes frustrated.”3

Consequences can be very effective if a child is in a state of mind to appreciate their meaning, but don’t work nearly so well if a child is not able to maintain such a state of mind.”4
Treating “out of control”, irrational, incoherent, destructive and sometimes abusive behavior with consequences is not routinely effective in children with autistic spectrum disorders. Even when the punishment is very meaningful to the child, he/she probably won’t be able to access that looming consequence in the middle of a meltdown and miraculously regain control, stop flailing around and return to the world of the rational. This is a very important concept in working with your explosive students.

Proactive strategies for maintaining a learning environment (ongoing):
Every time we work with a student, we begin our session with strategies already in place. The strategies we use are individualized but often include the following:


  • Access to communication

  • Access to choice

  • Predictability

  • Access to quality of life

  • Environmental adaptations

  • Analysis of common challenging behaviors and the motivation behind these behaviors

  • Utilization of strengths and special interests as a mechanism for teaching

  • Access to meaningful reinforcers

Yet even with these in place, there are times that new learning and growing expectations create frustration and our meltdown cycle begins.


Warning signs of agitation and escalation:

Each child is different and each child has their own set of warning signs that indicate mounting stress and frustration. However, we can be pretty sure that an episode of agitation starts with refusal. Refusal can be shown in lots of ways: By saying “No!” effectively; by falling to the floor; by not moving; by hitting, kicking, pinching, biting; or by hiding under the table. Children with autism may refuse for many reasons and most of these reasons are linked to the universal difficulty with shifting attention.

Intervening
So what can you do to de-escalate a refusing child?
First, it is important for you to think about the demand that you are making on the child. Is it one of those completely non-negotiable requests? Is it one that on a good day is worth pursuing but on a bad day is not? Or is it something that is simply not really important? You must prioritize your demands.
A level demands = Non-negotiable

B level demands = Important, but not totally essential, can be put on hold if the child is stressed about other things

C level demands= Non-essential, eliminate

So now you know that every time a child becomes agitated when requested to shift gears from what they are doing to what you want them to do, you need to make sure that your request is essential (A level) or you should consider deferring or delaying your request (C level). Do they really need to put on their shoes? Does it really matter if they eat dessert before their pretzels? If it is really a C level request (not important), give them a choice (modeling appropriate, non-agitated communication) and accept their selection.



Oh, you want your shoes off. Shoes on later? Okay, shoes later.
If you decide that it is a B level request that is fueling their refusal and subsequent agitation/escalation, you need to decide if this is the day and time that you want help this child learn new skills and new coping mechanisms. B level skills can provide you with the opportunity to teach more constructive and more effective ways of dealing with stress, inflexibility and difficult feelings. Agitation and escalation don’t have to be seen as avoidable at all costs. They can and should be seen as teachable moments.

But a B level request can be removed if you realize that there are too many other variables that are contributing to your student’s distress. If he/she is sick or tired, if there have been changes in routine, if there is sensory overload, do not choose this moment in time to teach your student about managing stress and frustration. Back off the request, give the student true choices, and accept their response.

If, however, it is a fine day to work for growth and the development of new skills and you proceed with your B level request, you still need to be wise about how you intervene so that you help the child with problem solving before the agitation escalates and a meltdown ensues.


  • At the first signs of agitation, you need to demonstrate to your child that you understand how hard it is to shift gears. You need to become his/her partner in this, not his/her adversary. As Dr. Greene says,

When children are stuck in the red haze of inflexibility and frustration, they respond a lot better if they perceive adults as potential helpers, rather than as enemies”5

To do this, you need to offer him/her the words and affect that describe the mounting feelings. I know you are mad. You are really mad that it is time to go! It is hard to stop playing with that toy. I understand.



  • You need to give your student time and space (remember that language processing can be slow and shifting gears even slower)

  • You need to provide visual information instead of constant verbal prompting and/or correction.

  • You should provide support and help in a calm, non-threatening manner.

  • You might offer to do the activity with the child.

  • You might try humor or surprise as a way of interrupting the upward spiral of agitation. If the child responds, and their affect changes to one of pleasure or curiosity, you now have a more cognitively available child for solving the problem that was fueling the agitation.

  • If your student is able, you might frame the problem and get them to help with the solution.
    • Uh-oh… we have a problem. I want you to get ready to go home and you want to continue to play. What can we do about this that makes both you happy and me happy?


    • Remember that with a B level request there should be flexibility in how things get solved. You need to be open to the child’s solutions as long as it fits the parameters (a solution that makes both you and your student happy).

    • You might need to help the child with a solution by offering choices and suggestions. After all, if they were good at coming up with solutions to these problems, they wouldn’t be autistic.

If, however, your request that requires them to shift gears is an A level request (not negotiable), you have a slightly different situation. There are some limits that can’t be bent or rearranged. Children have to be safe and healthy, clothed and fed. They also need to take medicine, go to school, and go to bed. They can’t hurt other people or pets, hurt themselves or destroy property. These are all A level requirements.


Many of the strategies for A level requests are the same as previously described for B level. We still want to help a child calm down and shift their attention to the request. We still want to empathize, to provide time and space for de-escalation and compliance, to use visual supports while decreasing the amount of language being used, to use humor if appropriate, and to offer help. What we can’t do however is change the limit that we are setting. We can’t compromise. If you find that you can and do compromise in the end, then that was not an A level request.

A level requests are usually the trigger for full escalations. For a child that is inflexible, rigid, and routine-bound (as many of our children with autism are), being told that he/she must or mustn’t do something is often intolerable. When the child finds that this limit can’t be changed or altered or negotiated but simply needs to be accepted, it can be very difficult. As the adult proceeds to follow-through with the requirement, the child becomes enraged. Now he/she can’t reason, his/her body often goes out of control and he/she becomes incoherent. This is the meltdown.

Meltdown:
What do you do?


  • You need to wait it out safely.

  • You need to have one person manage the meltdown with others nearby to help you (not to help the child).

  • The person who manages the meltdown should know the child well and should feel that they will do a good job. If you are uncertain or overwhelmed or if you have lost your objectivity, hand the job over to someone else.

  • You need to isolate the child. If he/she doesn’t want to come with you into a safe spot, then move other children and/or other staff away.

  • You need to stop talking unless your words have a soothing effect.

  • If the child is attempting to hurt himself/herself or others, including you, you need to use protective strategies so that no one gets injured.

  • Once the child has begun to calm down, you might offer sensory activities such as rocking or deep pressure if, and only if, you know that this is helpful in re-organizing the child.

  • Once the child has begun to calm down, you might offer the child a drink or something to eat if, and only if, you know that eating and drinking is helpful in calming and focusing this child.

  • You might offer to help the child with calming strategies that he/she has practiced during non-crisis times such as counting backwards, deep breathing or singing a repetitive song.


Recovery

When the child is out of crisis, and the request has been met (medicine has been swallowed, seatbelt has been fastened, whatever), it is important to let the child know that even though it was hard, they did a good job complying and you are proud of them. The recovery phase is short for children with limited insight. For those who can and do have insight, it is important to talk about how hard it was and how bad they felt and what can be done next time so that everyone feels better.

If the outburst was triggered by an A level or even a B level request, it is likely that that request, in the future, will once again cause the child to escalate and potentially meltdown even if the child has shown remorse and has “talked it through” with you during recovery. This is what we have been discussing throughout this training – that inflexible and explosive children cannot access previous experience during escalating agitation and meltdowns. The child’s team, then, needs to come up with ways of understanding why this particular request is so difficult for the child and what to do to make it easier on the front-end, proactively. You might try:


  • Gathering more information from the child and the team about why this request was so problematic;

  • Writing a social story that gives the child information and coping strategies;

  • Setting up regular and highly desired rewards for compliance;

  • Reading the social stories, rehearsal and role play;

  • Finding effective calming methods that can be practiced and made readily available to the child even when agitated.


Conclusion to Part III

There are numerous therapeutic techniques for intervening during a potential crisis or meltdown. Please remember, however, that each child will require you to first understand what fuels his/her frustration – not only in terms of this particular child, but also in terms of what the diagnosis of autism puts on the table. With that information in mind, you can then select techniques that seem to fit. These techniques fit the following hierarchy:


What you always do….

  • Responding to basic needs: Proactive strategies for helping to manage stress for the child and optimize functioning and learning are an important part of every child’s treatment, whether it be in the home, the school, the community or in groups. These include enhancing the opportunity for both receptive and expressive communication; adapting the environment; providing predictability; and fulfilling sensory needs.

But if they don’t work on a given day or in a particular circumstance…




  • Responding to agitation and escalation: The strategies for defusing potential meltdowns include: becoming the child’s partner as opposed to adversary; giving the child space and time to process the problem; decreasing language; using visual supports; and, if possible, helping the child frame and solve the problem in a way that is satisfying to both you and the child.

But if these interventions don’t work…




  • Responding to crisis: The strategies for managing a meltdown in a therapeutic manner include isolating the child for his/her safety and the safety of others, using protective strategies in the event of dangerous and/or aggressive behavior, and waiting for the storm to blow over. As the child begins to calm, you may find that certain sensory activities increase the child’s ability to grow calm and focused again.

After it is over…




  • The learning phase: Although many children with autism have limited insight into their own behaviors, it is important to eventually discuss what happened with the child and to devise, as a team, ways to rehearse similar situations during non-stressed moments. Social stories, rehearsal and possibly desensitization with regular reinforcement are all appropriate post-meltdown techniques.

Helpful resources


  • Fouse, B. and Wheeler, M. A Treasure Chest of Behavioral Strategies for Individuals with Autism. Future Horizons. 1997.




  • Greene, Ross W. The Explosive Child. Harper Collins. 2001.



  • Hewett, Dave. Challenging Behaviour; Principles and Practices. Taylor & Francis Group, 1998.





  • Hodgdon, Linda A. Solving Behavior Problems in Autism – Improving Communication with Visual Strategies. Quirk Roberts Publishing. 1999.




  • Kaiser, B. & Rasminsky, J. Challenging Behavior in Young Children: Understanding, Preventing and Responding Effectively. Allyn & Bacon, 2002.




  • Moyes, Rebecca A. Addressing the Challenging Behavior of Children with High Functioning Autism and Asperger Syndrome in the Classroom: A Guide for Teachers and Parents. Jessica Kingsley, 2002.




  • Myles, Cook, Miller, Rinner and Robbins. Asperger Syndrome and Sensory Issues. Autism Asperger Publishing Company. 2000.




  • Myles, B, and Southwick, J. Asperger Syndrome and Difficult Moments. Autism Asperger Publishing Company. 1999.



1 The concept of the inflexible-explosive child is taken from Dr. Ross Greene’s book, The Explosive Child, HarperCollins, 2001. Although his ideas are not specific to children with autism, they are very relevant and have been adapted for this training. Please refer to his work for a far more detailed discussion of the ideas presented throughout this training.

2 Dr. Ross Greene, The Explosive Child, p. 21.

3 Dr. Ross Greene, The Explosive Child, p. 91.

4


5 Dr. Ross Greene, The Explosive Child, p. 104

© Rebecca Klaw, 2006



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