Managing behavioural crisis situations in autism

Behavioural crisis, a severe and or prolonged outburst of behaviour when the child becomes too upset, angry or aggressive, creates a difficult situation for parents and carers. Knowing the situations or reasons that may precipitate such a crisis and ways of managing it may be helpful in dealing with the situation without making it worse.

Three main types of behavioural crisis in children with autism:

1. Severe and prolonged tantrums

Tantrums occur either when the child’s wish is denied. Typically developing children also do it, but in autism it is prolonged and severe.  A tantrum is often a learnt behaviour – they watch others and try to get other’s attention – and giving in to it is never a good idea as it only reinforces the tantrum behaviour. Sometimes, the situation gets out of the child’s control because of their poor emotional regulation, and even they do not know how to turn off the tantrum!

 

Managing tantrums

 

• Stay calm. Your panic will only make the situation worse. Don’t cry or yell and keep your voice firm and steady; children are reassured by firmness.
• Catch it early: read early signals and try distracting the child to something of the child’s interest and which is calming for the child, for example, their choice of music or game.
• Show that you are aware that the child is upset by saying in a calm voice: “I know you are upset.”
• Remove attention, unless doing so would put the child at risk
• DO NOT give in or bribe the child
• DO NOT reason or argue
• Do NOT try to teach good behaviour at this time.
• Remain aware of the child’s and others’ safety, act promptly if anyone is at risk of getting hurt.
• Praise the child when the tantrum settles and practise the right behaviour. Do not criticise the child.

 

2. Meltdown

Meltdowns happen when the build-up of anxiety and stress crosses the limit of what the child’s system can put up with, and their pent-up stress boils over, causing prolonged crying and aggression. There is no particular purpose to this behaviour apart from releasing stress.

Unlike a tantrum, the child does not show any awareness of others’ reactions.

 

Managing a meltdown

• Stay calm. Your panic will only make the situation worse. Don’t cry or yell and keep your voice firm and steady; children are reassured by firmness.
• Catch it early: read early signals and try distracting the child to something of the child’s interest and which is calming for the child, for example, their choice of music or game.
• Show that you are aware that the child is upset by saying in a calm voice: “I know you are upset.”
• Help the child by removing demands from the child and reducing any sensory overload such as noise, such as moving to a calmer place.
• Use some practised calming method, such as a sensory toy or listening to music.
• Use a soothing method that you know works on your child, for example, hugging, touching, holding or singing.
• Some children may need to be left alone, removing stimulation and demands, in a safe and calm place, to calm down, but do not create prolonged isolation for the child.
• DO NOT criticise the child. DO NOT reason or argue. Do NOT try to teach good behaviour at this time.
• Talk about the incident after the child has settled, and only about how the child calmed down and settled, what would be unacceptable (hitting others or breaking things) and what she/he could do better in the future. Build a reward programme (giving stickers) for the child showing good behaviour in future. Don’t criticise the child.
• Remain aware of the child’s and others’ safety, act promptly if anyone is at risk of getting hurt

 

Taking the child to a hospital in such a situation may only make things worse; children with autism don’t react well to hospital environments. Medicines have almost no role in managing such situations. Trying to medicate children with autism by giving sedatives often makes them irritable and aggressive. If you have tried the above plan, worked on the behavioural improvement plan and still have serious issues with your child’s challenging behaviour, then take advice from a counsellor and a child psychiatrist.

 

 

Remember, preventing is the best way of dealing with both these behaviours. Work on: ❏    Improving communication using symbols if required ❏    Practising alternative behaviours or favourite activities that could be used as replacements of demands, such as a sensory toy, music, reducing noise with headphones. Using a predictable plan will help the child too. ❏    Reducing stressful situations such as noise or crowd and creating frequent breaks or relaxing times. ❏    Teaching, practising and rewarding positive behaviours, such as asking, giving, showing, sharing

 

 

 

You need to think through the above and individualise it to your child. Plan and share it with others and have it ready to use in the event of a crisis.

3. Shutdown (mental and physical inactivity)

Some children slowdown in all their activities, such as talking to others, speaking, doing daily chores, and even eating food. Their body movements also decrease, and they often appear relaxed. It may also happen that at one time it seems that the child is in shut down and at other times he feels fine. This situation may worsen if the help is not provided.

 

Helping the child during the shutdown phase

• Is there a reason in the environment that is causing mental stress to the child?
  • First, reduce such stress.
• Is the child under pressure due to any other reason, such as any change in school or expectations from him to work beyond his capacity?
  • Reduce these reasons by meeting with the school
• Is any other child or elder taunting or bullying the child?
  • Intervene to change this state.
• Is there a lack of regular schedule in the child’s routine at home or at school?
  • Create a routine for the child with the help of visual timetables.
  • Help the child follow his routine.
• Is the child not getting enough mental encouragement?
  • Play games with the child or do things that he is interested in, he can easily complete and for which he gets praise on completion.
  • Do not allow the child to sit and watch TV or video throughout the day, encourage the child by making a routine of doing such tasks before and after more active work.
  • Start the child’s routine with his or her favourite work.
  • Make a routine of walking or playing outdoors with the child every day.
  • Motivate the child to work, but at this stage reduce the decision-making burden on the child.
• Is the child able to get the support he needs?
  • In this stage, the child needs 1–1 help; The child should have a good and sensitive relationship with such helpers.
• Is the child taking any medicine?
  • Shutdown-like conditions often occur due to the ill effects of some medicines. Check the medicine by taking the help of a doctor, and if necessary, stop or change the medicine.
• Does the child know how to relax and reduce stress?
  • Help the child to learn a plan to relax and reduce mental stress.

 

4. Self-injurious (hitting/biting self) behaviour

Such behaviour is extremely distressing for parents and makes it very hard to look after the child. Unfortunately, parents and teacher often react wrongly to such behaviour, which makes the situation worse.

 

Managing self-injurious behaviour

 

Does the child often choose such behaviour when frustrated or distressed?

If yes,

1. Modifying the environment to make it less stressful for the child
   

   Area of concern	Consider including the following in the daily routine of the child
   Difficulty in communicating needs and feelings
   1. Can the child convey needs and anything upsetting him/her?	If not: –        Organise use of appropriate means of communication, such as using gestures/signs or pictures. –        Help the child learn to use these means to express needs and feelings. –        Teach the child a way of asking for help and make sure that all around the child understand that method -practise it.
   2. Does the child understand what others say to him/her?	If not: –        Use gestures and expressions to help the child understand. –        Keep your language quite simple. –        Use short sentences and divide an instruction in small chunks. –        Use signs/gestures and/or pictures.
   Sensory difficulties
   Does the child become upset or anxious due to noise, light, or crowd?	If yes: –        Turn off or cover fluorescent lights when possible –        Minimise noise by speaking in a softer voice, turning down the volume for the radio or TV. –        Avoid using loud noises, such as shouting, clapping or whistling, to get the child’s attention. –        If the noise cannot be reduced, consider using earmuffs or headphones to reduce the sound perceived by the child. –        Give the child experience of handling and playing with different textures, for example, mixing dough, making sandcastles, counting beans or hand-painting to get used to multiple simultaneous sensations
   Fears and anxieties
   Does the child become angry and upset by a change of situation, or people?	If yes: –        Gradually supported exposure and preparation is the key to reducing the impact of the child’s fears and anxieties, for example, in a safe environment, when the child is with the mother or a known carer, first using a picture of the fear generating situation and talking about it. –        Introducing the child to the new place, one step at a time, for example, first showing the picture of the place, then just going to see the outside of the area and then going in briefly may help the child overcome the fear. –        First showing the child the fear inducing things from a distance and then supporting the child by reassuring. –        Using something to distract the child in such situations may help; the distractor must be something that the child likes, like a squeezy ball or a picture book or a toy that the child likes. –        Giving child some time and space to get over the stress.
   Making change tolerable by increasing predicatibility
   Does the child get upset or anxious by change of situation or starting a new activity?	If yes: –        Prepare your child for any change in the situation by using . Pictures in a sequence to show the child what to expect –        Creating routines so that the situations become predictable for the child –        Explaining to the child what is going to happen next or after some time. Using activities such as counting to five or clapping hands to indicate change and practising these activities.
   Attention and activity level
   Does the child find it hard to pay attention? Is the child overactive?	–        Do regular and varied fun physical activities with the child, such as running, jumping, moving stuff, lifting weight, and playing on swings. –        For a child who dislikes physical activities, starting with a brief fun routine of a chasing ball game or slot, and gradually increasing the time, may help. –        For a child who finds it difficult to sit still, start with doing an activity that the child likes initially for a brief period, such as looking at a picture book, keeping the general tone and environment calm. Gradually increase the time; reward and praise the child for every increase of a minute.
   General calming measures
   General stress-reducing measure for all children with autism	–        Help the child learn to relax by practising calming routines, such as: o   Slowly counting to 10 o   Taking five long breaths o   Listening to music o   Taking short breaks from activities o   Lying down and relaxing the whole body –        Reduce the impact of stress on the child by: o   Getting the child to do regular physical exercise for at least 30 minutes a day o   Making a calming sleeping routine: avoiding exciting activities before bedtime, avoiding mobiles/TV before falling asleep, reading a book or listening to some calming music

Does your child have difficulty in communicating, understanding others, or expressing?

If yes,

1. Improve the child’s communication. This is the most common reason underlying such behaviour – make it a priority for you and the child.
1. Does your child seem to be using such behaviour to get what they want or to reduce their boredom or to escape from a task that they don’t want to do?

If yes,

1. Teach the child ways to convey their needs and desires
2. Practise these ways when the child is calm,
3. Encourage by rewarding whenever the child uses the right way of conveying needs or desires

Does your child seem to do the self-injurious behaviours to generate certain sensations?

If yes,

1. Consider giving the child other sensation generating toys and activities such as for chewing, touching, stroking and sound/music.
2. Create opportunities for the child to play with such material – the child may need help and encouragement in using sensory material.

Does your child seem to do such behaviour for seeking attention from others?

If yes,

1. Stop giving attention to such behaviour
2. Instead,  give the child a lot of attention and praise for any other alternative behaviour such as playing with a toy or a sensory activity.

 

Finally, increasing children’s existing good behaviours and teaching them alternative behaviour, through rewards and reinforcement, should decrease opportunities for indulging in self-injurious behaviours.

 

 

 Self-stimulatory behaviour (stimming)

 

Some children with autism show repetitive behaviours such as flapping their hands, moving their hands or fingers, covering their ears, rocking their body, pacing up and down, biting or chewing objects or toys and sometimes even their fingers or hands and at times pinching their skin or pulling their hair. These behaviours are known as self-stimulatory behaviours or stimming.

What causes these behaviours?

There are several reasons for such behaviours to appear, and one or more of them could apply to your child:

1. becoming either over-excited and using these behaviours to calm down or feeling bored and trying to create some excitement
2. feeling anxious, angry, upset or distressed because of sensory or emotional overload, and expressing these emotions through these behaviours or using these behaviours to soothe themselves
3. being in pain because of some physical problem such as a toothache or ear infection
4. and finally, the behaviour may have started for any of the above reasons but then became a habit for the child even though the original reason no longer exists.

 

How can you reduce these behaviours?

Such behaviours cannot be removed entirely. However, they change with time, and using the tips below, you can make them less disruptive and more acceptable for the child and others.

 

First, consider whether there may be a physical cause that needs to be treated.

 

Next, make observations, as you have learnt to do earlier and reduce the conditions or situations that may trigger, maintain, or worsen your child’s behaviour.

 

Practical tips worth trying:

 

• Regular daily vigorous exercises often reduce such behaviours
• Do not let these behaviours put you off from doing joint fun activities with your child, rather do more of them if possible, without worrying about trying to stop stimming.
• Instead of showing negative emotions towards stimming, show positive and engaging emotions towards your child and keep building your relationship with the child.
• Whenever your child does such repetitive behaviour, start an activity of your child’s choice, which has been practised earlier. Praise and reward your child on starting that activity.
• For stimming, which may be socially inappropriate use pictures or words (depending on the child’s understanding) to convey to your child that he/she can do stimming in his/her room or later. That will improve your child’s self-control.
• Regularly praise and reward your child for not stimming. Do not shout at the child or use physical punishment for doing these behaviours.