Published on September 16, 2014
Management of Behavioural Crisis in Children with Developmental Issues Dr. Norharlina Bahar Child & Adolescent Psychiatrist Hospital Selayang 29 August 2014
Outline • What? • Causes • PrevenJon • Management: – Before – In the midst – ALer • Pharmacotherapy • Causes of ID and behavioural paNern 2
What is behavioural crisis? • In full meltdown mode • The child is not capable of reasoning, being redirected, or learning replacement skills. • One off or frequently or ongoing? 3
Challenging Behaviour in Children with Developmental Issues • 2 – 3 x more common (CorbeN, 1979; Richardson 1979; Eifeld, 1995; Tonge, 1998) • AgitaJon • Aggression • DisrupJve behaviour • Self-‐injurous behaviour • A significant change in funcJon (loss of interests, withdrawal from family, etc.) • School expulsion and/or an inability to leave the home. 4
PrevenJon • The most effecJve way to manage challenging behaviours is to try prevenJng them from happening rather than just focusing on what to do when or aLer the behaviour occurs. • Learn skills to help anJcipate and turn around an escalaJng situaJon. 5
PosiJve Behaviour Support Approach • Consider the purpose or ‘why’ of the behaviour • Focus on prevenJng the behaviour from happening by avoiding or changing the circumstances that trigger the behaviour • Teach new behaviours or skills to replace the challenging behaviour 6
What purpose (or FuncJon) does challenging behaviour serve? • All behaviour happens for a reason • Health problems -‐ may cause challenging behaviour or make it worse. • Common reasons are: – Interact with someone – Social aNenJon: e.g. shouJng – To get something: A person may learn behaviours that get them things they want. – Escape or avoid a demand/ request/ situaJon/ object/ person – Sensory: to get/ avoid sensory sJmulaJon i.e. rocking, humming – Get some control or predictability over their day or the acJvity – Reduce their arousal and or anxiety. 7
FuncJonal Assessment • To find out the exact causes of a person’s behaviour • Keep a record: 1. DescripJon of the behaviour i.e. exactly what happens 2. Early warning signs, e.g. becoming red in the face 3. What happens before the behaviour, e.g. does something trigger the behaviours? Noisy environment? Being told no? etc. 4. What happens aLer the event, i.e. what is the person gejng or not gejng from the behaviour that makes them do it again? 8
Have a Crisis Plan • PreparaJon and strategies for coping and staying safe in these situaJons • To be developed by family & the treaJng team 9
A well-‐designed plan includes 1. Defined sejng events, triggers or signs that a crisis situaJon might develop 2. Tools and strategies for keeping the individual and those around him safe in any sejng (school, home, community) 3. IntervenJon steps and procedures promoJng de-‐escalaJon that are paired at each level with increasing levels of agitaJon 4. Lists of things to do and NOT to do specific to the needs, history & fears of the individual 5. Hands on training and pracJce for caregivers 6. ConJnued re-‐evaluaJon of the effecJveness of the plan 7. Knowledge of facility if hospitalizaJon needed 8. Maintain safety first and foremost. This is not the Jme to teach, make demands, or to shape behavior. 10
Ways to Calm an EscalaJng SituaJon • Be on alert for triggers and warning signs. • Try to reduce stressors by removing distracJng elements, going to a less stressful place or providing a calming acJvity or object. • Remain calm, as his behavior is likely to trigger emoJons in you. • Be gentle and paJent. • Give him space. • Provide clear direcJons and use simple language. • Focus on returning to a calm state by allowing Jme in a quiet, relaxaJon-‐promoJng acJvity. • Praise aNempts to self-‐regulate and the use of strategies such as deep breathing. • Discuss the situaJon or teach alternate and more appropriate responses once calm has been achieved. 11
In the midst of a Crisis SituaJon • Remain as calm as possible • Assess the severity of the situaJon • Follow the Crisis Plan and focus on safety • Determine whom to contact • Dial 999 for an emergency • Remember: this is not a ‘teachable’ moment. 12
• Consider the safety of your child & those around them: – can you remove your child from the situaJon safely? – do you need to remove yourself and other family members from the room or situaJon? – do you need to remove items from the environment or room that could be unsafe? • Consider the language you use with your child to avoid escala7on: – avoid talking as much as possible (stressful to have to work out what your words mean) – Use short, simple instrucJons if needed (include a visual clue eg. Opening door to show your child they can go outside to calm) – use a calm even voice. 13
• Try to regain calm as quickly as possible by: – What will help the child calm as quickly as possible (Jme alone, access to an acJvity or item he/she likes that is calming) – What will help you calm as quickly as possible (leaving the room, gejng other family members safe, gejng back-‐up) – Allow lots of Jme for recovery 14
Challenges for Medical Professionals • Listen to the caregiver and the paJent to the extent possible. They're very unique in how they interact. • Do not think that we know beNer. • Aim to least restricJve care. • Family: be prepared to advocate yourself 15
Physical Restraints, Seclusion & Rapid TranquillizaJon • When behaviors pose a risk of physical harm to the individual or others, a brief intervenJon are someJmes necessary to maintain safety. • Physical restraints -‐ immobilizing or reducing the ability of an individual to move their arms, legs, body freely. • Seclusion -‐ pujng the individual briefly in a room by himself to ‘calm down’. 16
Physical Restraints, Seclusion & Rapid TranquillizaJon (cont) • As last resort and when less restricJve methods are not effecJve or feasible. • Improper use can have serious consequences physically and emoJonally • Must take place within the legal framework ie. Consent or Mental Health Act 17
Rapid TranquillizaJon • The aim is to achieve a state of calm sufficient to minimize the risk posed to the individual or to others. • Rapid tranquillisaJon with intramuscular or intravenous injecJons should only be used in healthcare sejngs with appropriate resuscitaJons need. 18
Assessment • History • Previous hx of anJpsychoJc? Non-‐drug approach • de-‐escalaJon techniques, e.g. talking down, distracJon, Jme out • Inform paJent/ carer re medicaJon Oral • Lorazepam 0.5 -‐ 2mg • Olanzapine Zydis 2.5 mg – 5mg • Risperidone 0.5 – 1mg IV/IM • (Lorazepam) • Midazolam 2.5 – 15 mg • Haloperidol 2.5 – 10 mg Monitoring & Nursing • Vital signs • Low sJmulus environment Repeat • Wait at least 30 minutes 19 Maudley Guideline, 2012, Byrne, 2012; Heyman 2003; NICE 2006
De-‐escalaJon • Maintain adequate distance. Respect personal space • Do not be provocaJve. • Ensure the environment is conducive for calmness. • Be calm & self-‐assured, use non-‐threatening, non-‐verbal communicaJon. • Be concise, use repeJJon. • Explained intenJon, set clear limits. • Offer choices 20
The Use of MedicaJon • Aimed at target symptoms eg. to achieve state of calm; paJent will hit others less frequently; psychoJc symptoms; irritability • Comprehensive assessment of the individual's emoJonal and behavioural disturbance and assessment of the efficacy of all previous modes of treatment. • Issue of informed consent & legal maNer • Should be integrated with other concurrent treatments. MedicaJon alone to is not sufficient. 21
The Use of MedicaJon (cont) • SomeJmes unrealisJc demands to solve the problem by prescribing medicaJon. • Children with developmental issues are more vulnerable for side-‐effects. 22
Pharmacotherapy • Risperidone -‐ effecJve and well tolerated for the treatment of agitaJon, aggression, or self-‐ injurious behavior in children with ASD (McCracken 2002, Davies 2006) & ID (Unwin 2011, DeDyn 2006) • Aripiprazole is effecJve for irritability in children with ASD (Ching, 2012) • Off-‐label use: QueJapine, Olanzapine, Paliperidone (Golubchik 2011, SJgler 2012, Hollander 2010) 23
Pharmacotherapy (cont) • SSRI ie sertraline, fluvoxamine : comorbid depression, OCD, anxiety (Hellings 1996, Campbell 1995) • Benzodiazepines : short term, anxiety. Paradoxical effect (Barron, 1985) • Valproate : mood lability, irritability, aggression (Kastner 1990) • SJmulant : comorbid ADHD (Arnold 1998, Handen 1999) 24
Causes of ID & Behaviour PaNern • Cause of a child’s intellectual disability can provide informaJon on: – Strengths and weaknesses – Can provide informaJon on what types of behaviour and emoJonal difficulJes child may present. 25
Causes of ID & Behaviour PaNern Fragile X • DistracJble, impulsive, overacJve, short aNenJon span • Anxious, shy, poor eye contact • Anxiety may present as tantrums • Hand flapping, sound / light sensiJviJes, sensiJvity to touch • Changes in rouJne -‐ problemaJc • DifficulJes with crowds, new situaJons – can be overwhelming Down syndrome • Typically fewer emoJonal and behavioural problems compared to other children with ID – but sJll higher rates than typically developing children • InaNenJon, hyperacJvity • Stubborn • Depression 26
Causes of ID & Behaviour PaNern AuJsm Spectrum Disorder • High levels of behaviour and emoJonal problems • DisrupJve behaviour – eg tantrums, aggression, abusive, noisy, impaJent, stubborn • Anxiety • DifficulJes with change in rouJne and surroundings • Symptoms of depression • InaNenJon, impulsivity, hyperacJvity • Social difficulJes Prader Willi syndrome • Hyperphagia -‐ extreme unsaJsfied drive to consume food • Food foraging / obsession with food • Increased appeJte, weight control issues • Temper tantrums, opposiJonal, argumentaJve • Stealing, lying, stubborn, rigid, possessive • Obsessive/compulsive behaviour • Skin picking • Impulsivity 27
Causes of ID & Behaviour PaNern Williams syndrome • Friendly, outgoing, loquacious • Short aNenJon span and distracJbility • Difficulty modulaJng emoJons -‐ extreme excitement when happy • Tearfulness in response to apparently mild distress • Terror in response to apparently mildly frightening events • Heightened sensiJvity to sounds (hyperacusis) • PerseveraJng on certain favourite conversaJonal topics • Anxiety, difficulJes with changes in rouJnes / schedules • DifficulJes building friendships 28
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