This document summarizes guidelines for managing behavioural crises in children with developmental issues. It discusses defining triggers and signs of crisis, developing a crisis plan, de-escalation techniques, and appropriate use of restraint, seclusion or medication. Pharmacological interventions like risperidone are effective for treating aggression, while functional assessments aim to understand the purpose or cause of challenging behaviours. The document emphasizes prevention, functional support approaches, and maintaining safety during crisis situations.

1. Management
of
Behavioural
Crisis
in
Children
with
Developmental
Issues
Dr.
Norharlina
Bahar
Child
&
Adolescent
Psychiatrist
Hospital
Selayang
29
August
2014

2. Outline
• What?
• Causes
• PrevenJon
• Management:
– Before
– In
the
midst
– ALer
• Pharmacotherapy
• Causes
of
ID
and
behavioural
paNern
2

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Have
a
Crisis
Plan
• PreparaJon
and
strategies
for
coping
and
staying
safe
in
these
situaJons
• To
be
developed
by
family
&
the
treaJng
team
9

10. 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

11. 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

12. 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

13. • 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

14. • 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Thank
you