Managing those Meltdown Moments

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Managing those Meltdown Moments

• Strathclyde University May 30th 2009

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Key Issues

• What is a meltdown? Are they distinct episodes
  of behaviour that follow common patterns?
• Why do children with ASD have age-inappropriate
  meltdowns?
• How can such episodes be prevented?
• How can meltdowns be managed?

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Meltdowns

• High energy episodes
• Fast-moving
• Physical expression of range of emotions
• Extreme behaviours
• Danger to self/others
• Uncommunicative/uncontrollable
• Irrational/bizarre
• Age-inappropriate response

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Flight/Fight/Freeze

• Autonomic Response
• Endocrine Response
• ASD differences in brain development,
  architecture and functioning.

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Impact on Families

• Emotional impact on parents/care givers
• Stress on relationship between parents
• On siblings
• On normal family activities avoidance
• Relationships between family and grandparents
• Relationships between family and friends

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Impact on Schools

• Teaching staff/support assistants
• Curriculum
• Peer group
• Senior managers

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• Our lack of understanding of meltdowns is the
  reason for the very negative, haphazard and
  sometimes irrational way that we deal with
  them. We may therefore be a part of the problem
  progress depends on a degree of
  self-reflection.
• There is often a tendency to seek resolution
  rather than strategies for prevention and
  effective management.

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Barriers

• Our understanding of challenging behaviour is
  undermined by
• A leap to moral judgement
• Decisions based on outcomes
• The need to satisfy others (parents, staff etc)

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Deficits/impairments

• Attention allocating attentional resources
• Sensory integration
• Mentalisation (Theory of Mind)
• Communication (expressive/processing)
• Verbal
• Non-verbal
• Meta-cognition
• Central Coherence
• Executive Functioning
• Case Study..\David.doc

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Central Coherence
The ability to derive meaning from apparently
disparate information, in order to form higher
order concepts. The ability of a class teacher,
for example, to recognise that something is
wrong by the body language, responses and
general atmosphere in a class situation. It
is intuitive in varying degrees amongst the NT
population but impaired in those with ASD. Core
deficit may be in the speed of processing.    
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A Difference of Focus

• Central coherence is lost in the focus on a
  local, rather than a global context.
• The contextualisation of information to derive
  meaning appears to be a central deficit in those
  with ASD.

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Executive Control Functions

• Complex (non-domain specific) brain functions
  that integrate and coordinate activity and thus
  support high order thinking.

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Conditional Stability
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How do we employ EF?

• Ability to stand back and reflect
• Central coherence (reflective coherence?)
• Objectivity and self-awareness
• Inner dialogue self-directed speech
• Verbal articulation planning, emotions
• Planned routes outcomes
• Contextualisation (proportion, perspective)

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ECFs

• Executive Control Functioning can be defined as
  (Brown, 2001)
• The capacity for autonomous behaviour beyond the
  structure of external guidance
• Initiative
• Motivation
• Spontaneity
• Planning
• Judgement
• Insight
• Goal-directed behaviour
• Ability to operate in favour of a remote or
  abstract reward.
• Capacity for self-monitoring
• Flexibility for self-correction

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ECF
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Inhibitors
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Role(s) of Language

• Capture and define state of mind
• Reference and retrieve past experiences
• Express and communicate
• Aid to visualisation and planning
• As a processing technology
• Joint roles of language and memory may therefore
  hold the key to understanding differences between
  NT and ASD functioning.

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Memory and Planning

• High order language skills and thinking allow
  us to contextualise past experiences and planned
  futures, and in so doing to develop a sense of
  proportion and a sense of perspective from which
  we draw comfort/security.
• NB Concept formation in REM sleep.

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Unstable State

• Disorganised thinking
• No referencing/contextualisation
• Reduced sense of proprotion
• Reduced sense of perspective
• No planned outcomes and therefore..
• No routes
• Steps defined by emotional outburst(s)

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Kaufman, Plotsky, Nemeroff, Charney 2000
(Effects of early adverse experience on brain
structure and function Clinical Implications.
Biological Psychiatry, 48(8), 778-790)
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Biological Response to Stress

• Flight/Fight triggered by corticotropin releasing
  hormone (CRH) which initiates endocrine response
  (glucocorticoids).
• Amygdala activated by ascending neurons in brain
  stem and by direct and indirect connections to
  pre-frontal cortex (NE and EPI).
• Hippocampus inhibits stress response by releasing
  GABA (gamma-aminobutyric acid).
• Serotonin further modifies stress response in
  amygdala, hypothalamus and hippocampus.

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Kaufman, Plotsky, Nemeroff, Charney 2000
(Effects of early adverse experience on brain
structure and function Clinical Implications.
Biological Psychiatry, 48(8), 778-790)
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ECF
Post-crisis
Trigger
Escalation/Crisis/De-escalation
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Why is self-regulation impaired?

• High state of arousal sensory challenges
• High state of arousal social isolation
  communication barriers/deficits
• Poor sense of self separation of self from
  environment/others
• Poor internal structure
• Poor contextualisation proportion/perspective
• Weak central coherence
• Poor situational control
• Weaknesses in impulse inhibition (NB ADHD)

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Processing Deficits

• Visualisation rather than verbalisation leads
  to weaker processing)
• Less efficient/effective recall mechanism
• Poor emotional referencing of past experiences
• Poor situational referencing of past experience
• Lack of internal dialogue

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Acceleration

• Aims
• To speed child through the process
• To help child organise own thinking (EF)
• To gain influence through shared dialogue
• To direct child towards safer options
• To inject humour (?)
• To reach normalised state

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Post Crisis Phase
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Post-crisis

• In some cases, no action is the most positive and
  constructive response.
• All staff should be de-briefed.
• The child/young person should be involved in
  discussing the incident, WHEN THEY ARE READY TO
  DO SO, in a dispassionate and objective way, and
  then involved in constructing alternative
  scenarios.

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Practical Strategies

• Anticipation
• Prevention
• Acceleration
• Planning
• Emotional self-regulation (of staff)
• Establishment of a low arousal/low-threat
  environment
• Normalisation

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Case Study - Hamish

• 9 years old 1 sibling
• Diagnosed ASD at 5 years (also dyspraxia,
  dyslexia)
• Parents articulate, resourceful, well-informed
• School successful, positive, inclusive,
  flexible
• Hamish excluded/self-excluded for violent
  behaviour (assaults on pupils and member of
  staff)
• Result ..\David.doc

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A Neuro-atypical Model