Question
My eldest boy J___ who is now 5-years-old was diagnosed with ASD (level 1) last July. We did 6 months of intense therapy with a child psychologist and a speech therapist before we moved over to Ghana. J___ has settled in well. He has adjusted to school very well and the teachers who are also expats from England are also dealing with him extremely well.
My current issue is his anger. At the moment if the situations are not done exactly his way he has a meltdown. Symptoms are: Extreme ear piercing screaming, intense crying, to falling down on the floor saying he is going to die. I have tried to tell him to breathe but his meltdown is so intense that his body just can't listen to words. I then have asked him to go to his room to calm down. He sometimes (very rarely) throws things across the room, but does not physically hurt anyone. As I have two younger boys (ages 1 and 3) I still need to be aware of their safety. I then managed to put J___ in his room with the help of a nanny. He throws all blankets off the bed (which doesn't bother me) and then hides under them. Today I waited 10 minutes then went upstairs to talk to him, but he then started again with the extreme crying and screaming at me. It took him over an hour to calm down fully. The situation arose as the nanny and I were helping him to make muffins and the nanny put a spoonful of the mixture into the muffin tin.
I am requesting your help on ways to calm him down in a manner that is acceptable. He is getting too old to be put in the "thinking corner/naughty corner" and I am a petite person so I'm not going to physically put him there. I am finding his resistance at the moment is a lot with me and his father.
I have structures in place by visual laminated pictures of how the morning is run and the structure before bed. This works fine, but like I said when things aren't done exactly his way, he can have an outburst in a flash. Please give me some strategies on how I can better manage these meltdowns.
FYI - he was diagnosed on the border on the CARS model. I have found a qualified speech therapist who is from England which we go to once a week (but as it is summer break we don't go back to August) to assist with his pragmatic language.
Answer
Problems related to stress and anxiety are common in kids with ASD (high-functioning autism). In fact, this combination has been shown to be one of the most frequently observed comorbid symptoms in these children. They are often triggered by or result directly from environmental stressors, such as:
- a sense of loss of control
- an inherent emotional vulnerability
- difficulty in predicting outcomes
- having to face challenging social situations with inadequate social awareness
- misperception of social events
- rigidity in moral judgment that results from a concrete sense of social justice violations.
- social problem-solving skills
- social understanding
The stress experienced by kids with ASD may manifest as withdrawal, reliance on obsessions related to circumscribed interests or unhelpful rumination of thoughts, inattention, and hyperactivity, although it may also trigger aggressive or oppositional defiant behavior, often captured by therapists as tantrums, rage, and “meltdowns”.
Educators, therapists, and moms/dads often report that kids on the spectrum exhibit a sudden onset of aggressive or oppositional behavior. This escalating sequence is similar to what has been described in children on the spectrum, and seems to follow a three-stage cycle as described below. Although non-autistic kids may recognize and react to the potential for behavioral outbursts early in the cycle, many kids and teenagers with the disorder often endure the entire cycle, unaware that they are under stress (i.e., they do not perceive themselves as having problems of conduct, aggression, hyperactivity, withdrawal, etc.).
Because of the combination of innate stress and anxiety and the difficulty of kids with ASD to understand how they feel, it is important that those who work and live with them understand the cycle of tantrums, rage, and meltdowns, and the interventions that can be used to promote self-calming, self-management, and self-awareness as a means of preventing or decreasing the severity of behavior problems.
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The Cycle of Meltdowns
Meltdowns typically occur in three stages that can be of variable length. These stages are (1) the “acting-in” stage, (2) the “acting-out” stage, and (3) the recuperation stage.
The “Acting-In” Stage
The “acting-in” stage is the initial stage of a tantrum, rage, or meltdown. During this stage, kids and teenagers on the autism spectrum exhibit specific behavior changes that may not seem to be related directly to a meltdown. The behaviors may seem minor. That is, children with ASD may clear their throats, lower their voices, tense their muscles, tap their foot, grimace, or otherwise indicate general discontent. Furthermore, somatic complaints also may occur during the “acting-in” stage. Kids also may engage in behaviors that are more obvious, including emotionally or physically withdrawing, or verbally or physically affecting someone else. For example, the youngster may challenge the classroom structure or authority by attempting to engage in a power struggle.
During this stage, it is imperative that a mother/father or educator intervene without becoming part of a struggle. The following interventions can be effective in stopping the cycle of tantrums, rage, and meltdowns – and they are invaluable in that they can help the youngster regain control with minimal adult support:
1. Intervention #1 involves displaying a chart or visual schedule of expectations and events, which can provide security to kids and teenagers with ASD who typically need predictability. This technique also can be used as advance preparation for a change in routine. Informing kids of schedule changes can prevent anxiety and reduce the likelihood of tantrums, rage, and meltdowns (e.g., the youngster who is signaling frustration by tapping his foot may be directed to his schedule to make him aware that after he completes two more problems he gets to work on a topic of special interest with a peer). While running errands, moms and dads can use support from routine by alerting the youngster in the “acting-in” stage that their next stop will be at a store the youngster enjoys.
2. Intervention #2 involves helping the youngster to focus on something other than the task or activity that seems to be upsetting. One type of redirection that often works well when the source of the behavior is a lack of understanding is telling the youngster that he can “cartoon” the situation to figure out what to do. Sometimes cartooning can be postponed briefly. At other times, the youngster may need to cartoon immediately.
3. Intervention #3 involves making the autistic child’s school environment as stress-free as possible by providing him/her with a “home-base.”. A home-base is a place in the school where the child can “escape.” The home-base should be quiet with few visual or activity distractions, and activities should be selected carefully to ensure that they are calming rather than alerting. In school, resource rooms or counselors' offices can serve as a home-base. The structure of the room supersedes its location. At home, the home-base may be the youngster's room or an isolated area in the house. Regardless of its location, however, it is essential that the home-base is viewed as a positive environment. Home-base is not “timeout” or an escape from classroom tasks or chores. The youngster takes class work to home-base, and at home, chores are completed after a brief respite in the home-base. Home-base may be used at times other than during the “acting-in” stage (e.g., at the beginning of the day, a home base can serve to preview the day's schedule, introduce changes in the typical routine, and ensure that the youngster's materials are organized or prime for specific subjects). At other times, home-base can be used to help the youngster gain control after a meltdown.
4. Intervention #4 involves paying attention to cues from the child. When the youngster with begins to exhibit a precursor behavior (e.g., throat clearing, pacing), the educator uses a nonverbal signal to let the youngster know that she is aware of the situation (e.g., the educator can place herself in a position where eye contact with the youngster can be achieved, or an agreed-upon “secret” signal, such as tapping on a desk, may be used to alert the youngster that he is under stress). A “signal” may be followed by a stress relief strategy (e.g., squeezing a stress ball). In the home or community, moms and dads may develop a signal (i.e., a slight hand movement) that the mother/father uses with their youngster is in the “acting-in” stage.
5. Intervention #5 involves removing a youngster, in a non-punitive fashion, from the environment in which he is experiencing difficulty. At school, the youngster may be sent on an errand. At home, the youngster may be asked to retrieve an object for a mother/father. During this time the youngster has an opportunity to regain a sense of calm. When he returns, the problem has typically diminished in magnitude and the grown-up is on hand for support, if needed.
6. Intervention #6 is a strategy where the educator moves near the youngster who is engaged in the target behavior. Moms/dads and teachers move near the autistic youngster. Often something as simple as standing next to the youngster is calming. This can easily be accomplished without interrupting an ongoing activity (e.g., the educator who circulates through the classroom during a lesson).
7. Intervention #7 is a technique in which the mother/father or educator merely walks with the youngster without talking. Silence on the part of the grown-up is important, because a youngster with ASD in the “acting-in” stage will likely react emotionally to any adult statement, misinterpreting it or rephrasing it beyond recognition. On this walk the youngster can say whatever he wishes without fear of discipline or reprimand. In the meantime, the grown-up should be calm, show as little reaction as possible, and never be confrontational.
8. Intervention #8 is a technique that is effective when the youngster is in the midst of the “acting-in” stage because of a difficult task, and the mother/father or educator thinks that the youngster can complete the activity with support. The mother/father or educator offers a brief acknowledgement that supports the verbalizations of the youngster and helps him complete his task. For instance, when working on a math problem the youngster begins to say, “This is too hard.” Knowing the youngster can complete the problem, the educator refocuses the youngster's attention by saying, “Yes, the problem is difficult. Let's start with number one.” This brief direction and support may prevent the youngster from moving past the “acting-in” stage.
When selecting an intervention during the “acting-in” stage, it is important to know the youngster, as the wrong technique can escalate rather than deescalate a behavior problem. Further, although interventions at this stage do not require extensive time, it is advisable that grown-ups understand the events that precipitate the target behaviors so that they can (1) be ready to intervene early, or (2) teach kids and teenagers strategies to maintain behavior control during these times. Interventions at this stage are merely calming. They do not teach kids to recognize their own frustration or provide a means of handling it. Techniques to accomplish these goals are discussed later.
The “Acting-Out” Stage
If behavior is not diffused during the “acting-in” stage, the youngster or adolescent may move to the “acting-out” stage. At this point, the youngster is dis-inhibited and acts impulsively, emotionally, and sometimes explosively. These behaviors may be externalized (i.e., screaming, biting, hitting, kicking, destroying property, or self-injury) or internalized (i.e., withdrawal). Meltdowns are not purposeful, and once the “acting-out” stage begins, most often it must run its course.
During this stage, emphasis should be placed on youngster, peer, and adult safety, and protection of school, home, or personal property. The best way to cope with a tantrum, rage, or meltdown is to get the youngster to home base. As mentioned, this room is not viewed as a reward or disciplinary room, but is seen as a place where the youngster can regain self-control.
Of importance here is helping the individual with ASD regain control and preserve dignity. To that end, grown-ups should have developed plans for (1) obtaining assistance from educators, such as a crisis educator or principal, (2) removing other kids from the area, or (3) providing therapeutic restraint, if necessary.
The Recuperation Stage
Following a meltdown, the youngster has contrite feelings and often cannot fully remember what occurred during the “acting-out” stage. Some may become sullen, withdraw, or deny that inappropriate behavior occurred; others are so physically exhausted that they need to sleep.
It is imperative that interventions are implemented at a time when the youngster can accept them and in a manner the youngster can understand and accept. Otherwise, the intervention may simply resume the cycle in a more accelerated pattern, leading more quickly to the “acting-out” stage. During the recuperation stage, kids often are not ready to learn. Thus, it is important that grown-ups work with them to help them once again become a part of the routine. This is often best accomplished by directing the youth to a highly motivating task that can be easily accomplished, such as activity related to a special interest.
Preventing Tantrums, Rage, and Meltdowns
Kids and teenagers with autism spectrum disorder generally do not want to engage in meltdowns. Rather, the “acting-out” cycle is the only way they know of expressing stress, coping with problems, and a host of other emotions to which they see no other solution. Most want to learn methods to manage their behavior, including calming themselves in the face of problems and increasing self-awareness of their emotions. The best intervention for tantrums, rage, and meltdowns is prevention. Prevention occurs best as a multifaceted approach consisting of instruction in (1) strategies that increase social understanding and problem solving, (2) techniques that facilitate self-understanding, and (3) methods of self-calming.
Increasing Social Understanding and Problem Solving
Enhancement of social understanding includes providing direct assistance. Although instructional strategies are beneficial, it is almost impossible to teach all the social skills that are needed in day-to-day life. Instead, these skills often are taught in an interpretive manner after the youngster has engaged in an unsuccessful or otherwise problematic encounter. Interpretation skills are used in recognition that, no matter how well developed the skills of a person with ASD, situations will arise that he or she does not understand. As a result, someone in the person's environment must serve as a social management interpreter.
The following interpretative strategies can help turn seemingly random actions into meaningful interactions for young people on the spectrum:
1. Analyzing a social skills problem is a good interpretative strategy. Following a social error, the youngster who committed the error works with an adult to (1) identify the error, (2) determine who was harmed by the error, (3) decide how to correct the error, and (4) develop a plan to prevent the error from occurring again. A social skills analysis is not “punishment.” Rather, it is a supportive and constructive problem-solving strategy. The analyzing process is particularly effective in enabling the youngster to see the cause/effect relationship between her social behavior and the reactions of others in her environment. The success of the strategy lies in its structure of practice, immediate feedback, and positive reinforcement. Every grown-up with whom the youngster with ASD has regular contact, such as moms and dads, educators, and therapists, should know how to do social skills analysis fostering skill acquisition and generalization. Originally designed to be verbally based, the strategy has been modified to include a visual format to enhance child learning.
2. Visual symbols such as “cartooning” have been found to enhance the processing abilities of persons in the autism spectrum, to enhance their understanding of the environment, and to reduce tantrums, rage, and meltdowns. One type of visual support is cartooning. Used as a generic term, this technique has been implemented by speech and language pathologists for many years to enhance understanding in their clients. Cartoon figures play an integral role in several intervention techniques: pragmaticism, mind-reading, and comic strip conversations. Cartooning techniques, such as comic strip conversations, allow the youngster to analyze and understand the range of messages and meanings that are a natural part of conversation and play. Many kids with ASD are confused and upset by teasing or sarcasm. The speech and thought bubble as well as choice of colors can illustrate the hidden messages.
Conclusion—
Although many kids and teenagers on the spectrum exhibit anxiety that may lead to challenging behaviors, stress and subsequent behaviors should be viewed as an integral part of the disorder. As such, it is important to understand the cycle of behaviors to prevent seemingly minor events from escalating. Although understanding the cycle of tantrums, rage, and meltdowns is important, behavior changes will not occur unless the function of the behavior is understood and the youngster is provided instruction and support in using (1) strategies that increase social understanding and problem solving, (2) techniques that facilitate self-understanding, and (3) methods of self-calming.
Children experiencing stress may react by having a tantrum, rage, or meltdown. Behaviors do not occur in isolation or randomly; they are associated most often with a reason or cause. The youngster who engages in an inappropriate behavior is attempting to communicate. Before selecting an intervention to be used during the “acting-out” cycle or to prevent the cycle from occurring, it is important to understand the function or role the target behavior plays.
More resources for parents of children and teens with High-Functioning Autism and Asperger's:
==> How To Prevent Meltdowns and Tantrums In Children With High-Functioning Autism and Asperger's
==> Parenting System that Significantly Reduces Defiant Behavior in Teens with Aspergers and High-Functioning Autism
==> Launching Adult Children with Asperger's and High-Functioning Autism: Guide for Parents Who Want to Promote Self-Reliance
==> Teaching Social Skills and Emotion Management to Children and Teens with Asperger's and High-Functioning Autism
==> Parenting Children and Teens with High-Functioning Autism: Comprehensive Handbook
==> Unraveling The Mystery Behind Asperger's and High-Functioning Autism: Audio Book
==> Parenting System that Reduces Problematic Behavior in Children with Asperger's and High-Functioning Autism
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What youngster hasn't dreaded September, the end of summer and the return to school – but for many ASD students, the prospect of school produces a level of fear so intense that it is immobilizing, resulting in what's known as school-refusal behavior. Some children with autism spectrum disorder have been known to be absent for weeks or months. 
