Particularly for those more significantly affected, the issue of agitated and aggressive outbursts is often a major concern, though even in those with less significant symptom profiles, affectively charged outbursts may occur. Helping families and caregivers better understand both the causes of these incidents and the course of such outbursts can aid in reducing and preventing aggressive behaviors and may lead to helpful intervention strategies when they do occur.

Most aggressive and agitated episodes in the ASD population are best conceptualized as “meltdowns” which are a typically a reaction to either an overwhelming intense sensory experience or an unanticipated external frustration.   While sometimes compared to and described as “tantrums”, these meltdown outbursts are typically not goal-directed as most tantrums are in non-affected individuals.

For those with ASD, it is always important to consider what may be causing a meltdown—- parents and caregivers can and should be tasked with being “detectives” in figuring out possible causal factors. This can be a very powerful tool in addressing and reducing meltdowns over the long term.

Things to consider include:

• Is this a medical problem—is the individual in pain or other distress?
• Does the individual not have ability to communicate their wants or needs?
• Are cognitive or social demands too high or too low?
• Sensory dysregulation: Is there too much or too little stimulus?
• Has there been reinforcement of the behavior in the past?
• Is there a co-occurring mental health condition that might explain the problem(s)?
• Are there family/school dynamics such as bullying, moving to a new home/school, caregiver burnout?

Once (and if) a causal factor(s) for the meltdowns has been identified, it will often be feasible for parents and caretakers to intervene, either to address or to minimize their frequency and/or intensity.

An understanding of the concept of the “Rage Cycle” can also be a helpful framework for parents and caretakers in managing meltdown outbursts more effectively. The following graphic of the cycle of rage is very useful for understanding when and how a caretaker can intervene. Although referenced here in the context of individuals with ASD, the concepts can also be applied to other individuals with similar issues of reactivity, impulse control and affect management.

Most importantly, it is important to know that once the cycle of a meltdown has begun, ,,,this is NOT the time to attempt teaching what to do or introducing a new task or skill.

Early recognition of the precursors to a meltdown –when a person begins to “rumble”– can sometimes be helpful and if seen, early intervention may arrest the cycle from becoming a full meltdown. For example, rumbling may present with heightened physical activity such as jumping or pacing about, yelling, fidgeting, rapid movements or making noises. If the individual’s level of agitation is not too advanced, parents and caregivers can utilize simple strategies that may be used during the “rumbling phase” such as:

• Acknowledge the difficulty and coach simply and calmly
• Attempt gentle redirection or refocussing
• Intervene without challenging or raising the temperature
• Keep verbal input simple:   Just “walk”, don’t “talk”
• Move the individual away from the ‘offending’ environment, if feasible.
• Use proximity control– stay with the person, be present and calm
• Refer to a schedule and highlight positive future activities, if available
• Go to a predetermined “home base” or “calming place”

If the meltdown reaches the rage stage, aggressive behaviors are more likely occur and appropriate caution is important. In this phase, the profile may include disinhibition, impulsivity, emotional lability, explosive behavior, property destruction, self-injurious behavior, yelling, biting, hitting or crying. During this time, it is of utmost importance to keep the individual and those around them safe. Interventions during a meltdown may include:

• Protect the individual and others
• Disengage emotionally, this is not about you—getting agitated or loud won’t help.
• Use few words, remain calm and quiet.
• Be flexible—extra tolerance and a bit of slack may help defuse the rage state.
• Have a plan and follow it— e.g., siblings go to their rooms, only certain people will interact with individual, have pre-identified the safe places to go, etc.
• Attempt to move the individual to a “safe place” or “home base”
• Obtain assistance if needed.
• Do not discipline– this is not the “teachable phase” and retribution does no good.

Once the meltdown has begun to pass, the individual with ASD (or any other predisposing condition) will enter a “recovery” phase.   Keep in mind that they have just gone through an intense sensory and emotional overwhelm— often we will see someone needing to sleep, cry, withdraw or appear exhausted. During this time, allowing the person time to sleep, rest or engage in a preferred activity may be needed.

Again, this is not the time to teach a new skill or place demands on the person as they are in cool down mode, not learning mode.

Helping families and caregivers understand meltdowns and the rage cycle is rarely simple, but sustained efforts can provide effective, long term tools for addressing agitation and aggressive outbursts. Consultation with mental health providers and behavioral experts can be an important asset and should be part of the clinical team helping the ASD individual.

Some services provided by the San Diego Regional Center for families struggling with aggression include:

1. Consultation with a behavioral psychologist
2. Safety Alert, Inc. ( https://www.safetyalert.net/ )
3. START program  https://www.exodusrecovery.com/vista-start/.
4.  Fred Finch Specialized Wraparound https://www.fredfinch.org/specialized-wraparound
5. Advance CIRT (Crisis Intervention Response Team) Advance North (760) 294-1188 Advance San Diego (619) 756-4095

   All programs require a referral from the SDRC. Families may request these services through their Regional Center service coordinator.

   Reference:

Myles, B.S., and Southwick, J. (1999) Asperger Syndrome and Difficult Moments: Practical Solutions for Tantrums, Rage, and Meltdowns. Shawnee Mission, KS: Autism Asperger Publishing Company.

https://www.cdc.gov/ncbddd/autism/data.html

Most people who experience a traumatic event, however, do not develop PTSD, so it is important to be aware of the risk factors for someone to develop PTSD after a traumatizing event. There is a genetic susceptibility to developing PTSD. PTSD shares genetic variance with other anxiety disorders like panic disorder and generalized anxiety disorder. PTSD also shares genetic variance with substance abuse disorders. People who experience an interpersonal assault are more likely to develop PTSD compared to people who experience a non-assault based trauma. PTSD is commonly seen in patients with military experience but can also be seen as a result of sexual assault, physical abuse, and domestic violence, in children and adults. PTSD is more commonly seen in situations where someone is exposed to a repeated trauma rather than a single trauma.

People with smaller hippocampi (the part of the limbic system that plays a role in both memory and inhibitory control) are more likely to develop PTSD after a traumatic event.  The hippocampus is an area of the brain with high numbers of gluco-corticoid receptors, glucocorticoids being part of the physiologic response to stress.  In PTSD, there is an over-activation of the Hypothalamic-Pituitary-Adrenal (HPA) axis which results in an increase in the fight or flight response. This contributes to the symptoms that are seen in PTSD, including hyper-vigilance, avoidance of triggers, nightmares, intrusive flashbacks, experiencing distress with reminders of the trauma, sleep disturbance, irritability, anger outbursts, and exaggerated startle response. Children experiencing PTSD will display it in their play and might also exhibit aggression, regression in their development and hyperactivity and impulsivity.

Patients with PTSD are at higher risk for suicidal ideation and suicide. They are at higher risk for other mental health concerns like other anxiety disorders and major depression. They are at higher risk for substance abuse problems, in large part in an effort to “self-medicate”.

The mainstay of treatment for PTSD is therapy (individual and group) and medication if needed. Trauma focused CBT is an evidence-based therapy practice used for PTSD. Additionally some patients find EMDR (eye movement desensitization and reprocessing) helpful for their symptoms. The SSRIs and other antidepressants can be useful for the depressive and anxiety symptoms of PTSD. Additionally medications like Prazosin can be used adjunctively for nightmares and sleep disturbance. Benzodiazepines are not particularly helpful for PTSD and therefore are not generally a recommended treatment.

It is our hope that this primer on PTSD is helpful for primary care providers to be able to screen for PTSD appropriately and refer for a more thorough assessment as needed.