I did a consultation recently regarding a young man named Stephen who needed some extra help. He had some explosive behavior episodes that caused his teachers to be quite concerned. This young man has a diagnosis of autism with moderate mental retardation. He has verbal language . . . characterized by lots of delayed echolalia, perseverative phrases, and a set of mumbled questions which are not easy to understand.

The other thing about Stephen is that he can get quite agitated. Sometimes that agitation escalates into greater distress and eventually physical aggression. The staff has done some excellent charting of Stephen’s behavior. They have identified sequences of behavior that eventually lead to the aggression.

There is a detailed plan on file to direct how the staff should respond when Stephen’s agitation is increasing. The plan identifies some specific directions to give Stephen at different levels of agitation. It goes something like this. When he starts pacing – redirect to the activity. Pacing continues and he starts uttering his perseverative phrases – give him the choice of another activity. The intensity of the pacing increases and the verbal language gets louder and more intense – get other people out of the way and offer Stephen some brushing or other calming activities prescribed by the OT. There are a few more steps in the plan but you get the idea.

Two more pieces
The plan also directs staff to use minimal language and do not make eye contact. Those are excellent recommendations. When students are starting to get upset, our natural tendency is to talk more . . . telling them what to do, what not to do or whatever. The more upset students get, the more the caretakers are tempted to talk. Then that gets the student more upset. Same for eye contact. Eyes that are watching can feel like they are invading the individual’s space. It’s a strange thing. At other times, students may not seem to be aware of our eye contact, but when things are not going well they can seem to know exactly where we
are looking.

Here’s the problem
The staff interaction with Stephen during the agitation episodes is with verbal communication. So they verbally offer him other options for activities. In my experience with individuals who are experiencing severe agitation or meltdowns, use of verbal language during that time can actually serve to accentuate the problem. Therefore, this is a perfect time to use visual cues for communication.

Time to Take a Break
My suggestion to add to this plan is to create a routine called Take a Break. Pick a location and two or three highly desirable, calming activities. (The OT can help select something that will meet the need.) The goal would be to “offer” or “tell” Stephen that it is time to take a break for a few minutes. Guide him to his location so he can engage in his calming activities. He can be done with his break when he is calm and ready to resume the regular schedule.

Use a picture card
Create a Take a Break card. On one side, write the words and put some kind of picture symbol that would represent the break.


On the back of the card you can put pictures of his choices for break activities.


Use the card to tell Stephen it is time to Take a Break. The goal is to interject the break time at the beginning of the agitation chain to try to keep it from progressing to more severe aggression. That means watching for those first cues that he is beginning to get upset. That is the time to show the card – before his behavior becomes more intense.

It’s not the same as time out
Conceptually, Take a Break is not the same as time out. People often think
of time out as a punitive thing – you are being bad or out of control so you will
go to time out until you calm down. Time out often occurs when the individual
is out of control.

The purpose of Take a Break is to provide an opportunity to relax, refresh and regain composure so we can go on with the day. The intervention occurs before, or at the beginning, of a little bit of agitation, hoping to avoid escalation.

Don’t forget to teach it
Train Take a Break as part of your daily activities. You might even put it in the schedule at some points in the day so it becomes associated as desirable and pleasant. Then you will be able to offer it at points when he is beginning to show signs of agitation.

Here’s the caution
The activity choices during Take a Break should also be available as
choices at other times during the day. Otherwise you may accidentally
set up a situation where he becomes agitated so he can take a break to
access those highly desirable activities. (I will get agitated, so I can take a
break, so I can do XXXXX.)

Create success with Take a Break
Using a Take a Break card helps manage a situation by using minimal verbal direction. Practicing when everyone is happy make it a pleasant activity. Choosing highly desirable calming activities will help calming so the student can return to his regular schedule without major problems.

P.S. One more thing. We need to do some more observing to see if we can identify any patterns of activity that occur before Stephen’s agitation begins. Analyzing the antecedents is an important part of a good behavior plan. Figuring out what he wants to communicate or what is bothering him will help the staff teach him what he needs to learn so the agitation cycle may not occur in the same way.


© 2009 Linda Hodgdon