Intermittent Explosive Disorder/Autism/MR

[Spicer09]

I've got a tricky patient that I need help with.

This guy is a frequent flier with MR, Autism and IED. He's aggressed at almost all of nursing staff- hitting, kicking, squeezing- He's gone after men and women, and is predictably unpredictable. Usually before he aggresses at staff, he'll start looking around for someone to go after, fixate on them briefly, and start to posture a bit. Then he'll go after us. We've tried having him on a strict 1:1, a loose 1:1, in a quiet room, and in seclusion. Nothing seems to work, and we're tired of getting assaulted. I tried starting music therapy with him, particularly classical music, as it is very centering for a lot of people- mentally delayed or not- but he struck out at staff tonight after using the bathroom.

This is becoming really frustrating. I know that he needs a certain level of social and tactile stimulation, but it's dangerous to have him in arm's or leg's reach! He's a sweet kid when he's not striking out, but it's getting worse and worse, especially over the last 2 months.

Please advise!!

[Davey Do]

Wow! You've got your hands full! It would appear that you've utilized interventions such as safety and relaxation methods with this volatile Patient. Good strategy attempts, Spicer09. I wish I could offer more, but I believe you've exhausted any interventions that I could suggest.

Reading your post made me wonder about his current medication regimen. I would like to know if this Patient is being treated with anticonvulsants (mood stabilizers), antipsychotics, benzodiazepines, or other anxiolytics. I've seen similar Patients respond well on the different medications.

Of course, the most we could do as Nurses would be to make suggestions to the Attending.

The best to you, Spicer09.

Dave

[morte, LPN, LVN]

has he had a recent physical?

[mentalhealthRN]

I have worked with individuals like this in both the psych ER setting as well as in a special school for kids with E/BD, where I was a 1:1 para (before I was a nurse) and learned a few things along the way. My mom also had a kid with autism in her class for like 3 years as a school teacher and I would hear all about her adventures and learned a lot.

So that being said...... stimulation generally needs to be kept to a minimum. I have found that the more there is the more behaviors I see. Almost like keeping the stimulation to like "none" like you would with a person in the ICU with increasing ICPs. Another thing is change. People with Autism don't deal well with change--in people/staff, environment, routine, etc. So try to keep the same staff--nurse, tech, etc and don't move his room, try to keep a routine, etc. Also when I was working inpatient psych we had a guy from like 6 hours away who came to stay for ECT treatments. They sent like 3 of his own 1:1 aides from home and the 3 of them rotated 12 hour shifts so that one of them was always with him (they put them up in a local motel) and this helped a lot. These women knew him well. and he knew them. They knew the little signs that he was about to blow. We listened to them. We would bring his meds just to the door, poured and hand them to the aide and stand and watch as they would give them to him for safety and legal reasons. When we would try to personally hand him the meds all hell broke lose so this worked best. We kept conversation with him to a minimum--not that we ignored him but would keep it short and sweet. We only once had to restrain him with our own security and staff. The 1:1 stayed in the room with him at all times....except 30 min for lunch that we covered and just stayed in the doorway to monitor him. This worked well. Keeping as much the same for him as possible.

The kid I had in the school did well with me rubbing his back. He was one of those kids who does the rocking for stimulation. Now they have weighted vests for this and some even like to be wrapped in a blanket like a newborn---crazy I know--but it makes them feel safe and calms them.

The last thing that comes to mind along the lines of limiting as much stimulation as possible is this. The kid my mom taught was REALLY sensitive to loud sounds. He would freak with them. So they would try to be proactive and do things like.....when she knew they all needed to walk down the hall to go to the gym or art class, etc. she would send a kid a couple of minutes ahead of the rest of the class to be sure there were no custodians vacuuming or anything like that. So that it could be turned off before the class with the autistic kid were in range to hear it. The vacuum would make him freak! This helped--being proactive as far as loud sounds.

The last thing is to get in touch with the staff where he came to you from. They likely know some tricks to calm him or know what sets him off. They can be a great resource.

Good luck........you have a challenge on your hands!!! Hope some of my advice helps!!!

[mentalhealthRN]

OP--we didn't hear back from you so I am wondering how things worked out. Did any of my suggestions help?

[Spicer09]

Thank you everyone for your responses! We did eventually get the patient on an increased dose of seroquel. After just a few days, we noticed remarkable improvement in his behavior, and we have since discharged him.