Managing aggression in an inpatient CAMHS unit Dr.Sachin Sankar Consultant Child psychiatrist The Sett Northampton
Disclosures of Potential Conflicts Source Consultant Advisory Board Stock or Equity >$10,000 Speakers Bureau Research Support Honorariu m for this presentati on or meeting SHIRE X yes X yes yes X FLYNN PHARMA X yes X yes yes X ELI LILLY X yes X yes yes X NHFT yes X X X yes X Northampton yes X Crown & Magistrates court
Non pharmacological techniques for management of aggression Before the patient is on the ward Before aggressive Episode During the episode After the episode
Before the patient is on the ward Vision and ward Philosophy Clear leadership structure Operational guidelines
STAFF Training Motivation R&R
When on the ward Groups for parents/foster carers Individual key worker sessions Skills from DBT Nurture Groups(Majorie p( Boxall)
Problem Solving techniques with key worker At the beginning of each session an agenda is set of behaviours to target based upon those reported by the client s diary card. A behavioural-chain analysis is conducted of a specific episode of the target behaviour. Identifying in detail the links between environmental triggers, cognitions, affect change, actions and the consequences. A solution analysis is then used to identify points at which something different could have been done. The therapist identifies blocks to the implementation of skills (e.g.negative cognitions) and use techniques to deal with them (e.g. cognitive re-structuring).
Strategies in DBT Skills Training DBT assumes that individuals with BPD lack critical skills. The aim is then to teach these skills within the acceptance-change dialectic. There are 4 core skills taught: Core Mindfulness & Distress Tolerance (focusing on Acceptance) Emotion Regulation & Interpersonal Effectiveness (focusing on Change) Eatingness (developed at a later stage)
Enhanced monitoring Bowlby (1969,1988) argued infants are born with a repertoire of behaviours (attachment behaviours) aimed at seeking and maintaining i i proximity it to supportive others (attachment figures). I hi i i it ki i In his view proximity seeking is an inborn affect-regulation device. g
The importance of empathic attunement Bomber (2007 pg 184) Before we are able to self-soothe soothe or calm ourselves we need the experience of another person getting alongside us giving ii us feedback on our thoughts ht and feelings Geddes (2006,pg.41) The mother s sensitivity to the infant s signals is at the heart of the infant learning about itself
Attachment and brain development evidence from neuroimaging g Schore (1997) attachment relationship is a major organiser of brain development. Fonagy and Target (2005) Regulatory function of mother-infant interaction acts as an essential promoter of the development and maintenance of synaptic connections during the establishment of functional circuits of the right brain.
Secure Attachment and emotional regulation So in a secure attachment child s emotional brain develops and they learn to be able to self-regulate Kochanska Securely attached children are less likely to respond with anger or fear
Nurture groups Cooper and Whitebread (2007) Found significant improvements for Nurture Group students in terms of social, emotional and behavioural functioning, especially over the first two terms.
Sensory Integration Theory Dr (Jean) Ayres developed sensory integration ti theory to better explain the relationship between behaviour and neural functioning, especially sensory processing or integration (Fisher, Murray and Bundy, 1991, p3.)
Sensory Integration For most children sensory integration develops in the course of ordinary childhood activities. But, for some children it does not develop as efficiently i as it should do. Sensory Processing Disorder in DSM-V Miller et al (2005) 2,410 children diagnosed with ADHD Co-morbidity of SPD with ADHD = 60 %
Sensory Integration/Modulation Interventions Systematic use of sound/sight/smell/ touch and movement. Traditionally used to help children with developmental disorders, autistic spectrum disorders d etc. to self-regulate. l Now also being used to help children with trauma histories to self-regulate
Sensory Diet: giving kids simple Movement sensory strategies Different Types of Touch & Temperature Auditory/Listening Vision/Looking Olfactory/Smelling Gustatory/Tasting/Chewing
Joining Forces: Sensory Attachment Intervention Eadaoin Bhreathnach argues that: Children with a history of separation, loss, abuse and neglect are likely to present with a combination of sensory processing and attachment difficulties. Their capacity to tolerate sensory stimulation from the environment and others is affected. Intolerance of everyday events may be because there is an association with early loss and trauma (emotional defensiveness) or because they find the actual sensory experience unpleasant (sensory defensiveness).
Rage cycle calm relief Rumbling recovery rage
Rage Cycle and tips for responding to 3 stages: dysregulated behaviour Rumbling stage - prevention Rage Stage minimise risk to self and others Recovery Stage develop problem solving skills
Don ts (Escalating Behaviours) Raising Voice Cornering Pleading or Bribing Acting Superior Ui Using Unwanted tdphysical lforce Insisting gyour right Humiliating Bi Bringing i up Unrelated devents
Do s (stepping in before it s too late) Proximity Control Signal Interference Touch Control soothing/regulating touch Support From Routine Interest Boosting Redirecting
REDIRECTING Rip paper Punch pillow/ beanbags Scribble on paper Write a letter to person you feel angry with, then rip it up Use stress ball Bounce big gym ball Stamp your feet Do some exercise Throw beanbags Humour can help: Watch something funny (e.g. DVD/ video) Think of something funny Talk with someone about something different Do something calming: Listen to music that t makes you feel good Have a hand massage Colour Have a bath/shower Spray soothing or favourite smell
Rage Stage Isolation and restrain should be used sparingly. Preferable to stay with the child. Remember child cannot regulate own emotion. If left on own may calm but unlikely to have learnt to regulate (likely internalised or just used up adrenaline) Calm voice or gentle touch to regulate. (baby is regulated by rocking) Match volume of emotion and model regulation.
Recovery and Relief
What does that mean No reward for calming down Join back activity that was disrupted
QUESTIONS PLEASE