Distress Management

Ryan’s Escalation Chart

This chart helps us:
(1) Understand Ryan’s behavior: See how his behavior relates to his anxiety level.
(2) Manage situations: Recognize his anxiety level and knowing how to respond to help him.

Color Zones

Behaviors Strategies to do
Green zone means Ryan is calm and happy. Generally, you can see it in his face. The behaviors you will see are:
  • Happy giggly mood, high pitched sound
  • Pacing (with a happy facial expression)
  • Jumping happily
  • Likes seeing his reflection on the mirror or any reflective surface
  • Able to do short simple tasks without promising a reward
 To keep Ryan in the Green zone, refer to ENSURING CALM DAY PAGE.
  • Learn new skills
  • Practice communication skills (ALS Touchchat)
  • Practice calming steps
  • Practice asking for help
  • Making choices & respecting his “no”
  • Regular social engagement
Able to follow his visual schedules Having a visual structure is key in supporting Ryan. It is vital in many ways:
  • Communicating with him
  • Letting him know what is going to happen
  • Letting him know whenever there is a change
  • Allowing him to learn new words, and thus improve his ability to communicate back to us.
Pausing before starting/resuming on his task Ryan sometimes does this — it is like someone pressed the “pause” button on him. It can happen at any time. Sometimes, his eyelids could be fluttering.When this happens – Wait for him to come out of the “pause” in his own time – be silent, do not call him repeatedly.

This video shows how it might look like:
Pausing before starting/resuming his task
Possible Triggers Behaviors Strategies to do
Yellow Zone – Low Anxiety. Goal: Reduce his anxiety level. Waiting Waiting is hard for Ryan, we use count-down timers to indicate how long he needs to wait. But sometimes he feels that time is moving too slowly for him (Ryan is naturally impulsive).
  • Bite timer
  • Gritting his teeth while looking at timer
  • Restless leg (he will sit but kept shaking his leg)
  • Try to distract by asking him to do other activity/tasks.
  • These are usually tasks that are easy for Ryan to do. We don’t want to add more stress by getting him to do another difficult task.
Repeated verbal instruction: This refers to the person giving Ryan instructions more than once. E.g. “go wash your hands, go wash your hands now” Repeat angrily the word that the other person is using (e.g. hands, hands, hands) – when Ryan repeats the last word said multiple times — that means he is frustrated. But if he repeats the last word only ONCE – usually means he understands or agrees with you.
  • Stop talking to Ryan.
  • Give him time to calm himself down.
  • If you need to repeat the instruction, you can do any of the following:
    1. Point to visual support
    2. Use gestures
Told “no” and not provided alternative activities Ryan will angrily repeat “No, no, no”
  • Avoid using the word “no” and provide alternative activities to distract him.
  • If there is no viable alternative that day or Ryan rejects the alternative — write down WHEN he can have what he wants.
Being denied food (either someone else’s or found in the house but he could not eat it)
  • Point his finger to the food
  • Will keep on looking for it
  • If he already saw them, try delaying him (give timer) or give him a portion and later show its empty packaging.

    This video shows various ways we navigate this issue:
    Ryan & Food (April 2024)
No wifi
  • Give you his iPad to “fix”
  • Reset Wi-Fi connection or change to another iPad. We now have an iPad with a SIM card that can access data instead.
  • If it still doesn’t work, go to an alternative site that might have WIFI, for example, an office, or bring Ryan for a drive to distract him; he will most likely go along for a drive to McDonald’s.
  • Give him a timer – set it to the highest possible duration. Meanwhile, give him something else to do.

 

Possible TriggersBehaviorsStrategies to do

Orange Zone – High Anxiety
This is when he usually starts to self-injure.

  • Angry/loud/excessive talking in background (even when not directed to Ryan)
  • When things do not go the way he wanted
  • Ate “Wrong” food – Pork, chocolate, potato chips, jackfruit, too much sugar.
  • Introducing new activities – activity may not have been structured or explained to him adequately
  • Unknown events that trigger his anxiety (we do not know why)
  • Flap hands with a very tensed face
  • Distressed sounds “eh..eh” and continue to escalate
  • Crying/Anxious facial expression
  • Bite object very hard, with an angry expression
  • Rocking vigorously with shouting/angry noise
  • Rub ears vigorously
  • Grab his head with angry expression
  • Bite his palm or any object near him
  • Squeeze other person’s arm/hands with minimal to moderate pressure.
  • Give water – usually, we fill up his water bottle for him.
  • Model calming steps
  • Stop talking, be aware of noise in the environment that you can switch off
  • Apply deep pressure using a big pillow or give him his weighted blankets
  • Reduce verbal communication, increase visual or gestural prompts
  • Increase support, reduce demand
  • If he looks like he could be in pain, give Panadol
  • Give Ryan a towel to bite
  • Verbally tell him that it’s painful (with a calm, gentle voice) and ask him to let go or count backward from 5 to 1 and wait for him to let go
Last resort:
If the above doesn’t work, give medication. Xanax at 0.125mg first, and wait for 5 minutes. If he still doesn’t calm down, then give another 0.125mg. Max dose per day is 4mg.

 

TriggersBehaviorsStrategies to do
Red zone means danger – to himself and others.
Priority for red zone is safety.
De-escalation techniques no longer work.

1. Escalate from Yellow Zone

Injures Self:

  • Bite himself very hard – usually on his palms and hands
  • Pound/bang on own head repeatedly, rocking and legs shaking very vigorously (trying to calm himself)
  • Screaming and crying badly
  • Eyes will appear glazed

Injures Others:

This is Ryan’s desperate call for help — so help him, not punish him.

  • At this stage, he will be actively going after people to grab — most of the time, he will grab your neck/head first and squeeze with his arms and head.
  • Scratch / squeeze / part parts of your body
  • The place must be safe for him, let him explode in a safe space.
  • If there are others that might get injured, get them into a locked room, away from Ryan.
  • Utilize Crisis Prevention Skills if Ryan is holding on/has grabbed you to get yourself out of his grip
  • DO NOT YELL AT HIM. DO NOT PIN HIM DOWN AGAINST THE WALL OR ON THE FLOOR — this will make matters worse.
  • Try to keep calm. If you need to say anything, keep to 1 to 2 words said in a calm voice.
  • Last resort – give Medication Zydis – put immediately onto Ryan’s tongue, it will melt. No need to drink water to wash it down. Ryan should de-escalate within 5 mins max.
1. Medical Issues

Seizure

  • Eyes fluttering (silent seizure)
  • Sudden mood change: he will be suddenly very quiet, not moving and then scream/shout or have a major meltdown
  • Body stiffen, eyes rolled back, drop to the floor (grand-mal seizure)

Migraine

  • He will grab and squeeze his own head, screaming and crying.
  • Squeeze other person’s head
  • Wait for him to come out of it. If he was in the middle of a task, help him finish it quickly and let him rest.
  • Give him water, and move away. If he continues to escalate – follow the strategies above.
  • For grand-mal seizure: get Ryan to lie on his side, make sure his body is not banging against any object. DO NOT PUT ANYTHING INTO HIS MOUTH. When he stops shaking, he will be very confused, let him rest. DO NOT INSIST HE STANDS UP IMMEDIATELY
  • For migraines: Apply deep pressure on his head and give Panadol.
Zones Dropdown
Green Zone

Green zone means Ryan is calm and happy. Generally, you can see it in his face.

The behaviors you will see are:

  • Happy giggly mood, high pitched sound
  • Pacing (with a happy facial expression)
  • Jumping happily
  • Likes seeing his reflection on the mirror or any reflective surface
  • Able to do short simple tasks without promising a reward

Strategies to do:

To keep Ryan in the Green zone, refer to ENSURING CALM DAY PAGE.

  • Learn new skills
  • Practice communication skills (ALS Touchchat)
  • Practice calming steps
  • Practice asking for help
  • Making choices & respecting his “no”
  • Regular social engagement
Behaviors Strategies to do
Able to follow his visual schedules Having a visual structure is key in supporting Ryan. It is vital in many ways:
  • Communicating with him
  • Letting him know what is going to happen
  • Letting him know whenever there is a change
  • Allowing him to learn new words, and thus improve his ability to communicate back to us.
Pausing before starting/resuming on his task Ryan sometimes does this — it is like someone pressed the “pause” button on him. It can happen at any time. Sometimes, his eyelids could be fluttering.

When this happens – Wait for him to come out of the “pause” in his own time – be silent, do not call him repeatedly.
Youtube Video Pausing (2024)
Yellow Zone

Yellow zone means Ryan is experiencing low anxiety. The goal is to reduce his anxiety level.

Possible Triggers Behaviors Strategies to do
Waiting Ryan may bite the timer, grit his teeth while looking at the timer, or have restless leg movement.
  • Try to distract him by asking him to do other tasks that are easy for him to complete.
Repeated verbal instruction Ryan might angrily repeat words like "hands, hands, hands" if frustrated.
  • Stop talking and give Ryan time to calm down.
  • If needed, repeat the instruction with visual support or gestures.
Being denied food Ryan may ask persistently for food.
  • Give a small snack and tell him when mealtime is.
  • Set expectations for the next meal.
Orange Zone

Orange zone is a cautionary area. Ryan may be exhibiting signs of rising frustration or overstimulation. Keep an eye on his behavior.

Possible Triggers Behaviors Strategies to do
Orange Zone – High Anxiety This is when he usually starts to self-injure.
  • Angry/loud/excessive talking in background (even when not directed to Ryan)
  • When things do not go the way he wanted
  • Ate "Wrong" food - Pork, chocolate, potato chips, jackfruit, too much sugar.
  • Introducing new activities - activity may not have been structured or explained to him adequately
  • Unknown events that trigger his anxiety (we do not know why)
  • Flap hands with a very tensed face
  • Distressed sounds “eh..eh” and continue to escalate
  • Crying/Anxious facial expression
  • Bite object very hard, with an angry expression
  • Rocking vigorously with shouting/angry noise
  • Rub ears vigorously
  • Grab his head with angry expression
  • Bite his palm or any object near him
  • Squeeze other person’s arm/hands with minimal to moderate pressure.
  • Give water - usually, we fill up his water bottle for him.
  • Model calming steps
  • Stop talking, be aware of noise in the environment that you can switch off
  • Apply deep pressure using a big pillow or give him his weighted blankets
  • Reduce verbal communication, increase visual or gestural prompts
  • Increase support, reduce demand
  • If he looks like he could be in pain, give Panadol
  • Give Ryan a towel to bite
  • Verbally tell him that it’s painful (with a calm, gentle voice) and ask him to let go or count backward from 5 to 1 and wait for him to let go
Last resort: If the above doesn’t work, give medication. Xanax at 0.125mg first, and wait for 5 minutes. If he still doesn’t calm down, then give another 0.125mg. Max dose per day is 4mg.
Red Zone

Red zone indicates Ryan is in a highly distressed state, possibly leading to emotional or physical outbursts. Immediate intervention may be required.

Triggers Behaviors Strategies to do
Red zone means danger - to himself and others. Priority for red zone is safety. De-escalation techniques no longer work. 1. Escalate from Yellow Zone Injures Self:
  • Bite himself very hard - usually on his palms and hands
  • Pound/bang on own head repeatedly, rocking and legs shaking very vigorously (trying to calm himself)
  • Screaming and crying badly
  • Eyes will appear glazed
Injures Others:
  • At this stage, he will be actively going after people to grab -- most of the time, he will grab your neck/head first and squeeze with his arms and head.
  • Scratch / squeeze / part parts of your body
  • The place must be safe for him, let him explode in a safe space.
  • If there are others that might get injured, get them into a locked room, away from Ryan.
  • Utilize Crisis Prevention Skills if Ryan is holding on/has grabbed you to get yourself out of his grip
  • DO NOT YELL AT HIM. DO NOT PIN HIM DOWN AGAINST THE WALL OR ON THE FLOOR -- this will make matters worse.
  • Try to keep calm. If you need to say anything, keep to 1 to 2 words said in a calm voice.
  • Last resort - give Medication Zydis - put immediately onto Ryan's tongue, it will melt. No need to drink water to wash it down. Ryan should de-escalate within 5 mins max.
1. Medical Issues Seizure
  • Eyes fluttering (silent seizure)
  • Sudden mood change: he will be suddenly very quiet, not moving and then scream/shout or have a major meltdown
  • Body stiffen, eyes rolled back, drop to the floor (grand-mal seizure)
Migraine
  • He will grab and squeeze his own head, screaming and crying.
  • Squeeze other person’s head
  • Wait for him to come out of it. If he was in the middle of a task, help him finish it quickly and let him rest.
  • Give him water, and move away. If he continues to escalate - follow the strategies above.
  • For grand-mal seizure: get Ryan to lie on his side, make sure his body is not banging against any object. DO NOT PUT ANYTHING INTO HIS MOUTH. When he stops shaking, he will be very confused, let him rest. DO NOT INSIST HE STANDS UP IMMEDIATELY
  • For migraines: Apply deep pressure on his head and give Panadol.
Message to present and future caregivers
What I want for Ryan’s future

My promise to Ryan
that he will lead a life worth living.

A life that:
“Allows him the maximum level of Choice and Control
His days filled with genuine choices and interests
Has a balance of Work and Play
He is surrounded by people who loves him”

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