Simulated Patient Scenario

Autism Spectrum Disorder - Behavioural Distress

Scenario Details

Scenario: Behavioural Distress in Adolescent with ASD

Simulated Patient: 16-year-old Male

Actor/Actress: Student Actor (Patient), Student Actor (Parent/Carer)

MDT Information

Urgent Response - Behavioural Disturbance / Welfare Check
16-year-old male with Autism Spectrum Disorder
Patient is highly distressed, agitated, possibly self-injurious behaviour
Parent/Carer unable to de-escalate
No physical illness reported
Location: Home address
Police requested for backup, ETA unknown

On Arrival

You arrive at a house where a visibly stressed parent meets you. They explain their son, who has ASD, is having a "meltdown". You hear loud vocalizations (e.g., repetitive sounds, shouting) from a bedroom. The parent leads you towards the room, explaining he's overwhelmed and won't let them near. Peeking into the room, you see the patient pacing rapidly, flapping his hands, and occasionally hitting his head lightly against the wall. The room has posters on the wall, several objects on shelves, and fluorescent lighting.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Highly distressed, agitated patient. Potential risk of self-injury. Overstimulating environment.
Response	Appears conscious but not responsive to verbal commands/interaction due to distress. Internally focused. (AVPU = A/V - difficult to assess engagement)
Airway	Clear and self-maintaining (loud vocalizations indicate patent airway).
Breathing	Rate appears rapid, depth may be irregular. No obvious signs of respiratory compromise.
Circulation	Skin colour appears normal, may be flushed due to agitation. Pulse likely tachycardic.
Disability	Known ASD. Current severe behavioural distress. Possible minor self-injury (head hitting).
Exposure/Environment	Indoor bedroom. Assess for immediate hazards. Note potential sensory triggers (lights, noise, clutter).

Secondary Survey and Simulation Progression

History (Obtain primarily from Parent/Carer. Direct interaction with patient may be minimal initially.)

Allergies	NKDA (Parent confirms)
Medications	Risperidone (for irritability/aggression associated with ASD). Parent unsure if dose was taken today.
Past Medical History	Autism Spectrum Disorder (diagnosed age 4). History of sensory sensitivities (light, sound, touch). Occasional episodes of distress/"meltdowns", sometimes involving self-injurious behaviour (head banging, skin picking). Attends special school program. Followed by paediatrician and psychologist.
Communication	Parent states patient is verbal but communication becomes very limited/non-verbal during distress. May use some sign language or picture exchange system (PECS) when calm (parent can show examples if available). Responds best to simple, direct language; literal interpretation.
Baseline Behaviour	Usually calm at home but prone to anxiety. Enjoys routine. This level of distress is significant but has happened before.
Triggers/Events Preceding	Parent reports a change in routine today (planned outing was cancelled). Patient became increasingly agitated over the past hour. Usual de-escalation strategies (quiet space, preferred activity) were ineffective. Distress escalated to current state ~15 minutes ago. Parent denies any signs of physical illness (fever, pain) preceding this episode.

Vital Signs/Assessment (Attempt when safe and feasible, may be limited initially)

Parameter	Value (Approximate/Estimated)
Resp. Rate (/min.)	26 (Rapid)
Lung Sounds (L/R)	Likely clear, difficult to assess formally.
SpO2 (%)	>96% likely (Observe for cyanosis)
EtCO2 (mmHg)	Not indicated unless sedated/resp compromise.
Pulse Rate (/min.)	120-130, regular (Tachycardic due to distress)
CRT (sec.)	Likely < 2 sec.
ECG rhythm	Sinus Tachycardia likely. Formal ECG difficult.
12-lead ECG	Not indicated unless specific cardiac concerns arise.
BP (mmHg)	Likely elevated due to agitation, difficult to obtain.
Skin	May be flushed/sweaty from exertion/agitation.
Pain (/10)	Difficult to assess. Distress is primary feature. Assess for signs of underlying pain/injury.
GCS (/15: E,V,M)	Difficult to apply meaningfully. Appears aware but non-interactive. Motor response is agitation/pacing.
BGL (mmol/L)	Consider if prolonged poor intake or altered LOC, but likely normal.
Pupils (mmL/mmR)	Likely equal and reactive, may be dilated due to stress.
Temp. (°C)	Likely normal, check if infection suspected.

Physical Examination (Observe initially, perform hands-on exam only when safe/calm)

General Appearance: Highly agitated, pacing, hand flapping, loud vocalizations. Avoids eye contact. Resists approach.
Behavioural: Demonstrating significant distress. Repetitive motor movements (pacing, flapping). Possible self-injurious behaviour (head hitting - assess for injury if safe).
Communication: Non-verbal or limited functional communication during distress.
Sensory: Appears overwhelmed by environment. May cover ears or squint eyes. Reacts negatively to touch.
Head/Skin: Check for signs of injury from head hitting (bruising, lacerations) once safe to assess.
Rule out medical causes: Consider if behaviour change could be due to pain, illness, constipation, or medication side effects (gather history from carer).

Assessment and Treatment

Appropriate Management Focus

Prioritize Safety (Patient and Crew):** Maintain safe distance initially. Assess environmental hazards. Await police if behaviour escalates or poses significant risk. Ensure clear exit path.

Environmental Modification: Reduce sensory input: Dim lights, reduce noise (turn off radios, speak quietly), minimize number of people present, remove clutter if possible.

Communication Strategy:

Use calm, quiet, simple, direct language. Avoid jargon or complex sentences. Allow processing time.

Use visual aids (PECS, written words) if known to be helpful (ask carer).

Approach slowly, avoid sudden movements or direct sustained eye contact initially.

Communicate primarily with carer initially to gather information and understand patient's needs/communication style.

Involve Carer/Parent: Ask carer about known triggers, successful de-escalation strategies, communication preferences, and baseline behaviour. Empower carer to assist if safe and appropriate.

De-escalation Techniques: Focus on reducing arousal and providing sense of safety. Offer space. Use distraction with preferred items/topics (ask carer) once initial agitation subsides slightly. Validate distress non-verbally (calm presence).

Physical Assessment: Limit hands-on assessment until patient is calmer, unless immediate life threats suspected. Explain intended actions simply before touching. Assess for injury from self-harm or underlying medical cause for distress.

Pharmacological Intervention (Sedation): Generally a last resort. Consider only for severe, prolonged agitation posing significant risk despite environmental modification and de-escalation, following local protocols and preferably after consultation/police arrival. Use agents appropriate for behavioural disturbance (e.g., IM Midazolam, Droperidol - check protocols).

Transport Decision: Transport to ED is likely necessary for assessment, especially if distress is severe, prolonged, involves significant self-injury, or if underlying medical cause suspected. Discuss with carer. Transport can be highly stressful; plan carefully (minimize sensory input, allow carer presence, consider pre-notification).

Teamwork & Communication: Maintain calm communication between crew members. Liaise with police if present. Clear handover to ED, highlighting ASD diagnosis, triggers, effective strategies, communication needs, and reason for presentation.

Debrief Focus Points

Recognizing behavioural distress/"meltdown" in ASD vs. other causes.

Importance of carer/parent input for history, communication, and de-escalation.

Strategies for environmental modification to reduce sensory overload.

Specific communication techniques for individuals with ASD (clear, simple language, visuals, processing time).

De-escalation strategies tailored for ASD.

Safety considerations for patient and crew during behavioural disturbance.

Considering and ruling out underlying medical causes for behavioural change.

Appropriate use and considerations for sedation in this population.

Planning for transport to minimize distress.

Importance of detailed handover emphasizing patient's specific needs.