Preventing Escalating Behaviours in the ED

Introduction

Jack: Welcome back to the series. This podcast is brought to you by Clintix Labs, a team of emergency clinicians and innovators.

Jock: You can learn more about their work at clintix.com.au.

The Build-up before the Breakdown

Jock: Now that you know a little bit about Clintix Labs, let’s turn our attention to recognising and preventing escalation in the ED. But before we dive in, I think it’s really important to discuss one key thing first—language. Specifically, how we refer to autistic people.

Jack: Right, because language shapes perception, and small changes in how we speak can really make a big impact.

Jock: Exactly. So throughout this series, you might notice we usually say "autistic person" and not "person with autism."*

Jack: And that’s, it’s intentional. It’s called identity-first language.

Jock: Yeah, it might sound technical, but the idea’s simple: It puts being autistic front and centre, as a core part of, well, someone’s identity. It’s almost like saying, “Hey, this is who I am—and I’m proud of it.”

Jack: Whereas person-first language—like saying "person with autism"—tries to prioritize the person over the diagnosis. But, here’s the thing, for many autistic individuals, it can feel like, like that approach makes autism sound separate or, or even like something negative to be 'removed.'

Jock: Right. And, you know, not to complicate things, but—some people *do* prefer person-first language, yeah? That’s why it’s always okay—actually, encouraged—to ask. Something as simple as, *“How would you like me to refer to your diagnosis or your support needs?”* Or even asking a family member, *“What language does your son or daughter lean toward?”*

Jack: It’s such a simple question, honestly, but it shows, I dunno, just a lot of respect. And starting things off on the right foot is huge—especially in a stressful setting like the ED.

Jock: Yeah. So, for the series, we’re sticking to identity-first—saying *autistic person*—because that’s what many in the community prefer. But for clinicians listening, always, always follow the individual’s lead.

Jack: And that ties into the next point. In emergency departments, people often talk about 'challenging behaviours'—

Jock: —but those behaviours are actually, you know, *communication*. Like, they’re a way for a person to say, *“Hey, I’m not okay.”*

Recognising the Early Signs

Jock: You know, like we were saying about behaviours being communication, it’s important to recognize these cues early. In the ED setting, escalation isn’t like a switch flipping suddenly—it usually builds over time. And the tricky part is, those early signs, they’re really subtle.

Jack: Right. And I think one of the challenges for clinicians—especially in a high-pressure environment—is catching those subtle signs early enough to intervene.

Jock: Exactly. Like, let’s, let’s start with something like selective mutism. For autistic folks who are verbal, hitting a point where they stop speaking altogether? That’s a red flag.

Jack: It’s almost like a way of conserving energy, isn’t it? Communication—verbal communication—can be exhausting. So, when someone starts withdrawing like that, it’s not something to ignore.

Jock: Right. Or, you know, repetitive behaviours—things like rocking or hand-flapping—they might get more intense. Those actions, it’s like they’re saying, *"I’m overwhelmed."*

Jack: And here’s where context is key. Those behaviours, if someone’s already self-regulating, might be totally fine in one scenario. But if you notice a shift—increasing intensity or a change in routine habits—it could mean things are escalating.

Jock: Yeah, and, um, let’s talk about avoidance. Like, if someone’s suddenly turning away from people or, I dunno, refusing to go into a certain area—it’s their way of trying to cope or reduce whatever’s causing stress.

Jack: And facial expressions too, right? Or a lack of them. Sometimes people interpret that wrongly as someone being 'difficult,' but it could just be a sign they’re shutting down as a way to manage overstimulation.

Jock: Exactly. I think if, if there’s one big takeaway here, it’s that these behaviors are all forms of communication. You’re not just looking at what the person’s doing—you’re asking yourself, *why?*

Jack: Yeah, it’s, it’s about being curious instead of reactive. If you approach those early signs with that mindset, you’re already setting up a foundation to prevent escalation.

Jock: And those signs, they—

Practical de-escalation strategies

Jock: —they give us a starting point. But here’s the thing: recognizing them is just the first step, right? The next challenge is figuring out, okay, what do we actually do about it? Like, what practical steps can clinicians take to stop things from spiraling?

Jack: Right, because it’s one thing to recognize escalation, but intervention—that’s where things can really make a difference. And honestly, one of the simplest strategies? Slow down.

Jock: Slow down?

Jack: Yeah. I mean, you know how chaotic the ED can get. It’s loud, fast-paced—just sensory overload for most people. If a clinician slows their approach, speaks a bit softer, or even just lowers themselves to eye level, it can change the dynamic immediately. It signals calm.

Jock: Right, and I think um, that idea of meeting someone where they are—like, literally and figuratively—it’s so powerful. If someone’s sitting on the floor because they’re overwhelmed, instead of, you know, insisting they stand, why not sit down with them?

Jack: Exactly! And that ties into another strategy: giving space. Sometimes the best thing you can do is back off a little—don’t crowd the person. It’s amazing how much difference, say, one step back can make.

Jock: Yeah, and, even reducing the sensory input, if possible. Like, dimming the lights a bit, closing a door to reduce noise, or even offering something like noise-cancelling headphones if you’ve got them available.

Jack: Or giving options, right? It’s not always about telling someone what to do—it’s about presenting choices. Like, “Would you rather wait here, or go to a quieter area?” It gives the person a sense of control, which can be really grounding.

Jock: Control is huge. And it doesn’t have to be big decisions, does it? Even something as small as asking, “Would you like me to explain what’s happening, or would you rather I just get on with it?” It shows respect and helps reduce uncertainty, which is often a big trigger.

Jack: Exactly. And then there’s the power of clear and simple communication. When someone’s overwhelmed, long sentences or medical jargon just, it doesn’t help. Stick to short, straightforward explanations. Like, “We’re going to take your blood pressure now. It won’t hurt.”

Jock: Yeah, and avoiding those vague reassurances like, “It’s going to be okay.” Because at that point, the person might not feel like it actually is going to be okay yeah? Instead, be specific—ground your reassurance in something concrete.

Jack: Totally agree. It’s about being present and acknowledging their experience without trying to rush them out of it. You can say something like, “It looks like this is really tough for you right now, and I’m here to help.”

Jock: Yeah, that kind of validation—it’s, it’s honestly such a simple thing, but it can make all the difference. Especially when someone feels like their voice isn’t being heard otherwise.

Jack: And these strategies-

Regulating ourselves

Jock: And these strategies, they’re great, but you know, there’s another layer here, right? Like, as clinicians, if we’re not regulating *ourselves*, it’s hard to put any of this into practice effectively. I feel like that’s so often overlooked when we talk about de-escalation in the ED.

Jack: Absolutely. I mean, the way we carry ourselves—our tone, posture, even how we breathe—it ends up sending signals we might not even be aware of. And those signals matter.

Jock: Yeah, it’s that idea that, like, emotions are contagious, right? If we’re showing frustration or, or impatience, the person in front of us, they’re gonna pick up on that—even if it’s subtle.

Jack: Exactly. And for autistic individuals, who might already be hypersensitive to different cues in their environment...well, it can make a tough situation even tougher.

Jock: That’s why, I think self-awareness is key—like, noticing when we’re getting worked up ourselves. Taking a deep breath, resetting our tone—it’s not just helpful, it’s necessary.

Jack: Right, because if we’re not grounded, how can we expect to help someone else feel grounded? It’s like, we have to model that calm ourselves, even when the environment kind of pulls us in the opposite direction.

Jock: And it’s not just about the words we use, yeah? It’s how we say them. If, if our voice stays steady, our body language open—that says *I’m here, you’re safe,* without us even needing to explain it.

Jack: And posture, too. If we’re standing over someone, that can feel intimidating, especially when someone’s already feeling vulnerable. Slowing down, softening our tone, crouching to their level—small changes, but they add up fast.

Jock: Yeah, and there’s, there’s something about just…giving yourself permission to pause, you know? It’s okay to take a step back, to take a beat before responding. That pause can make all the difference.

Jack: Totally. Because, at the end of the day, whatever’s happening around you, you can’t really control that, but you *can* control your own response. Self-regulation isn’t just, you know, nice to have—it’s foundational.

Jock: And we’ll talk more on self-regulation tools for providers in episode 6

Jack: —Now, connection.

The Power of Connection

Jack: —yeah, connection. It’s something we don’t always think about explicitly, but at the heart of regulating ourselves and supporting others, it’s the key layer underneath all of this. *That* connection is what makes everything else—behaviour, environment, language—fall into place.

Jock: Yeah, it’s, it’s that idea that before any intervention, any strategy—you have to build a, a sense of trust. Without that, nothing else really sticks, does it?

Jack: Exactly. You can have all the best de-escalation tools in the world, but if the person in front of you doesn’t feel that you’re genuinely there for them…then, well, those tools just don’t land.

Jock: Right, because trust isn’t about, ticking boxes or saying the 'right' things—it’s about making that person feel seen. You’re not just treating symptoms or behaviour; you’re engaging with the *person* behind it all.

Jack: And it’s so important in an emergency setting, where people are already, I dunno, maybe feeling overwhelmed or scared, and that’s just heightened for autistic individuals.

Jock: Absolutely.

Jack: So, how do we foster that kind of connection? I think one of the simplest ways is just...listening. And not the kind of listening where you’re waiting for your turn to speak, but really taking in what that person is saying—or not saying.

Jock: Yeah, and sometimes it’s, it’s about more than words, isn’t it? Like, you might have someone who’s not verbalizing how they feel, but their body language is saying everything. If you’re paying attention, you’ll see it.

Jack: Right, it might be as subtle as avoiding eye contact, or a change in posture—small cues that tell you, *“Hey, something’s not right.”* And acknowledging those cues, even silently, can go a long way.

Jock: And that’s where empathy comes into it. Like, not just reacting to what you see, but trying to understand why. The *why* is so important—it’s what connects you to the person in front of you.

Jack: Totally. And, you know, when we talk about empathy, it’s not about having to, like, fix everything in the moment. Sometimes just letting someone know, “Hey, I see you; I’m here,” that’s enough to start building a connection.

Jock: Yeah, and there’s something really grounding about that, isn’t there? Like, when someone feels you’re not just reacting to their behaviour, but genuinely trying to connect—it can completely change the trajectory of a situation.

Jack: Absolutely. Connection isn’t just this, like, nice-to-have extra—it’s foundational. And when you start with connection, everything else, all the strategies we’ve talked about, they sort of, well, they just work better.

Jock: Yeah, it’s…connection first. Always.

Closing

Jock: So building on what we’ve been discussing about connection—it really is the starting point, isn’t it? Before we even think about implementing strategies or tools, it’s about creating that relationship of trust. That’s what allows everything else to fall into place.

Jack: Yeah, and if there’s one thing to take away, it’s that behaviours are communication. Spotting those early signs and approaching them with curiosity instead of reactivity can make a world of difference.

Jock: Right, and it’s, it’s not about doing everything perfectly. It’s about showing empathy and being present. Small changes, they really add up.

Jack: Absolutely. And next time, we’re diving into something huge—meltdowns. What they actually are, how they’re different from tantrums, and what clinicians can do to help during one, particularly in the ED. It’s a complex topic, but an important one, for sure.

Jock: Yeah, definitely something worth exploring. But for now, just remember—it’s about connection first. So, thanks for listening, and feel free to share this with colleagues or trainees who might find it helpful.

Jack: And, as always, take care of yourselves, because how we show up matters just as much as the tools we use. See you next time.