Another way to respond to (deal with) tantrums

The typical and recommended response to a tantrum is to ignore it whenever possible. This can be very effective when consistent. There are two potential problems with ignoring tantrums.

1. It can be difficult to be consistent across all settings and with all people.

2. There are times when there are safety concerns and it can not be ignored.



There are other ways to respond to tantrums which in some situations can be more effective and produce quicker positive results. With this said, one intervention does not work best for either all parents or interventionists or with all children or clients.



Many years ago I worked in an institution. During that time I spent some time working with a group of young adult men with sever developmental and behavioral problems. There was one young man who, when he would get upset and throw a tantrum, he would tear his clothes, throw beds and at times even tear sinks off the wall.

One day he started into a tantrum, I do not remember why, and he started screaming and tearing his shirt. I’m not sure what caused me to respond in this way, but I started yelling and also tearing his shirt. He immediately stopped with a shocked look on his face and mumbled the question “are you crazy?” That was the end of the tantrum.

Another time I was with a young man (about 10 years old) who was very upset because he wasn’t able to go on an outing (this was a consequence for his behavior). He was swearing and complaining about one particular staff member. I listened and then suggested that we write it all down. He just responded “naw” and that was the end of the tantrum. We of course discussed what got him to that point and on a long term basis worked on skills that would help to avoid the same problem. On another occasion a young girl (about 6 or 7) started throwing a tantrum in a clinic setting (screaming, kicking). I told her that she wasn’t doing a very good job of throwing a tantrum and that I could throw a better one. Which I did. There were two or three other adults in the room with us who joined in on the act, each trying to out do the other. She never threw a tantrum in front of me again.

My grandson is another example. He is almost four years old and had started throwing tantrums. The first time he did it I responded by saying “that’s just not working for me, why don’t you try….” I would then suggest different things like hitting the couch or stomping his feet a little harder and lying down and kicking his legs. Each time I would respond and say, “nope, that’s still not doing it for me” and suggest something else. Before very long at all he had given up. I believe I did it with him one other time and that has been it. More recently he thought screaming might work on me so I took him to a room, there were some other interesting things in the room but I wouldn’t let him play with them because our purpose was to scream REALLY loud and long. I told him we were here to scream and to go head, he said “no thank you.” He did not get to play with the things in the room but returned to what we had been doing instead.

Here’s the point for tantrums, another possible alternative. Ratchet it up, take it to the next step, perhaps even a challenge, and participate in the tantrum without becoming overly anxious. Make sure the person is safe. (Generally the head is where I am most concerned. You do not want to allow something that may cause damage to the child such as banging a head against the wall. There can also be other areas of concerns.) You can also redirect to safer ways to tantrum. Instead of ignoring, turn it into a game, such as a stomping contest.



Address what brought the child or person to this point in an appropriate and positive manner.

I wanted to add one thing to our tantrum discussion, it's not just that the child may be worn out, but children are smart, even children with disabilities are smarter than we often give them credit and they quickly learn that there's just no leverage in the tantrum, with adults who react in this way. It's more like, "hey this adult just doesn't get it, no use trying it on him or her any more."

It's similar to some of Milton Erickson's techniques where he just wouldn't get flustered and would actually jump right into the drama with the client. He believed that it wasn't his job to turn people around, just move them out of their entrenched trance by a degree or two and then allow them to figure it out and "right" themselves.

Short exchange with Dr. Richard Solomon

Dr. Rick,A few days ago I was reviewing a web presentation on attachment. Nothing new but a nice refresher. This morning I was reviewing a comprehensive assessment on a child diagnosed with PDD NOS. I was also thinking about some thoughts a co-worker had recently shared, about co-occurring dd and cmh disabilities and it struck me that the diagnosis of autism or something in the spectrum almost requires an attachment issue. I also thought about the LOVAAS approach and autism treatment in the clinical or community setting with non family members who sometimes change frequently. Where there has been some corroboration of positive outcomes with LOVAAS in IQ, those positive outcomes have not generally included behavior. The best overall outcomes must include family participation and even LOVAAS/ABA has now acknowledged the importance of joint attention. Yesterday I also read an article about the longing that many if not most children in the spectrum have, in spite of inappropriate or ineffectual attempts, for relationships. (Hope that wasn't too long of a segue.)If most children with autism also have attachment issues, is center based or even community based treatment ultimately counter productive for the overall and long term benefit of the child and family? From a mental health perspective you would NEVER prescribe a child with an attachment disorder, especially a young one, with 30, 20, or even 10 hours per week in a center or community setting with strangers and without a family or caregiver present. That would be almost unfathomable. Your thoughts, please?Pete

Hi Pete,I fully agree. Drilling a young child 30-40 hours per week is developmentally inappropriate and can interfere with multiple developmental processes including attachment, affect, initiation, and autonomy. ABA is good for cognitive gains but depends on naturalistic settings for generalization and attainment of true social abilities. The fundamental relationship in ABA type interventions is: 'Do this. Good job' which is a very impoverished form of relationship. The adult leads. Child led interventions promote affect, initiation and autonomy--three very high values for me. Joint attention is just the beginning. I'm afraid we've let the tail wag the dog. By using empirical approaches only without a respect for what we know to be developmentally necessary, we've been able to teach discrete skills at the cost of developmental integrity. You can quote me on this. Hope this helps.Take care,
Rick
Richard Solomon MD
Medical Director
Ann Arbor Center for Developmentaland Behavioral Pediatrics

Added note from Pete: This does not mean that children with Autism have an attachment disorder. Children with Autism generally do development strong attachments: however it is often an irregular and sometimes difficult attachment. The developmental needs of the child as well as the relationship and what is called "joint attention" are central to the needs of the child and family.

Some additional resources for working with children with autism

These were recommended in a class I recently attended and I am passing on the recommendations to you.


Verbal Behavior Therapy

Social Thinking

Social Stories

Social Stories and Comic Book Conversations

The Grey Center

Relationship Development Intervention with Young Children: Social and Emotional Development Activities for Asperger Syndrome, Autism, PDD and NLD

Relationship Development Intervention with Children, Adolescents and Adults

A Work in Progress: Behavior Management Strategies & A Curriculum for Intensive Behavioral Treatment of Autism

Behavioral Intervention for Young Children With Autism

Meaningful Functional Outcomes and Parental Involvement

As many know, one of the problems with the SIB-R is how much it lends itself to malingering. Sometimes this malingering comes from coaching by the provider and other times it is just a parent's rationalization due to a feeling of desperation. This desperation comes from a number of sources, sometimes it is out of a hope that something will be better for their child and sometimes it comes from the need to have someone watch their child and their fear that there is no one except someone from an agency who will watch their child. Often times they have given up on the possibility that their young child with a disability might be accepted by a typical day care or that their older child with a disability might be able to be included in typical programs. While there are always going to be some children who will need specialized supports in order to participate in some type of child care or other activities including family based, for the majority of children we work with there is real hope for significant improvement. Unfortunately there are two primary obstacles, with numerous ancillary obstacles.
#1 Meaningful Functional Outcomes.
If we do not start with the end in mind, we will not know where we want to go. If the end is not meaningful to the parent, the parent will not feel vested and involved and will be less willing to participate. If the path or route taken towards the end does not involve the parent, let alone make sense to the parent, then the parent will disengage further. On the other hand, if the outcome is meaningful to the parent and it's practical functionality is obvious to the parent (because it originated from the parent), the parent will be more likely to be invested in the intervention especially when the parent has been taught both the essentiality of their involvement and been assured that they will be given the requisite skills and supports.
#2 Parent involvement. It is no wonder that SIB-R Maladaptive scores often get worse while the child is making progress in the center or even community with the therapist or tech when there is little or no parental involvement in the actual intervention for the child. There are three primary reason for parental involvement in the actual intervention with the child. 1. It provides more and more consistent intervention for the child. 2. It provides better outcomes for the child. and 3. The parents perception of their ability to help the child, handle the child during difficult times, interact and communicate with the child are heightened. This last issue has become so important in the research that for early intervention there has even been developed The Early Intervention Parenting Self-Efficacy Scale (EIPSES) which you can find on my page at: http://www.collaboration.me.uk/q.php
When used correctly, the SIB-R Maladaptive score is actually reflective of two things, one is the actual behavior of the child and the other is the parent's perception of that behavior, which includes their perception of their personal self-efficacy in relation to those behaviors.

Of course and as is well known, any research about the efficacy of intervention or even any kind of extended additional hours clearly demonstrates that parental involvement is essential.

Reinforcement

There are many types of reinforcement. For our purposes here we will talk about natural reinforcers and contrived (or artificial) reinforcers.A natural reinforcer is any reinforcer that would occur out in the natural environment without therapeutic intervention. They are either spontaneous or come after time with delayed gratification. For example, you work you get paid. There is a natural connection between the behavior and the reinforcement. Any child in a healthy environment would likely receive the reinforcement. Generally speaking, when you are nice to people, they are nice to you. Generally speaking, when you say please and thank you, you get a more reinforcing response. You learn to make a PB&;J sandwich and you get to eat it. You appropriately ask an appropriate person for a hug in an appropriate manner and you get a hug. If you are a child and you appropriately ask for a glass of milk in the right place and time from the right person, you get a glass of milk. You put together a model airplane or a car, you get to keep it and feel good about what you have accomplished. As a child, you ask for what you want that is appropriate, in an appropriate way from the right person and at the appropriate time and you get it if possible. You learn to do something for yourself and you develop independence and feel good about that. You play "nice" (I know that has to be defined) and other children want to play with you. You do things that are appropriate and people say thank you and I'm proud of you. (This one is kind of in-between)
Contrived reinforcers are those provided by or arranged by the therapist and in some cases the parent or teacher. "High fives" (plus some additional strange behaviors usually only seen in football players and avid fans) are also in-between. You ask for a hug and get an m&m. You complete a task or step and get a sticker. You are quiet in class and you get a star while other children who are quiet do not get stars.You do something appropriate and get points and eventually get to buy something with those points. The "point" here is that there is an artificial connection created between the behavior and a reinforcement that would not typically occur for a child not in therapy, or an artificial reinforcement that would not typically occur.

Supplimental Information:
Artificial and Natural Reinforcement

Desensitization

Desensitization is also a fairly simple concept; however it requires the coordination of a number of interventions. As you help someone to desensitize you build self efficacy. You do this by first helping them to relax, this can be through play and doing an activity they both enjoy and for which they already have high self efficacy. Using successive approximations you then gently introduce the concept or activity that you and/or they want to build self efficacy for and be desensitized to. For example, you may help someone to relax with music and relaxation techniques or through play and/or an enjoyable activity, without making a bid deal about it and perhaps even a little in the distance, uncover the picture of a spider. Over time and a few sessions you would hand them a picture of a spider then have a toy spider and eventually have a real (safe) spider in a jar and continue this to the point needed. It would probably never be needed that they actually hold the spider. It is the same thing with almost anything else. If it is fear of flying this would continue until they actually took a short flight with someone they trusted and who would help them to relax. They may carry relaxing music with them or even a relaxing and enjoyable video to watch. This of course is all individualized. If someone does not have a problem with pictures of spiders but is afraid of spiders, you would not need to start by uncovering a picture of a spider. Starting with a toy spider may be more appropriate.

Chaining

Chaining is a simple concept. You can do both backwards and forwards chaining. It is simply teaching one step at a time. For example if you are teaching someone to use a computer, if you are doing forward chaining you first teach them to turn it on. If you are doing backwards chaining you first teach them to turn it off. If you are teaching someone to get dressed, you may first teach them to put on their underpants (it could be broken down even more basic if needed teaching them to first pick up the underpants in a certain way and then teaching them to put one leg in and then the other and then pulling them up. That is forward chaining. If you were training doing backwards chaining you may put most of the top on and put their head through and one arm through and teach them to put the other arm through on their own. The next step would be to teach them to put both arms through on their own. With either forwards or backwards chaining you continue to redo the steps already learned.

Quality Treatment for Children

An evaluation treatment matrix for parents of children with developmental disabilities, mental health and/or behavioral issues.

How do you tell what is good quality therapy for a child with a disability, mental illness, and/or behavior problems? This system is not perfect; however, it is based on extensive research and can be used as a GUIDE for evaluating treatment options as well as evaluating the quality of treatment being provided.

The program will be strength based. While this does not mean that the program ignores deficits or problems, the primary focus will be strengths. Safety should always come first; however, is the long term and clear emphasis on increasing appropriate behavior?
Providing a best practice, research documented and peer verified approach that matches the disability, disorder, issue, and individual situation for your child i.e. PLAY, Lovaas, ABA. Does the provider provide a well researched, developmentally appropriate, and best practice intervention that is known to provide best outcomes for a child of (age of your child) and (disability, condition, or diagnosis of your child)? They should be able to tell you exactly what intervention they are providing and provide you with the research to back it up. If they can not, they should have a very good explanation of why they can not.
When therapy is integrated into yours and the child's typical routines, more really is better. Are you an integral part of the therapy, are you being taught things that you can do to support therapy and is there follow-up to see how well you are doing and what you might do differently to adjust for better results for your child? Are you listened to as a partner and an expert on your child? Does therapy support and promote inclusion in typical healthy productive routines that your child's peers are involved with i.e. 4-H, scouting, school activities, church activities etc.?
I.E. Speech, Physical Therapy, Occupational Therapy, or other type of specialist. Is there a global approach to your child? This does not mean that the other therapists have to be providing direct therapy. Sometimes this can be only for consultation and evaluation. This is not essential for every child but the need should be explored through the Functional Analysis or Behavior. Is this occurring or has it been thoroughly explored?

Is there both communication and an integration or support of services being provided by other professionals. Does the therapist working with your child, collaborate with and integrate suggestions provided by other therapists?

Evidence that the child is making significant progress with the existing therapies. (May include maintenance for certain degenerative syndromes.) Can you easily recognize significant achievements made by your child, that were written as specific goals or objectives on your child's plan.

Quality and appropriate (including developmentally) Measurable Behavioral Objectives. Does your child's plan contain objectives that are so clear and concise that you know exactly what your child is to do and when your child is to do it? Do you also clearly understand when your child will have achieved this objective?

Quality and appropriate (including developmentally) Functional Outcomes.
Are the outcomes and goals on your child's plan something that s/he will be able to use as a part of his or her normal routine? Is this a skill that you would teach a typically developing child? Is s/he learning something that s/he could possibly use if s/he were living on his or her own?

For some interventions and disabilities this would include the first three years of life; however if Best Practice is provided can extend through age 8 or 9. (This does not mean that treatment is not important for older children, it is. It does mean that early intervention is crucial if at all possible. This is partially because of what we know about brain development.
Some other crucial times can be times of transition, including between schools, moving, family transitions, puberty etc.
Is therapy being provided at a crucial time period and if not, does the therapist acknowledge and understand the importance of these periods and is s/he prepared with a transition plan for these periods?

Medication is not needed for most children. If it is being used, has it been prescribed by an expert. A children’s psychiatrist is recommenced if at all possible. If there is medication is there close collaboration between the therapist and the physician?

Existence of a functional behavioral analysis. (Also called a functional analysis of behavior.) (Must include, environment, setting events, sleep, diet, medical, communication etc.) Was a functional analysis of behavior conducted, especially for a child three years or older?

Does your child have a positive caring relationship with the therapist or do you believe that they will be able to develop one. (Knowing that the therapist personally cares about the individual is important for any therapy.)



View additional information by clicking here.

Transition plans

There are all kinds of transition plans. So many that it would be impossible to talk about all of them. If you have a question, please ask and we’ll talk about it. A transition can be from one place to another, from one activity to another, from one program to another and from one life stage to another. They sometimes cover; gathering information, looking at options, and a list of who will do what when. For a transition from one activity to another or from one place to another, it would depend on how difficult the transition may be for the individual. This may include a regular predictable schedule, cues to indicate that the transition is coming up (music can be helpful for this as noted in: http://www.collaboration.me.uk/Stress_Reduction.php see letter m., or charts can also be used), a very specific and safe process for the transition and something to relax into the transition. For some individuals, environmental structure can both be very important and helpful. It just depends on the needs of the individual.