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Unpacking Tantrums

In the April 2017 Journal of Developmental and Physical Disability, Mayes et. al, published an article entitled: Tantrums are Not Associated with Speech or Language. This research is important from clinical, research as well as advocacy perspectives.

The authors investigated the common notion that children with autism tantrum because they cannot communicate effectively. This notion is connected with research that behavioral methods can replace tantrums with words. Most behavioral plans for children with autism including ‘manding’ training, that is, training children to ask for things they might want. And yet what Mayes, et. al. found was the opposite: less language was not associated with parent reports of more tantrums. In fact those with more language had more tantrums. They conclude that we need to think of tantrums as not associated with language deficits, but perhaps a learned behavior.

The article that underlines the need to understand rather than merely ‘treat’ behavior. It is an excellent starting point for rethinking why we do what we do in the Developmental – Individual Differences – Relationship based (DIR) approach.

It is helpful to think about, language aside, how having autism can lead to people being more prone to upset. Maybe this is something about autism itself, broad as that diagnosis has become. Maybe there is tendency to learn tantrum behavior. In DIR we cover a range of areas of ability and challenge to understand what is happening: sensory, motor planning, receptive and expressive communication, visual-spatial function, executive function, etc. There is certainly rigidity of thinking among many people who land on the Autism Spectrum, as well general proneness to dysregulation or reactivity, including traumatic experiences, sometimes from environmental conditions (noise, crowds, etc. ) that most of us would consider routine . Any combination of these might explain why a person gets upset a lot and can give us clues to how we might help. And it is important to note that the fact that while the finding in this study was that groups of people stratified for language ability did not have more tantrums correlate with less language ability, that doesn’t prove that for some individuals that this is not the case.

Group means and comparisons do not speak about individuals: the very interesting finding in the research reported here that having less language ability is not associated with more tantrums in ASD is powerful. Yet most of us have clinical instances where we have see a person who cannot find a way to communicate and who becomes frustrated, and who is far more able to regulate when they have a better way to tell what is going on. This is the story of teaching ‘manding’. It is very likely that because of such instances, the specific has been turned into the rule. That is, because clinically some kids have responded, and with research showing the ability to take groups of kids with ASD with tantrums and replace tantrums with words, teaching manding has become ‘what these kids need’ without regard to whether that is in fact what is happening for any individual person. It is part of a massive and lucrative one-size-fits-all business.

To me the more interesting question is this: How do we understand the manding research? Even if the reason isn’t due to a language deficit, wouldn’t we in any case want to teach manding to reduce tantrums? If it works, why not do it? Certainly this is how it works with medications, where we often embark on trials of a number of medications, never really knowing if one will work, much less why it might work, and plenty of people respond. Pharmaceutical companies have conducted studies of Risperdal and Abilify showing reduced irritability in ASD, gaining FDA approval to market these medications for this purpose and making lots of money. The lawsuits for such things as gynecomastia came later. For the behavioral approaches, what are the side effects that come later? In my view these are characterized by a lack of problem solving ability beyond the specific limited situations: learning to ask your ‘friend’ (defined as a classmate..) “What’s your favorite color?” doesn’t carry into the development of real friendship and joy. Over time families realize that this approach doesn’t really work – no invitations for playdates, for instance – it becomes painfully clear that training in such superficial social skills has severe limitations in supporting meaningful social-emotional development and function.

The typical story for us in the DIR world: families who have only been told of behavioral approaches become disillusioned. They look for other approaches and they find us. We try to unpack and understand the individual situations of people and their families, culture and circumstances. And we are often successful where others have not, because we have taken the time to investigate, think and reflect, and then we have made an effort to respect the people and connect with them. Amazing and powerful.

So in understanding and addressing tantrums, I think the bottom lines are these:
1. Just because there are ‘studies’ that show you can replace tantrums by teaching manding, doesn’t meant that it really supports development, and doesn’t mean that there won’t be side effects.
2. Same goes for medications: they might work, but you really need to be careful.
3. It pays to really unpack and understand what is happening. Take the time and effort for a respectful and empathic look at all aspects of what is happening, biologically, developmentally, in relationships, and in the context broader community circumstances. Watch over time how your understanding develops and deepens, looking at the quality of relationships and the ability of people to be regulated, connected, and in a flow of meaningful interaction with those around them.

I hope this is helpful!

Joshua Feder, M.D. Dr. Feder's Blog

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