Anger Fits, Behaviour
Here is an excerpt from the chapter on TS out of a book I bought last year from my Asperger Specialist. Since I have both TS and AS, I read this chapter first. It gives a good explanation on why kids with TS (who may also have AS) misbehave, and why rewards and punishments may not work very well.
Collaborative Problem Solving (CPS) by Trina Epstein and Jennifer Saltzman-Benaiah, taken from the book ?Children, Youth and Adults with Asperger Syndrome?
An approach to treatment that has been helpful with the AS/TS population of children is one that has been developed by Dr Ross Greene, a psychologist at Massachusets General Hospital (Greene 1998). Greene?s approach, called Collaborative Problem Solving (CPS), was not designed for the AS and TS population per se, but rather more broadly for ?inflexible/explosive? children. However, CPS fits well with the types of difficulties faced by these children.
While CPS has a direct impact on the child, the focus of the intervention is on the parents and/or teachers who are managing the child?s behaviour. CPS offers an alternative to traditional behaviour management approaches that are based primarily on rewards and punishments. The CPS approach stresses understanding the underlying reasons, or ?pathways?, for a child?s inflexibility or explosion. For instance, a child may experience frustration because of a deficit in his language pathway that impairs his communication. Anxiety or obsessiveness may contribute to frustration, as may low mood. Executive dysfunction, such as planning or shifting set, can contribute to explosiveness. Weaknesses in understanding social cues can lead to misinterpretations of interactions that can, in turn, result in frustration and explosive behaviour.
By definition, children with AS are impaired in their social pathway. Children with AS are also typically rigid and obsessive, as are children with TS. Of course, many weaknesses along many pathways can contribute to explosiveness, and although knowing a child?s diagnosis can give us some clues about the pathways that are implicated, diagnosis does not provide all the answers.
Regardless of the pathway(s) affecting a given child, Greene argues that children who display inflexible or explosive behaviour are impaired in the domain of frustration tolerance for which the behavioural manifestation may be internalized (e.g. crying) or externalized (e.g. yelling, hitting). It is proposed that a deficit in frustration tolerance is no different from any other skill deficit, such as a weakness in reading or math. In this way, impairment in frustration tolerance can be thought of as a learning disability. In much the way that rewards and punishments are unhelpful in remediating a reading disability, it is argued that these approaches are equally unhelpful in ameliorating an underlying deficit in frustration tolerance. Simply dispensing consequences for disruptive behaviour or offering rewards for the absence of behaviour is not helpful and will not teach the child the requisite skills that are lacking.
For instance, a child who has difficulty changing from one activity to another (i.e. shifting set) may throw a tantrum when his parent asks that he stop a favourite activity and come to dinner. If we believe the tantrum is because of a difficulty shifting set and managing the frustration that comes with this weakness, then punishing the child will not have an impact on her future behaviour. Punishment does not accomplish the goal of teaching the child to shift set more easily. Similarly, offering the child a reward for coming to dinner when asked will prove equally ineffective because the child does not have the shifting set skill required to comply. Parents with children with this difficulty often report frequent utilization of reward and consequences without any demonstrable learning. Parents of children with AS and/or TS may find this example familiar. It is important to recognize that the reason little learning occurs is that, in developmental neuro-psychiatric disorders, cognitive difficulties have a neurological basis. Of course, this does not mean that children are incapable of learning, but it does mean that they require explicit instruction and repetition to do so.
Parents trained in the CPS model are reminded that rewards and punishments work well at increasing motivation when the child already possesses the underlying set of required skills. Such strategies also work well when teaching a simple skill. Few would agree that skills such as shifting set and managing emotions in the face of frustration are ?simple? and that they can be taught merely by using rewards and consequences.
Accepting the CPS model involves making a philosophical shift from ?my child is having a tantrum to be manipulative? to ?my child is having a tantrum because he cannot cope in the face of frustration?. This philosophical shift is sometimes difficult for parents to make since the deficit presents as behavioural. Greene reiterates that the deficits are cognitive but are expressed in behavioural ways. He suggests the mantra ?Children do well if they can? as a replacement to the preconceived mantra that parents often uphold: ?Children do well if they want to?. That is, he takes as the starting point the fact that typically children are already motivated to do well since the meltdowns are as destabilizing for they child as they are for the family.
Once parents come to believe that their children are not exploding as a means of getting their own way, but rather are behaving inflexibly because they lack the requisite skills to problem solve in the face of frustration, parents are encouraged to use preventive approaches to keep the child from experiencing frustration. CPS advocates a proactive rather than a reactive approach.
At the same time that parents are working preventively with their children, they are also attempting to teach the lacking skills (for instance, by direct instruction and modeling). Depending on the implicated pathways, sometimes parental coaching is insufficient. For instance, a child whose quick frustration and explosiveness is related to underlying problems with depression may benefit from a pharmacological and/or a cognitive-behavioural intervention to address the mood issue. Similarly, a medication intervention is often helpful for an underlying attentional problem since this is an area that does not respond well to teaching. Children with specific weaknesses in the social pathway may benefit from participating in a social skills group.
They go on to tell where you can learn this CPS approach, one such place is the TSN clinic in Massachusetts (Massachusetts General Hospital, where Dr. Greene practices). Here is the link to their site: http://www.explosivechild.com/ .
German citizen, married to a Canadian for 28 years, four daughters, one son, eight grandchildren (and one on the way).