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Public Meltdowns
and Self-Injury
Among the most unbearable experiences parents of children with autism experience are tantrums in public places. None are worse than episodes involving self-injurious behavior (SIB) that they are unable to avert or stop. Teachers and other caregivers also endure the embarrassment of public meltdowns and the anguish of being unable to prevent or stop self-injurious outbursts. In this chapter, I discuss strategies for preventing or averting public meltdowns. The causes of the most enigmatic behavioral challenges associated with autism, self-injury, and their prevention and treatment are discussed.
Celia and her children stop at the supermarket to pick up food for the weekend. As they enter the foyer to the store, 4-year-old Hannah, who has autism, notices several large vending machines filled with colored gumballs, various kinds of candy, and clear plastic capsules containing trinkets. Hannah runs over to one of the machines and begins shouting, “Candy, candy, candy!” Celia says, “No, Hannah, that is bad candy. We’ll have a treat later.” She takes Celia’s hand and tries to lead her away. Hannah pulls away screaming, “Candy, candy!” Celia firmly repeats, “We’ll get a treat later, Hannah,” at which point Hannah’s face is contorted as if in pain.
Hannah drops to the floor and begins striking her face with her fists. Celia squats beside Hannah and tries to restrain her arms, but Hannah kicks and pushes Celia away. People entering and leaving the supermarket stare in disapproval at the little girl having a tantrum, with her mother by her side seeming to do nothing about it. A woman with white hair and a cane approaches and asks, “Is the girl having a fit? Should I call 911?” “No,” Celia replies, attempting to sound calm, “she’s just upset; she’ll be okay in a minute.” Aaron, Hannah’s 8-year-old brother, walks to the opposite side of the glass-enclosed foyer, creating as much distance as possible between him and the fracas and looking away in embarrassment. Hannah’s younger sister, Sarah, who is sitting nearby in her stroller, begins to cry. An assistant manager approaches from inside the store and asks whether there is a problem. Celia thinks to herself, “Yes, there is a problem. I’m dying of embarrassment, humiliation, and guilt, and I only wish there were a way I could make this all go away, because there is nothing I can do about my daughter’s meltdown.”
THE DREADED PUBLIC MELTDOWN
Every parent of a child with an autism spectrum disorder (ASD) can share similar experiences with dreaded public meltdowns. What those experiences have in common is a sense of intense shame over one’s inability to control your child’s outburst in a public setting. Parents believe they should be able to teach their children to behave appropriately, and when they can’t seem to do so, they often interpret that to mean they are failing as parents. Equally painful, they know that many of the people witnessing the public meltdown believe the same thing and are judging them. Although public outbursts are inevitable from time to time with any child with an ASD or attention-deficit/hyperactivity disorder (ADHD), there are specific steps to help prevent these outbursts and to minimize their impact when they do occur.
It’s Your Child’s and the Public’s Problem
If your child had epilepsy and dropped to the floor unconscious in a shopping mall, it is much less likely you would be embarrassed. Your concern would be for your child’s safety and well-being.
You would not blame yourself for your child’s brain condition, and you would realize that most of the general public is aware that epilepsy is a brain disorder and that you should not be judged because of your child’s seizure. Most people would sympathize with you and your child’s plight. One of the main reasons parents of children with autism are embarrassed about their children’s public meltdowns is that they are unsure about the role they play in their child’s behavioral outbursts. When a child with autism has a meltdown in public, it is natural for the child’s parents to believe they should have been able to stop their child’s outburst. But just like children with epilepsy, their child has a brain disorder: autism. Although children with ADHD generally have a less severe disability, they, too, have brain-based problems with impulse control. When a child has an unpredictable meltdown that is provoked by an unexpected event, there is usually little a parent can do to stop the outburst once it has begun. Although parents can learn to prevent and reduce many outbursts in public settings, it is nearly impossible to totally eliminate them. When strangers stare at a child with autism having an emotional meltdown in a public setting, the child’s parents might say, “My son has autism. It is a brain disorder. He doesn’t know what he’s doing,” and leave it at that. Some onlookers will accept such a statement at its face value, empathize with the parent and child, and ask whether they can help. Others will continue to believe, incorrectly, that “he just wants his own way.” Parents can’t hold themselves responsible for other people’s lack of understanding.
General Rules of Thumb
About Preventing Public Meltdowns
Here are some general rules of thumb about preventing public meltdowns.
Be realistic about the length of time you can spend in public places. All children have short attention spans and little tolerance for staring at their parents’ knees during outings. Children with ASDs and ADHD have less tolerance than most children the same age.
Tired children are irritable and are easily set off. Don’t plan to be out beyond your child’s usual naptime.
Hunger is also a problem. Hungry children are crabby children. Younger children get hungry frequently, so it is wise to bring a bottle or a baggie containing pieces of fresh fruit or crackers for snacks.
Give your child a visual list of the places you are going to be visiting while out on an errand. This way, he or she will be able to anticipate what will occur next and see a clear end point. Such a list is called a visual schedule. Cut a 4 x 6 inch card in half lengthwise so that each half is 2 x 6 inches. Save one half for another outing, and paste photocopied images of each of the places you are going to visit, arranged sequentially from the top to the bottom of the card. If you don’t have access to a photocopying machine, cut ads out of magazines and use them instead. The top image might be an image of the grocery store, the one below it could be a picture of the dry cleaner, the next one could show the drug store, and so forth. That way, your child will know what to expect. Anything that reduces uncertainty tends to reduce meltdowns. As you are leaving one place on your morning’s outing, ask the child with an ASD, “Where do we go next?” This will focus your child’s attention on the list. It’s also a good idea to have your child help you arrange the order of places on the list.
Build in opportunities for choices along the way so that your child with an ASD or ADHD feels he or she has some control. For example, if you are going to take a break in midmorning during a shopping trip, you might include a choice of snacks on your child’s schedule so that he or she can choose between an orange drink or a smoothie. On the visual schedule, the item that comes after the visit to the drug store can show two images side by side—an orange drink and a smoothie—from which your child can choose.
Avoid verbal examinations. Although it is a good idea to talk with your child when you are on an outing, avoid creating the impression that outings are verbal examinations. Sometimes, well-meaning parents present their child with a rapid-fire series of questions, such as “What color is the balloon?” “What shape is that?” and “Point to the doggy,” as they navigate through their outing. Children with ASDs have speech-processing delays. Because they are already distracted by everything they see during an outing, asking them a series of questions can create additional cognitive demands and, in some cases, trigger tantrums. Allow your child’s interests to guide occasional questions from you. If your child is staring intently at a poster of a popular children’s book character in a store window, you might ask your child the name of the character he or she sees.
Avoid a physical struggle. If a meltdown begins to occur, physical restraint or force may be necessary at times for the child’s safety; however, you should try to minimize your use of physical coercion. A physical struggle usually makes matters worse, except in the very youngest children (under 2), who may find comfort in being held. The problem with hugging or holding your child as a way of managing meltdowns is that the child may come to see this physical attention as a reward for having meltdowns. As a result, parents may find their child having more, not fewer, outbursts.
Two Types of Public Meltdowns
Public meltdowns come in two varieties: potentially preventable and unpreventable. Hannah’s meltdown was potentially preventable, as we will later see in this chapter. Occasionally events catch parents and children completely off guard. Something that couldn’t have been anticipated might happen abruptly and precipitate a meltdown.