Monday, April 9, 2007

M&M’s and a Spray Bottle Part 2

I wish I had asked for more than a week to address your question from the last installation.

You indicated that your four year-old daughter presents with multiple developmental delays along with eating non-food items, self-stimulation, self-abuse, some biting and rocking. The cluster of behaviors that you are describing tend to be classified as being primitive, meaning that the symptoms emerge during the neonatal/infant period and are generally related to limbic system-driven drives (eating/biting) and instincts (fight or flight). Under “normal” conditions of development, these instinctual behaviors are suppressed starting at about age three years. Onset of inhibition of these primitive drives/instincts corresponds with emerging development or maturation of frontal lobe inhibitory processing.

The same frontal lobe mechanisms that inhibit lower level drives/instincts (biting, pica, exploratory behaviors, “fight or flight”) are responsible for inhibition (over-rides) of sphincter reflexes for successful completion of potty training. Prominence of instincts/drives in governing behavior beyond about 3-4 years of age typically indicates a high potential for frontal lobe dysfunction or maldevelopment (which also undermines cognitive, adaptive and social development giving rise to references to “mental retardation”).

The behavioral program you described as being a “failure” in our last installation was an operant conditioning model. The frontal lobes learn via operant conditioning. Taken together, it should not be terribly surprising that a child who shows delays in frontal lobe development should fail to show benefits to an operant conditioning intervention. Development of a software program (operant conditioning intervention) that relied on hardware (frontal lobe) that the child did not possess was doomed to fail and as a result, you and your frontal lobe have been “punished” by the failure with resulting high levels of frustration.

In contrast, the limbic system is 40,000 years old, has not changed appreciably in 40,000 years and I’m guessing that you will not change it with a few M&M’s. Limbic system responses are elicited by unconditioned (no learning necessary) stimuli that are “hard-wired” into the system. However, the limbic system can be modified via classical or Pavlovian conditioning. Remember Pavlov? His work went something like this… present a dog with food (unconditioned stimulus) and it salivates (unconditioned response). No learning necessary. Use the can opener (neutral stimulus), present the food (unconditioned stimulus) and the dog salivates (unconditioned response). Eventually, open the can (conditioned stimulus) and the dog salivates (conditioned response). Limbic system responses are not modified by consequences, but are elicited or controlled by antecedents (triggers).

Hmmmm … and what has this to do with our child? The first strategy is to record the ABC’s (antecedent – behavior – consequence) of unwanted behaviors with an emphasis on identification of those antecedent stimuli or triggers that consistently elicit maladaptive behaviors. Recall (in previous installations) how I preach evaluation and assessment? This time, you get to do my job. Assessment is not a specific set of tests or tools, but a way of thinking and your assessment and recording are central to any program. Antecedent (A) stimulus recording generally includes the date, time and external environmental stimuli (who, what, when, where, etc.) that were present prior to the onset of maladaptive behaviors. Recording is an important part of the entire intervention process since it both sets a baseline against which to judge the effectiveness of any interventions and provides important information regarding potential antecedents. Once specific antecedents are identified, the next step is to avoid antecedents. I love this one (that I hear once a month) “every time we go to K-mart, my child acts out.” Solution, “do not go to K-mart.” The goal is to have low elicitation of limbic system-driven “fight or flight” responses. If one cannot avoid the antecedent (such as a sibling coming home from school), the next step is to “put the frontal lobe in front of the antecedent.” This rule suggests that once specific antecedents are identified, attempts should be made to introduce structured activities (frontal lobe functions) during high risk time frames. Provide your child with a routine task or set of tasks to complete (ie., set the table) when antecedents (ie., sibling coming home from school) are present.

You are probably wondering, “then what?” Hmmm… give me 2-3 weeks (see my frontal lobes are learning).

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