Monday, April 2, 2007

M&M’s and a Spray Bottle

“Our four year-old daughter has always been slow… slow to sit up, slow to walk (she never really crawled but sort of GI-Joe’d it across the floor), slow to talk (she has only a couple single words that sort of telegraphically communicate her wants)… and potty training?… it seems like it will never happen with no progress during the past year. She was diagnosed with mental retardation.”

“The most recent problems have been eating non-food items, she eats every piece of fuzz on the carpet, self-stimulation, self-abuse, she hits her head on the floor when frustrated, some biting and rocking. When recently seen by a professional (psychologist, physician, therapist, etc.), it was recommended that we initiate a behavior modification (operant conditioning) program in which we reward her with preferred items (attention, M&M’s, touches, etc.) when she displays positive behaviors, ignore her (extinction) when she is engaged in negative behaviors that are not physically injurious and spray her with a water solution (punish her) when she is engaged in self-injurious or aggressive behaviors. After two months, our daughter has shown a dramatic increase in physical aggression and has learned to adeptly avoid sprays to the face while we have felt like total failures as parents while our child appears to fear our presence. What do we do?”

First things first. The diagnostic system adopted by the American Psychiatric Association and utilized by the American Psychological Association is an “axial” system that is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM for short). Numerous versions and revisions have been completed across time that reflect changes in our understanding of various symptom complexes.

The axial system has five axes that include: Axis I (Clinical disorders that may be the focus of clinical attention or treatment), Axis II (Personality disorders and mental retardation including factors that may mediate symptom expression), Axis III (General medical conditions that are potentially relevant to understanding and treating Axis I and II problems), Axis IV (Psychosocial and environmental problems or stressors that may affect symptom/problem severity and Axis V (Global Assessment of Functioning or the clinician’s judgment of the individual’s overall level of functioning).

My take on the process? Axis IV and V are so poorly correlated among observers to be irrelevant or meaningless (this opinion may not be shared by others). Axis I is analogous to the current weather conditions (it is raining, it is snowing, it is a thunderstorm, etc.). Axis II is analogous to the severity of the weather conditions or associated factors (28 degrees, high winds, etc.) and Axis III is analogous to the underlying cause of the current weather conditions (a cold front from Canada merging with a warm front from the Gulf of Mexico) that cause or contribute to the Axis I (thunderstorm) and Axis II (high winds) diagnoses.

For your daughter the Axis I diagnosis is the presenting symptoms/problems or what you are seeking assistance in addressing. Axis I diagnoses may include Pica (eating non-food items) and a Disruptive Behavior Disorder (self-abuse, aggression). To discover that your child has been diagnosed with Pica or a Disruptive Behavior Disorder is not particularly enlightening (particularly since you told the professional what those symptoms were). The Axis II diagnosis of mental retardation is similarly unenlightening, it simply refers to the degree to which your child’s cognitive, behavioral, adaptive living and social development deviates from the average or middle of the bell curve. You said “slow” or “delayed”… the IQ score simply provides an estimate of how much (IQ = 60 = 40% delay relative to peers, IQ = 55 = 45%, got the idea, 100 – IQ = % delay).

To discover that you finished fifth in a race does not provide insight into how to improve your running speed.

In contrast, the Axis III diagnosis refers to biological and/or neurological factors that underlie or are the cause of the Axis I and II diagnoses. Axis III diagnoses could potentially include maldevelopment of myelinated axonal connections from limbic to frontal regions secondary to premature birth, frontal lobe disconnection secondary to perinatal hydrocephalus, stroke involving the left middle cerebral artery, shear strain injury secondary to high force trauma to the head, etc. The Axis III diagnosis is designed to identify the “hardware” (computer analogy) limitations or factors that contribute to, drive or cause the presenting symptoms (Axis I).

Does your daughter have mental retardation? No… she may show a slow (retardation) rate or incomplete development of skills. What do we do?” Hmmm… give me a week to think on that one.

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