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).

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.