Biology vs. Behavior: an interactive seminar
IEP Day April 11, 2008 Joshua D. Feder, MD Faculty, Interdisciplinary Council on Developmental and Learning Disorders Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego School of Medicine
The Problem: How do we tell the difference if a behavior is due to the diagnosis, and therefore harder or perhaps impossible to treat, or is a learned behavior that might be more easily removed?
The Problem: Attitudes • “Supratentorial” • Mind vs. Body • “It’s a Behavior”
Attitude is Everything…
• We tend to externalize the problem –instead of thebuck-stops-here…. • We tend to take it personally when we do not have the answer • We tend to blame instead of thinking productively
The Blame Game
• Blame the person • Blame the family • Blame the illness • All of these tend to be reductionistic and unhelpful
Getting Past it… • A better response? • Pull it apart and sort it out • Accept that it will be complicated • Solutions will be imperfect, but, we hope, helpful
The range of symptoms: • ‘Hard-wired’: e.g., pure mania, pure tics • ‘Grey area’: e.g., the early part before many a wild-eyed tantrum • ‘Totally learned’: whining, look & hit • YOUR IDEAS HERE:
Deconstructing the symptom:
• Biological factors • Psychological functioning • Social/ environmental
Common Biological Factors I: Individual Differences in Regulation and Processing
• Sensory processing and integration disorders • Motor tone, function and planning disorders • Central auditory processing disorders; receptive and expressive language disorders • Visual-spatial processing disorders • Praxis –executive functioning: ideas to plans to sequences to execution, adaptation
Common Biological Factors II: “Etc.” • Other Neurolological conditions – e.g., seizure disorders, Retts Syndrome • Medical conditions – e.g. disorders of glucose metabolism, allergies, anemia, nutritional deficiencies • Medication effects (including supplements and other complementary medical approaches) • Etc., Etc., Etc.
Common Psychological Factors I: Square peg, round hole…
• Discouraged kids • Anxious kids • Frustrated kids
Common Psychological Factors II: Cracking the peg • Depressed kids • Controlling kids • Explosive kids
Triggers and Responses: Collecting Data
• Date and time • Place • What happened? • What happened before that? • What happened after that? • What else is going on?
ABC’s
• Antecedants • Behaviors • Consequences
But it’s more than ABC’s… • Hydra – 5000 neurons in a net? • Clams? • Fish in schools? • Octopus swipes fish? • Packs of hyenas hunting? • People on cell phones driving on the freeway
Common Social Dynamics Ia: The Oppositional Dynamic, part a • ‘Square peg, round hole’ situation – leads to frustration or anxiety • Child balks at demands, expecting more emotional pain • Adults react, usually in a punishing manner • Child balks, again expecting more pain
Common Social Dynamics Ib: The Oppositional Dynamic, part b • Over time the child’s reaction becomes more automatic • The pattern becomes predictable for the child and the adults • Predictable is better than unpredictable, psychologically speaking, so there is little reason for the child to change his reaction • Child may become a ‘control junkie’, sensing that he can control what happens next, and so reduce the anxiety of not knowing what happens next, by taking the ‘easy’ way and failing to control his impulse to react against commands or control of adults.
Common Social Dynamics II: Support vs. Expectations - Dr Arnold Miller
• Low Support/Low Expectation – e.g., unengaged, alone in room, playing videogames (can be neglectful) • Low Support/High Expectation – e.g., “He needs to just be normal and he WILL be!” (can become abusive) • High Support/Low Expectation – e.g., accommodations and excuses with little progress (often very frustrating) • High Support/ High Expectation – e.g., continuous daily engagement, wooing into new areas of thought and function, wraparound model (this is usually best).
Intervening: • Sort out and prioritize where in the bio-psycho-social system you can intervene and make a difference • Usually need to intervene at several levels • Can’t do much if a person is not regulated • But medication never makes up for problems in the environment • And meaningful progress does not happen without engagement and a plan to move forward
Intervening I: ‘Biological Modalities’ • Occupational therapy – sensory and motor • Speech and language therapy – communication is the better, broader term, to encompass critical gestural/ non-verbal aspects • Many, many others • All work toward neuro-biological change, and all, at their best, are also by their very nature social and ‘psychological’ • Medications, supplements, etc. – a talk for another time...but if there is a clear underlying disorder, e.g. seizures, or a target symptom than can be ameliorated, such as obsessiveness, it should be addressed
Intervening II: A Few examples of Psychological Modalities
• Classic behavioral approaches – addressing any surface symptom to eliminate it, offer alternatives, achieve compliance • CBT – cognitive behavioral therapies - for mood, anxiety, compulsions, anticipatory guidance (incl. Carol Gray’s work) • Family based CBT Barkley – especially for defiant and oppositional behavior • DIR®/Floortime – BPS/Relationship based developmental model, looking at regulation, engagement, and reciprocity to create useful relationships and ‘buy-in’ to better function
Intervening III: Examples at the Social/ Environmental Level • Home-School Communication • Wraparound: Home-School Collaboration • DIR®/Floortime – wraparound focused on engagement, with coaching and reflective processing built in
An Easy Example: ACTING OUT ‘Slow Talker’: Possible symptoms….. • Withdrawn • Hits • Doesn’t do work • Not getting along with peers
ACTING OUT ‘Slow Talker’: What’s going on? • Biologic – can’t process and / or express himself fast enough to keep up • Psychological – frustrated, discouraged, etc. • Social – ‘left in the dust’ by adults and kids; people do not wait for him to respond
ACTING OUT ‘Slow Talker’: Things to try…. • Wait for the person to talk • Teaching the person delaying tactics • “Quick Guide” for teachers and others • The intervention is so simple and the difference in function is remarkable!
A tougher example: ‘Stimming’ • It’s always different for each person but… • Neurobiological aspects: trouble communicating, overactive basal ganglia? • Psychological: anxiety, stress • Social dynamic: left unengaged, and /or avoidance of tasks
‘Stimming…’ • There is probably a biological tendency to stim • There is probably a trigger in the environment • There is probably a psychological need that stimming helps the person to manage
Still Stimming….. • Turn B-P-S to S-P-B • Social/ Environmental: Try engaging the person – work on regulation, engagement and creating a continuous flow of back and forth reciprocal interaction – make yourself a part of his world • Psychological - Work toward affective communication, whether verbal or non-verbal, so the interaction with you becomes more interesting than the stimming. Coregulating affective experience (we can do this together) • Meds, maybe inositol, maybe omega 3’s…
Your Examples‌.
Conclusion: It’s usually not ‘either/or’, it’s usually ‘and/and’; these things can often be understood, and a BPS/‘bottom-up’ developmental approach is often helpful.
Resources:
• www.circlestretch.blogspot.com • www.icdl.com • www.Floortime.org • Barkley, R. Defiant Children