Why has the "syndrome" approach failed? The "syndrome" approach to diagnosis, treatment and research applied to communication and learning disorders has generally failed so far. Why has the syndrome approach failed? It is because the currently defined syndromes (i.e. Autism, ADD, etc…) are defined with respect to "Behaviors," which are almost always learned or derived. The exact same learned or derived behaviors can be caused by completely different biological states or original traits and their modifiers. In fact, sometimes the very same learned behavior can be caused by totally opposite original traits or biological states (i.e. an "autistic" child may bang his head on the floor to drown out overwhelming sensory input or may similarly bang his head to create sensation to break through extreme sensory insensitivity; or as another example, very similar behaviors may be caused by serotonin deficiency or serotonin excess).
The BOLD Alternative In order to simplify this "individualistic 'functional'" approach, I would like to present a newly derived "conceptual framework" for addressing communication and learning disorders. This "conceptual framework" can help when evaluating a child, to identify and present the origins and modifiers of his or her behaviors and how and where intervention may be successful. The "BOLD" approach consists of four (4) levels of structure for investigating, evaluating, and treating these and other developmental disorders. We recommend that each child’s underlying biological structure be identified (level 1), each trait or behavior be placed at the appropriate level (2, 3, or 4), and all significant and relevant modifiers charted. Once properly structured, we believe this approach will clearly identify those behaviors that are modifiable and recognize potential ways to modify them. For our purposes, we have labeled this the "BOLD" Approach to Assessment and Treatment of children with communication and learning disorders. The four levels of the model include: Level 1: B – Biological State Level 2: O – Original Traits Level 3: L – Learned Behaviors Level 4: D – Derived Behaviors
BOLD – Level 1: Biological State
These are the genetic and fundamental biochemical and structural components of the child’s body, brain, and nervous system that are essentially unchangeable. Note that certain aspects of the biological state may be predictable and/or preventable at some earlier point in development and as technology improves may indeed be modifiable. However, at the current state of the art, we must regard them as unmodifiable. The components of the biological state are: DNA (the basic genetic structure) the brain and nervous system sensory and motor organs the immune system all other biological systems
Level 1 Biological State Modifiers The biological state is constantly acted upon by environmental factors. The end results of these interactions are the "primary" or "original" traits of the child’s functioning (Level 2 "traits"). Recently, researchers have investigated how use of antibiotics (Bolte, 1998), abnormal sleep patterns (Patzold, Richdale & Tonge, 1998), diet (Carlsson, 1998), medical illness (Volkmar, 1998) and epilepsy (Kobayashi & Murata) have exacerbated the developmental functioning of children with communication and learning disorders, especially autism. These external factors are Biological State Modifiers. Some modifiers include: The Womb Environment: the mother's nutrition, stress, antibiotics, drug use: street or prescribed, alcohol or tobacco abuse, diseases (HIV, CMV, chicken pox etc.), radiation exposure (pre or post conception) The Birthing Process: use of pitocin, hypoxia Food & Drink: contaminants, food additives, fluoride in water, vitamin deficiencies The Environment: air, water or noise pollution, vanishing ozone layer, other noxious stimuli Medical Interventions: vaccinations, inappropriate antibiotics for otitis media (ear infection) or pharyngitis (sore throat) Intentional modifying factors: brain surgery, medications such as neurotransmitters, endocrine agents, anti-seizure drugs, steroids Plus other, not yet identified primary therapies that directly manipulate the biological state and impact on primary traits. Note: biochemical interventions should generally be targeted at this level, so as to modify an identified or theorized biological state dysfunction and so impact on original traits, thereby resolving the "core" problem. A drug given to a child primarily to "control" unwanted behaviors (i.e. Ritalin in most cases) will inevitably lead to other expressions of the primary problem, causing other unwanted behaviors or compromising the child’s ability to learn how to act appropriately without the use of the medication.
BOLD – Level 2: Original Traits Original or primary traits are the functional, operating, core determinants of the individual’s behavior. They are the biologically based "individual differences" with regards to each child’s motor, sensory, reasoning, and affective patterns, etc. These Level 2 original or primary traits may or may not be modifiable, depending upon where the child is in the developmental biological life cycle. The earlier one intervenes with the child, the more likely that one can modify an original trait. The earliest possible intervention is important to increase the chance of modifying any trait. Original traits, for the purposes of evaluating and treating communication and learning disorders, can be represented as strengths or weaknesses in i.e.:
Motor planning and sequencing
etc, etc, etc…
Level 2 Original Trait Modifiers These modifiers are sensory stimuli from the environment and all individuals who interact with the child. The level 2 modifiers include:
Parents, siblings, caregivers and peers
TV, radio, games etc.
All other tactile, auditory, visual, gustatory and olfactory stimuli
Interactions with therapists
The interactions of the child with all these personal, interpersonal and sensory/communications factors can result in Level 3 Learned or Secondary Behaviors. For most children the Level 1 and 2 modifiers are sufficient to produce constructive, socially appropriate behaviors and allow the child to progress appropriately through the developmental levels. However for children at risk for a communications or learning disorder these modifiers can result in more dysfunctional Level 3 Learned Behaviors.
BOLD – Level 3: Learned or Secondary Behaviors There are three (3) types of Learned or Secondary Behaviors which are the direct result of the child’s Original Traits and the basic interactions with his caregivers and the environment. They are:
The child’s developmental level
"Normal" coping behaviors
"Abnormal" coping behaviors
It must be true that, if we were to know the child’s Biological States, Original Traits, all of their modifiers, and the developmental level, then all "abnormal" behaviors will be understood as normal and predictable given the entire scenario. Unfortunately, many syndrome diagnoses are made at this Level 3 or Learned Behaviors level. This can be very misleading, since many of these "abnormal" behaviors may be caused by very different combinations of biological states and original traits and level 1 and 2 modifiers, and require VERY different intervention strategies to be successful. Learned or Secondary Behaviors (and some problems) include:
Speech: (pronunciation problems)
Language (poor sentence structure, vocabulary, receptive language, expressive language)
Socialization: (unusual responses to sensory stimuli, resistance to change and insistence on routines, difficulties with typical social interactions, social and emotional unrelatedness, stereotyped behavior – routines, rituals and attachment to objects, lack of eye contact).
Fine Motor Skills: (clumsiness, poor pencil grip, poor letter formation): Impaired fine motor skill, including dysphasia and apraxia, impaired motor planning, hypotonia – low muscle tone, soft ears, double jointed, upper body weakness
Developmental Level and Executive Developmental Functions: The four executive developmental functions also can be seen as Level 3 or Learned Behaviors. Executive functions are any behaviors which serve to organize a series of events over a long period of time, i.e:
Prolongation: Holding & evaluating events in working memory
Separation & regulation of affect: Splitting facts from feelings
Internalization of language: Reflection, self-control, will power
Reconstitution: Break events into parts and reassemble into new ideas
Diminished proficiency in executive functions may contribute to a communication or learning disorder by leading to:
Deficient self-regulation of behavior, mood, response
Impaired ability to organize/plan behavior over time
Inability to direct behavior toward the future
Diminished social effectiveness and adaptability
Theory of the Mind Research Addresses Learned Behaviors In recent years, research has suggested theory of mind (TOM) (i.e. the ability to understand the mental states of the self and others) as an explanation for the social, cognitive, and communicative impairments of children with communication and learning disorders (Baron-Cohen, 1996; Happe, 1995, 1997; Tager-Flusberg & Sullivan, 1994). See Appendix 3 for a discussion of "Theory of The Mind and Learned Behaviors."
Level 3 Learned Behavior Modifiers: The abnormal behaviors in Level 3 tend to evoke responses from everyone the child interacts with: parents, friends, but also society in the form of schools, public places, legal system, the community at large, etc. Their responses help modify these Level 3 Learned Behaviors. In the case of abnormal behaviors inappropriate intervention will further damage the child’s functioning. Some inappropriate interventions are:
Sole use of drugs to control behavior
Isolating the child in a locked facility
Restricting the child to a special needs environment and not including "typical" children
These inappropriate interventions can lead to Inappropriate Level 4 Derived Behaviors, which can be even more disruptive.
BOLD – Level 4: Derived Behaviors Includes all Complex and Derived Behaviors (which typically can be more disruptive or dysfunctional than Level 3 Learned Behaviors) of children in response to the response they receive from people and institutions in response to their original traits and learned behaviors. At this level the behaviors may be so far removed from the Original Traits and Biological State that it is most difficult or impossible to assess a child and implement proper intervention strategies. Frequently and unfortunately, this is the level that many syndromes are also evaluated at. Abnormal behaviors which are observed at this level may include:
Severe head banging, rocking, spinning
Physically attacking others by biting, kicking, head butting, spitting
Yelling out inappropriately
Constant seeking out of attention by negative behaviors
Severe uncontrollable temper tantrums and anger flare ups
Complete social withdrawal and social isolation
Lack of development of spoken language
Constantly in motion
Research seems to indicate that there is a way to prevent Derived Behaviors from developing and that is by placing children with these disorders in "inclusion environments" in which they can gain the positive social and communications role modeling of typical peers. Mesibov (1984) suggests that many children with these disorders may exhibit social deficits because they have few friends and limited opportunities to socialize with peers. Evidence from previous studies demonstrates that children with these disorders are responsive to social stimuli. Strain et al. (1979) and McHale (1983) both found increases in social behavior when peers actively engaged children with these disorders in social interaction. Positive social behaviors included sharing toys, hugging, handholding, verbalizations to maintain interactions, increases in cooperative play, and decreases in solitary behavior. These findings emphasize the positive effects of social interaction through peer engagement on the behavior of individuals with these disorders. Research specifically on inclusion with special populations has been encouraging (Wang and Baker, 1986; Strain & Kerr, 1981; Carlberg & Kavale, 1980). Studies show gains in socialization with a total inclusion model ( Hoyson, Jamieson, & Strain, 1984). There are positive benefits in both social and cognitive development (Hoyson, Jamieson & Strain, 1984; Harris, Handleman, Kristoff, Bass, & Gordon, 1990). There are also positive benefits in the social interaction areas (Roeyers, 1996).