Dichterbij Specialistische Zorg, Venray. Trajectum-Hanzeborg, Zutphen Altrecht-Wier, Den Dolder. De Bruggen Specialist

1. Treatment oriented diagnostics with mildly mentally retarded adults with challenging behaviour

2. Gert-Jan Verberneclinical psychologist and psychotherapist

3. 1: therapist: we found in our assessment that you are completely normal� 2: completely normal; she: oh3: I understand that this is quite a shock for you. May be psychotherapy can help you to accept this new situation; She: thanks, I should like this Sigmund (therapist)

4. contents Introduction: recent developments Diagnostics and indication What is relevant for my clients? What is important for indication and what are the consequences for diagnostic thinking? What is evidenced based and what should be developed? Some concluding comments and some remarks on behavioural deficits, evoking factors and chains of behaviour elements

5. Some scientific developments End of nosological thinking? Dimensional diagnostics Connection to biology and medication Experimental psychopathology Rational planning of treatment and evaluation of treatment effects

6. Diagnostics in function of indication Which treatment methods are effective in a certain group of people? Then investigate how to assess for suitability: indications, contraindications Examples: trainings: alexithymia, verbal self-regulation What is the relevance for your group of clients? Example: infant healthcare: weight, otitis

7. Characteristics of mildly mentally retarded adults with severe challenging behaviour Environment is disrupted and disorganized by the behaviour Exhaustion and rejection Insecurity and anxiety Loss of familiarity Needs: safety, firm handhold, perspective, respect, control Problems in the social environment More agendas Mutual lack of freedom Deficits in behavioural repertoire Chains of behavioural elements

8. and Challenging behaviour as adaptive behaviour Challenging behaviour as part of existential design Challenging behaviour as communication Challenging behaviour as a reflection and sjablone of former interactions

9. But: Combination of many unfavourable conditions And: what helps? How?

10. Evidence based? Psychopharmacology Environmental therapy (Cognitive) behavioural therapy and (cognitive) behavioural training Offering perspectives. Negotiating on needs, perspectives and ways to achieve them, not underestimating or overestimating competences Enlargement of behavioural repertoire Changing fixed and stereotyped patterns of stimulus-response, reaction types

11. Do we know what is crucial in obtaining treatment success? A little bit

12. Some conclusions Start with ABC analysis (behavioural analysis) Egodystonic vs egosyntonic Alexithymia Side effects of psychoactive medication Autistic spectrum disorders: different learning style

13. Do these thoughts correspond with what we find in our test library? Well eh, no�. Distance between what our tests measure and the purposes we need them for We must rely heavily on results of observation and interviews

14. We lack instruments for Assessing behavioural deficits Learning potential Developmental level and learning style, dynamics, assimilation, accomodation Social competence Coping Theory of mind Networks and support

15. So development of assessment methods is necessary for Diagnostics of behaviour Cognitive schemes Self directional skills Motivation and suffering Egodystonia or egosyntonia Alexithymia Coping Learning style and best teaching methods per client Attachment and temperament

16. Current instruments: problems: Questionnaires: reading; dynamic interpretation of profiles of more tests probably not reliable Children�s tests: when appropriate and reliable? Shortage of well normed tests We think that we measure relevant dimensions with coping lists, Toronto alexithymia scale, Observer Alexithymia scale, TOM-test, forensic risk assessment, neuropsychological tests, temperament questionnaires

17. However, we also need basic testing: Intellectual functioning: IQ tests, reading, writing, arithmetic, learning and employment history, adaptive skills, analysis of discrepancies Neuropsychological screening Questionnaires and rating scales Interviews Analysis of behaviour

18. We are working on a formularium on test usage and standardized test series Important to describe which tests are appropriate and suitable for our clients But: the real question remains: how to use tests for indicating therapy, prediction of success and failure of therapy, how to diagnose environment, interactions with environment and can we find ways of reliable assessment of behaviour and contingencies?

19. Rorschach, you will come to nothing!; will you get your feet on the ground?

20. Intellectual functioning AAMR: multidimensional construct IQ: formal testing Adaptive skills including reading etc., social skills, activities daily life Participation, interactions, social roles Health Context

21. Translation to testing Intelligence tests, profile interpretation History of development, learning (school) and jobs Developent of IQ: previous testing Adaptive functioning Reading, writing, arithmetic Discrepances between and within these areas

22. neuropsychology Establish baseline Specific methods, anamnesis, theoretical models May include judgment of personality and emotions Only after physical examination Hypothesis-oriented in more stages of the investigation Assessment of neuropsychological functions:

23. Neuropsychological functions Arousal, attention and concentration Memory Language Motor and psychomotor functioning Perception �higher� executive functioning Speed Style of information processing

24. Personality etc. Does not exist? Temperament Eysenck dimensions Development of behaviour Attachment Access to emotions and experiences Psychodynamic structures and �self� Theory of mind, perspective taking, empathy

25. and Stress regulation and coping Attitudes towards health workers, current problems and expectations Topography of challenging behaviour Risk assessment

26. psychopathology Interviewing techniques Questionnaires Rating lists Classification NB: differences in presentation dependent on level of functioning and genetic syndromes

27. Behaviour, learning Learning paradigms Autism: stimulus dependent learning Motivation assessment scale: limited useful Pay attention to detailed description of behaviour, antecedent stimuli and consequences Video analysis Behavioural deficits, behavioural chains, maintaining environmental aspects

28. Context and social aspects Social competence Few instruments for investigating context and systems Parental stress Transgenerational diagnosis, genogram analysis Support systems

29. Behavioural deficits Frequent Defective social learning as a result of poor learning conditions Learned helplessness Punishment of spontaneous behaviour Inconsistent reinforcement Chronic anxiety Low mental tone Autism

30. Learning paradigms Classical conditioning: many discriminative stimuli Respondent: avoiding, no intrinsic reinforcers Social: poor history Insight: irrational ideas, avoidance Confusion and corruption of reinforcers

31. Diagnosis of non existing behaviour??? Transitions Having more options of behaviour Coping behaviour General social competence Independent living and skills

32. Pay attention to Variability of behaviour Specific features: Immobilization, going on with the same acts, intensifying Maladaptive substitute behaviour: Acting idiotically, playing the fool Flying forwards, flee to disaster Fusion of reflex patterns, jumping over Paralyzing Repetitive behaviour, walking up and down

33. And: Shyness Lack of problem solving, avoidance Better regulation if alternative behaviour has been communicated explicitly?

34. also Behavioural experiment: define maladaptive substitute behaviour type, train alternative behaviour, check results Standardized observations

35. Evoking and maintaining stimuli Diagnostics: Maintaining Symmetrical and complementary Evoking Functions of behaviour Autism

36. Maintaining: attention for: Surroundings Territorial No way out, no escape route Unambiguous? Contingencies Corrupted reinforcers? Extincted reinforcers? Stimuli: stability, appropriate presentation Order Symmetrical vs complementary reactions

37. Symmetrical and complementary reactions, characterized by: Immediateness Feeling: no choice Wearing out Predictable Long existing, like filmscripts Complementary or symmetrical

38. Evoking factors Disqualification and rejection Threatening Provocation Opportunity for self chosen behaviour Unsafety vs familiarity

39. Functions of behaviour Motivation assessment scale: proper handling; eg. functional congruence Possibility of wrongly concluding to attention seeking as motivation of behaviour Autism: behaviour seems maintained by C but C is a Sd Example: �party�

40. Chain of reactions Move and counter move Feels as manipulated Predictable Starts with crossing boundaries Quite frequent but we often do not notice

41. Diagnostics of chains Video-recording Writing supposed scripts Testing scripts in new video-recording Writing out scenario Formulate other counter moves Define alternative behaviour, evoke, reinforce Carry into effect Evaluate