© Borgis - Postępy Nauk Medycznych 1/2013, s. 100-102
The current issue of “Postępy Nauk Medycznych” (“Progress in Medicine”; PNM) is devoted to problems related to developmental disabilities and evidence-based approaches to their treatment. Gathered papers have been written by representatives of separate disciplines – medicine and psychology – and are presented by us in order to convey interdisciplinary knowledge to family doctors and doctors practicing within primary health care. Reporting medical and psychological information was our goal, because in case of developmental disabilities, recommended treatment should be comprehensive, and thus provided by a variety of professionals. It is very important that there is a transfer of knowledge among those professional as it will likely result in faster and more appropriate recommendations that are given to parents by family doctors and primary health care providers. This issue on PNM is divided into three parts: review papers, original papers and clinical corner.
In the introductory article, prof. Irena Namysłowska writes that in Poland about 10% of children and adolescents suffer from psychiatric disorders. Taking into consideration that in our country there is around 7,5 million individuals from this age group, 750 000 young people need help. We cannot forget about their families, who often also need support. Thus, mental health of children and adolescents is an important social issue exacerbated by the fact that the majority of patients do not have access to help. What are the aims of mental health care system for children and adolescents? Prof. Namysłowska writes that they are as follows: 1) supporting families, teachers, social services, pediatricians, general practitioners and the care system of mother and newborn child, as well as other social agendas in the process of rising the children, 2) developing systems of early interventions, 3) delivering effective health care, and 4) providing services that are accessible to all children in order to minimize their suffering, reduce disability and help to promote their developmental potential. The most needed are community services such as outpatient clinics, day departments, crisis interventions centers. Unfortunately, there are several obstacles to optimal functioning of health care system in Poland. One of the solutions can be offering prophylactic programs as well as effective and generally available therapy.
We present to the readers of PNM six review papers. The first one is written by an American psychologist – prof. Joseph Wyatt. This paper is devoted to a phenomenon that is common in the United States, namely overreliance on the biological model in trying to explain causes of many psychological disorders. Wyatt calls this phenomenon “medicalization”. The roots of contemporary medicalization in the U.S. are traced to two primary factors – psychiatry’s efforts to re-gain lost status, and the pharmaceutical industry’s profit motives. Given that both psychiatry and the drug industry are global enterprises, medicalization threatens to escape the boundaries of the U.S. and spread to other nations. We realize that some of the theses set by prof. Wyatt are controversial, but we have decided to present his paper in order to point the attention of the readers to potential negative results of medicalization and offer some recommendations regarding therapeutic interventions.
Malicki, Dudek-Głąbicka and Ostaszewski also write about the medical model. The article focuses on the role of general practitioners and pediatricians in prevention and treatment of children’s mental health problems. The authors emphasize the role of communication between clinicians and parents of child patients, because practitioners’ attitude to and understanding of the nature of treated problems is thought to have a significant impact on children, their parents and other caregivers, and can be crucial for treatment outcomes. Malicki et al. describe a functional-contextualistic approach to mental health which can be seen as an alternative to the medical model. Functional-contextualistic approach situates psychological problems within the context of personal history and current life circumstances of an individual. Presented symptoms are seen as behaviors which have developed in the course of life as an apparently unsuccessful way of coping with life problems. The paper presents fundamentals of functional-contextualism and contains a discussion of their implications for understanding of health problems. The article concludes with advice regarding practical applications of functional-contextualistic philosophy of health to the relationship between clinicians and parents.
The next four articles describe the foundations of behavioral approach and the effectiveness of behavioral therapy for several childhood problems. Presti, Cau and Moderato write from the perspective of behavior analysis about changing eating habits of children. The authors report that a number of feeding and eating problems may arise early in a child’s life and are defined by his/her inability or refusal to eat or drink a sufficient quantity or variety of food to maintain proper nutrition. Problematic feeding is ascribed to many causes, and it mainly arises from the interaction of biological and environmental factors. In this paper the authors discuss a wide range of strategies elaborated within a behavior analytic framework to show how feeding and eating in children can be effectively modified. They focus on how behavior analysts conceptualize problematic feeding, examine some examples of intervention strategies for different feeding problems, and sketch how a behavioral based intervention on a large scale may increase fruit and vegetables consumption in children between 2 and 11 years old and ultimately help in preventing child’s obesity. This article is an important source of information, especially in the light of a fact that 20-40% of children present some problems related to feeding, with the number reaching 80% in case of developmental disabilities.
Bąbel, Trusz i Ziółkowska discuss behavioral techniques of pain management used in clinical practice in children and adolescents and review the results of the studies aimed at assessing their effectiveness. The results of the studies both on the epidemiology of pain in children and adolescents and the effects of pain on children and adolescents’ functioning are summarized. Three types of behavioral therapies of pain are discussed: operant, respondent and cognitive-behavioral. Case studies and meta-analyses of the randomized controlled trials of the effectiveness of behavioral techniques of pain management in children and adolescents are reviewed. The authors conclude that the results quite clearly support the use of the behavioral techniques in pain management in children and adolescents.
Suchowierska and Novak focus on a very important issue of science and pseudoscience in the treatment of autism. Terms such as “evidence-based practice” or “best practices” reflect a crucial aspect of clinical work, as they point to science as means for evaluating treatment effectiveness. Unfortunately, in the area of developmental disabilities dubious and pseudoscientific interventions are all too prevailing. Suchowierska and Novak describe premises of the scientific method and contrast it with pseudoscience. They also list the reasons for popularity of unsubstantiated claims in autism treatment. One of the main contributions of this article is a summary of a recent report on practice guidelines prepared by the National Autism Center. We believe that information from the current article will be a very good source of facts regarding therapeutic interventions for parents of children with autism as well as practitioners who may come in contact with those parents.
Suchowierska and Rupińska focus on the theoretical underpinnings and empirical research related to Early Intensive Behavioral Intervention for children with autism. Autism is one of the most severe developmental disorders that is a life-long disability. Although autism is called an “enigma” because many questions still remain unresolved, more than 50 years of treatment research resulted in a substantial body of knowledge on effective methods of therapy. Scholarly work shows that early intensive behavioral intervention can lead to significant and clinically important changes in an autistic child’s cognitive, social and emotional functioning. Suchowierska and Rupińska describe tenets of behavioral approach to autism, characterize therapy based on applied behavior analysis, summarize research on early intensive behavioral intervention, and conclude with guidelines for health care providers and a list of institutions in Poland that offer behavioral intervention to children with autism. We hope that this list will be a valuable resource for family doctors who give recommendations to parents of children with autism where to seek help.
In the section regarding original work, we present four papers. Suchowierska and Walczak describe their research on knowledge about autism among Polish pediatricians. The study involved a total of 50 physicians (25 from Warsaw and 25 of Wloclawek). All the respondents specialized in the same field, that is pediatrics. The Autism Questionnaire based on the research of Pisula (1998) was used. The results showed that the pediatricians’ knowledge varies depending on the topic associated with autism. In case of some of the questions, the pediatricians showed high familiarity with the issue giving many good answers, but some areas proved to be problematic for them. There was no difference in the level of knowledge on autism among pediatricians from Warsaw and Wloclawek. Both groups had almost the same number of correct answers in the questionnaire. Summing up the results of this research, one can conclude that the pediatricians’ knowledge about autism is incomplete. Undoubtedly, such situation may have a negative impact on the diagnostic process and, in the long run, on the future of an autistic child. Providing education to medical students and practicing doctors about the various aspects of autism would therefore be very useful, as their expertise will most likely lead to a better prognosis for autistic children.
The next article is devoted to a rather narrow, but quite important issue of functional assessment of problem behavior. The significance of the problem is related to the fact that students with developmental disabilities are more likely than their counter-parts to display challenging behaviors at school. Based on the Individuals with Disabilities Act, students that display behaviors that interfere with their learning and that of their classmates require a functional behavioral assessment (FBA) in order to develop an intervention plan based on function. In some instances, the FBA process includes a functional analysis (FA), or the systematic manipulation of environmental variables to determine the effect on behavior. For some children, this process does not produce a clear pattern of responding. The study described by Heitzman-Powell and colleagues was based on two such children and was developed to assess a modification of the escape condition in a traditional functional analysis to determine the effects of holding attention constant in the escape condition. This research expands on FA technology in order to be more effective at developing function-based intervention for children whose functional behavioral assessments suggest that their behavior is maintained by multiple functions. Strengths and limitations are discussed, along with implications of the mediating effects of establishing operations on the results of a functional analysis.
Suchowierska and Cieślińska describe use of one behavioral technique – a token economy – with children with ADHD. The aim of the conducted experiment was to study the effects of the introduction of a token system on the level of hyperactivity in three children age 8-9 years, diagnosed with the Attention Deficit Hyperactivity Disorder (ADHD). The study was conducted at the boys’ homes and also at the schools they attended. During individual home sessions – while the children were doing their homework – levels of three main ADHD symptoms: hyperactivity, inattention and impulsiveness were measured. The independent variable consisted of two elements: the introduction of “good behavior” rules and awarding tokens for following the established rules. Following baseline, intervention took place during four consecutive sessions, then return to baseline, and finally intervention was reintroduced. The obtained results demonstrated the effectiveness of the administered intervention in all participants – the level of hyperactivity was decreasing while the token system was used. Additionally, the experimenters measured the degree of generalization of the treatment effects to the other ADHD symptoms, and also to the other environment (i.e. the school). The results show no generalization across behaviors and settings. Despite the fact that this article concerns a rather narrow range of interventions – only one technique, we hope that it will be helpful in showing that for some children with ADHD non-pharmacological interventions alone bring expected results.
The last original paper – by Heitzman-Powell, White, Tafs and Buzhardt – describes a model of distance learning for clinicians who want to work with children with autism. This is a very current topic as supervision of students and professionals learning a new trade is standard practice in professional fields. In the behavior analytic community, the current lack of research and appropriate technologies for consistent, high quality supervision is a potential liability for the field as a whole. The impetus for the conducted study came from the significant increase in demand for behavior analytic services and the corresponding need to increase providers well trained in best practice techniques. The training was developed so it could be delivered via remote/distance technology. General outcomes are positive with trainees increasing in both knowledge and skill application from entry into the distance supervision program until successfully exiting the program. We hope that this article will be a good example so that similar strategies can be in Poland because in our country there is also a growing need to effectively train parents and professionals where direct supervision is often not possible.
The last part of the current issue on PNM is a “clinical corner”. We devote this section to doctors who are interested in practical applications to solving some of the problems of atypically developing children. Two articles relating to major areas of difficulties for children with developmental disabilities (i.e., communication and social skills) are presented. Suchowierska, Rupińska and Bondy offer a short “tutorial” regarding one of the most commonly used systems of alternative communication – Picture Exchange Communication System (PECS). One area of persistent difficulties for children with autism is communication, with about 25% of individuals with autism not developing spoken language at all. In light of this information, it is of paramount importance to have means of teaching those individuals how to pass to others information about their needs and wants in a socially appropriate and easily understood manner. Picture Exchange Communication System (PECS) is an empirically-validated alternative and augmentative communication method. Suchowierska and colleagues provide a brief tutorial on PECS that may be of help to health care professionals who in their work come across children with autism. Moreover, the authors wanted to convey to the readers that in case of autism, teaching communication to children should begin as early as possible, potentially long before the child develops speech.
Blok and colleagues focus on one approach to explaining social difficulties presented by individuals with autism. Individuals with autism may come across as awkward to other people. The reason certainly does not lie in ill-will of the individual, but it is rather related to many deficits that autistic people present, especially in the area of social skills and communication. Cognitive literature suggests that individuals with autism have a deficit in “theory of mind”, which is understanding mental states of other people, their thoughts and feelings. The authors explain, based on clinical examples, how the deficit in the theory of mind may be an obstacle to proper functioning for children with autism. The article offers and interesting “insight” into the way of thinking of an autistic person. It can be helpful in evaluating their behavior, in terms of deficits they have to deal with, not in terms of labels such as “unruly” or “ill-behaved”.
To sum up, we hope that the readers of PNM will evaluate positively the current issue and, even more importantly, that they will find information presented by us useful in their practice. We also trust that the idea of conveying interdisciplinary knowledge will be met with interest, because our goal is lofty – to improve comprehensive services for children and adolescents with mental health problems.
Dr. Monika Suchowierska