Developmental medicine and dentistry reviews & reports

Exceptional Parent, The, July, 2007 by Philip May

Message from the Editor: In this issue of the AADMD Reviews & Reports, Dr Zelenski addresses the complex problem of destructive/maladaptive impulsive behaviors, which often occur in persons with severe cognitive dysfunction. Those of us who work with this patient population are intimately familiar with the various types of aggressive, self-injurious, or ritualistic-like behaviors that at times seem to "come-on-out-of-the-blue" with no obvious reason. Since it is "behavior," it makes sense to consult with a psychologist or psychiatrist since "behavior management" is what they do; however, as Dr Zelenski points out "the person with a hammer usually looks for a nail." So for the health professional, if you are a surgeon, you look for the opportunity to operate. If you are a psychiatrist, you think about prescribing a psychotropic drug. And if you are a psychologist, you develop a Behavior Management Plan-because "that's what you do." Dr Zelenski, on the other hand, addressing the behaviors encountered in folks with severe/profound cognitive dysfunction, is asking us to "think out of the box." Using another analogy, the cry of the baby is a non-specific behavior, which could represent hunger, thirst, a wet diaper, boredom, or pain. The caregiver, when confronted with the cry of a baby, goes through a number of diagnostic maneuvers, such as picking the baby up, trying food, checking the diaper, etc. in search of the specific etiology of the behavior. Addressing the specific etiology will resolve the behavior. On the other hand, an injection of haloperidol will also resolve the behavior. In either case, the crying baby, once "treated," will now "sleep like a baby." The question is: what is the most appropriate treatment, a "treatment" based on accurate diagnosis, which specifically addresses the underlying problem, or one that merely suppresses the symptom? Hopefully, the answer to this question is obvious. Unfortunately, clinicians too often take the mindless, non-analytic "symptom-suppression" approach, which at times may have tragic consequences. This is the broader problem Dr. Zelenski is addressing with his excellent case discussion/analysis that follows below.

--Philip May, M.D., Co-Editor, R&R