DSM and the issue of co-morbidity in childhood mental disorders - a functional perspective and proposed solution
This episode is primarily relevant to professionals and students.
In this episode, R. Trent Codd, III, Ed.S. interviews Ennio Cipani, PhD about the DSM system and it's problem with co-morbidity. They discuss a number of things including:
- The difference between a topographic and functional approach to diagnosis and treatment
- How the functional approach might be an approach that escapes the DSM problem of co-morbidity
- His functional diagnostic system
- How an analysis of negative symptoms can have utility for a diagnostic system to discern chronic conditions
References related to this podcast:
- Functional Behavioral Assessment, Diagnosis and Treatment (2nd Edition, 2011). Cipani and Schock.
- Cipani, E. (2012, May 7). The issue of co-morbidity in DSM-V Childhood Mental Disorders: A functional perspective and proposed alternative diagnostic system. (audio podcast). Retrieved from www.CBTRadio.org
Prior podcast on function-based diagnostics
- Cipani, E. (2011, September 4). Function-based diagnostics. (audio podcast). Retrieved from http://behaviortherapist.podbean.com/2011/09/04/function-based-diagnostics/
Ennio Cipani, Ph.D., a graduate of Florida State University, is a licensed psychologist and a full professor in the Department of Special Education at National University - Fresno. He has published numerous articles, chapters, books, and instructional material (including software), in the areas of child behavior management in homes and schools. Among his latest books are "Children and Autism (2001)" and "Functional behavioral assessment, diagnosis and treatment, 2nd edition (co-authored with Keven Schock, 2011)." He has given many workshops at state and national conventions, as well as continuing education courses for psychologists, social workers, marriage and family therapists and others, focusing on the effective management of problem child behavior. Dr. Cipani has been doing in-home and school based behavioral consultation for families and school personnel since 1982. He has dealt with many families and a variety of behavior problems, conducting assessment and intervention activities in homes and classrooms. A copy of his book, Punishment on Trial is available as a free download at www.ecipani.com/PoT.pdf (make sure to capitalize where indicated).
Discussion questions (for undergraduate and graduate students):
- Do you agree or disagree with Dr. Cipani's analysis of why children can often be diagnosed with several disorders, i.e., co-morbidity?
- What are the implications of using the proposed method of determining the presence/absence of a symptom, when contrasted with the static methods used currently (i.e., measures do not manipulate any environmental variable, merely observes/describes behavior under whatever contextual conditions are present).
- How would you explain a rapid change in a negative symptom, given a manipulation of a contingency when compared with data from a baseline measure (where it does not occur). Is there any argument that can be made as to the chronic nature of such a symptom when such a behavior reaches a reasonable level of occurrence quickly when powerful reinforcement contingencies are stated and applied?
- How practical would this system be in clinics? Facilities? Group homes? Private practice?
- Does this approach make sense? Why or why not? Do you see this being relevant for DSM-VI? DSMXXV?
Seemed like a long way to go to say that most childhood disruptive behavioral disorders are due to inconsistent discipline by the parents and not skills deficits in the child. I agree that this obvious fact is not reflected in the DSM.
The test you propose could be misleading because any positive reinforcement for the child you might propose could be offset by everything else the parents are doing in the child’s enviroment. Also, if the parents intermittently reinforce negative behavior, that sets up a variable interval reinforcement schedule for the negative behavior, which would mean that the bad behavior would be almost impossible to extinguish. Even if the parents were totally consistent later on, the bad behavior would be expected to get much worse before it got better.
You make a great point about the intermittent schedule of reinforcement that often exists with child behavior problems! The test would have to be in an analogue assessment, where the integrity of the two conditions,; test and control were imposed. Dr. Brian Iwata and colleagues at Johns Hopkins (published in 1982 as a landmark ABA study) developed this assessment methodology (aka functional analysis of behavior). He was able to glean controlling variables without reliance on reports from parents about the child’s behavior.
Thank you for your comment, Dr. Allen!
I’m posting this for Dr. Cipani…he’s having some technical problems posting currently although we hope that will be resolved soon. In any event, here is his response.
Dr. Cipani response:
Thank you for your comments, we agree on much.
On the test, I do not specify how it is conducted in the podcast, so it is ambiguous. In my field of ABA, we often do analogue assessments to allow for treatment control to determine the variables responsible. You are exactly right that having the parents conduct such might yield inaccurate data, and be more a function of their ineffective strategy. But if the mental health professional, maybe in a clinic where enough time might be available, you would possibly run the experimental and test condition, so that one is sure of the integrity of both conditions. I have something called the “get me game” for young children where such an analysis could be conducted by a behaviorally oriented therapist. In brief sessions, the experimental condition sets up a preferred event following completion of the game to criterion, in the control condition (baseline), no such contingency is put int effect.
How many physicians would share your views (and mine)? Are we trying to swim up stream? or is the tide turning? I believe history will eventually side with us, but I am not sure I’ll be around to witness it!