Case study: ADD, autism, behaviour therapy and Starflower oil (borage) as an alternative to Ritalin

 Jane Ellwood Dip(HE) RNLD MISPA 

Mark is an 8 year old boy with Attention Deficit Disorder (ADD), autistic tendencies and mild learning disabilities. This case study shows how understanding of his condition and positive reinforcement along with a dietary supplement was used to significantly reduce incidents of difficult and often aggressive behaviour. 

Behaviour is not seen in isolation but as part of a chain of events: a trigger (antecedent); a response to the trigger (the behaviour); and the outcome (consequence) that acts to encourage or reinforce the behaviour (Prior et al. 1985, p104, Presland 1989, p3). By manipulating the chain of events before and after, behaviour can be modified and replaced with more appropriate behaviour (Barkley 1982, p234). In ADD, ADHD and autism, often the most important antecedent is 'invisible', in that it is due to a chemical or neural imbalance in the brain as opposed to an observable event.  This makes Marks particular problems very difficult to deal with as without knowing him well, his behaviour could be attributed to naughtiness, laziness, and poor parenting.  Marks difficult behaviours included biting, spitting, kicking, head butting and non-compliance on a daily basis, far above what would be expected from a naught but 'normal' child.

The main features of ADD are: 

Inattention which interferes with learning (Prior et al. 1985, p65, Hinshaw 1994, p47); behavioural and cognitive difficulties; and low frustration and tolerance levels that can lead to aggressive and oppositional behaviour (Prior et al. 1985, p25). Often with ADD, 'normal' parenting is ineffective (Hinshaw 1994, p18) and as a result, there can be a high level of coercive interaction within the family which can lead to secondary problems such as aggression, oppositional defiance, or even obsessive compulsive disorders and self harm (Batshaw et al. 1995, p389, Rutter et al. 1994, p872).  

ADD and other mild learning disabilities can also cause significant conflict between the affected child, between parents or carers as they struggle to decide how best to deal with difficult situations, and also with the child's school - particularly if his academic work is not giving cause for concern and bad behaviour is attributed to naughtiness.

ADD requires greater management consistency than one would expect from a 'normal' child (McAuley 1977, p197), so I would not have attempted this plan without being positive of total commitment from the parents to ensure a consistent approach. I was also the Special Educational Needs Governor at Mark's School and was able to gently inform the school of the real issues to ensure the same responses to his behaviour at school to help with consistency. 

Children with ADD and autistic tendencies minimal distraction, with routine and structure to help anticipate everyday activities and lower anxiety (Green et al. 1995, p71). I suggested making Mark's home and school environment more structured to help him gain maximum benefit from the intervention programme. While adverse to conventional medication to help control Marks behaviour, his parents were keen to explore the possibility of an alternative (complementary) medication. After some research, I decided to recommend Star flower oil (borage) supplements as it is a natural stimulant (not dissimilar to Ritalin) also high in essential fatty acids which have been reported as being effective in treating ADD-type disorders. Borage has also been reported as having seratonin-like properties in the leaf, and also antihyperactivity properties from the chemical niacin found also in the leaf (Pizzorno et al. 1985, Werback 1993). The agreed dose was 1500 mg in capsule form daily for the first 2 weeks, followed by an assessment with the aim of reducing the dose to a maintenance dose of between 500-1000 mg daily. 

After advice from Mark's Consultant, and agreement with the parents to use a borage supplement, the following target behaviours and responses were defined: 

I planned a reinforcement strategy with the full support of Mark's parents. It included a combination of positive and negative responses to the various target behaviours including selective ignoring, and a removal and time out particularly aggressive or injurious behaviour. (see Appendix 1). Marks parents were shown how to use a buddy system of support where one parent would take over from the other during times of extreme confrontation to help diffuse the confrontation and anxiety being suffered by both parent and child.

The parents were willing to undertake recording of behaviour in a diary for the baseline (before intervention) and during the intervention period to help determine the success or non-success of the intervention.  Recording would take place every 4 days and the results plotted on a graph. The behaviours to be observed were defined clearly in order to eliminate ambiguity. We decided to record the frequency of target behaviours, but not the duration, because this would be too complicated and distract from the planned intervention strategies. 

I explained to Mark's parents how behaviour modification and positive reinforcement works. Mark was included by helping to choose his favourite treats for rewards, such as fish and chips, comics, and swimming for each day he refrained from verbal or physical aggression. He was also given clear boundaries of what was and was not acceptable behaviour. Mark's interest in the reward system was maintained by an imaginative and varied use of rewards that included tokens that he could save up for larger treats.  Inappropriate behaviour was to be dealt with immediately to help Mark realise the outcome of such behaviour and to help reinforce the 'consequence' part of the behavioural plan.

One of the most difficult aspects of the programme for myself and the parents was to ignore bad behaviour, particularly during the reactive burst at the beginning of the programme which is normal in such a programme. Even though selective ignoring of inappropriate behaviour is recommended in all the literature, it was very difficult to ignore the normal parental instinct to chastise bad behaviour. At this point we all had to have faith in the literature and hope for a positive outcome. An important point was agreed, which I believe considerably contributed to the success of the regime, was that despite poor behaviour at times, the day always ended on a positive note, with reflection and praise for things that had gone well. This was critical in developing Mark's self esteem after such a long period of negative chastisement. 

The results  

I used a stacked bar chart to represent the collected data (see Appendix 2: chart) and over several weeks, the target behaviours showed a significant reduction. 

Conclusion  

Marks parents provided both a quantitative evaluation through their diary-keeping, and a qualitative evaluation of the programme by observing that he had become much more manageable and easier to live with. They also felt more positive about handling his difficult behaviour because they had a set of rules to adhere to, which took a lot of potential conflict away from having to decide how best to deal with his behaviour during times of intense confrontation. The reward system had helped to promote new hobbies and Mark seemed a much happier boy in a less stressful home and school environment. While the incidents of aggression had been significantly reduced, it was not possible to say whether this had been due to the behavioural approach, or medication, or a combination of both. However, by using a behavioural approach alongside the medication, a holistic approach to care was achieved with good results. 

Appendix 1 

Definitions of target behaviours and responses 

1. Disruptive - Interfering with another person so that they are prevented from doing something, or causes displeasure (Jehu et al. 1972, p10). 

     Consequences: (a) Distract or occupy other person so disruption does not continue (removing antecedent) (b) If (a) not practical: Ask to stop Repeat request once Remove privilege (e.g.. TV programme, toy etc.), (negative reinforcement) or Send to room (punishment) 

2. Tantrum - Throwing themselves on the floor, crying, agitation (Herbert 1987, p163) 

     Consequences: Ignore (Prior et al. 1885, p109) 

3. Defiance - Not obeying a request on first repeat (Herbert 1987, p163) 

     Consequences: No negative actions or negative verbal responses (ie ignore behaviour without fuss) (a) Made to do request (b) Minimum fuss, minimum force (c) Praise when done 

4. Verbal attack - Screams, shouts, talks loudly enough to be unpleasant, or abusive speech (Jehu et al. 1972, p1) 

     Consequences: Ignore by walking away (Serfontein 1994, p120) Positive attention about something else when calm (so as not to reward previous bad behaviour) 

5. Physical attack - Actual or attempted assault or intentional damage to property (Jehu et al. 1972, p1)

     Consequences: 

To person (a) Remove self from situation. (b) Positive attention about something else when calm, or (a) Other partner takes over. (b) Take by hand and take to a chair or other room (c) Positive attention about something else when calm 

To property (a) Remove from situation (b) Supervise until calm (c) Positive attention about something else when calm 

Agreed boundaries 

Appendix 2: Behaviour chart

References

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