An Ego Disturbance Model of MBD

An Ego Disturbance Model of MBD

Rudolph Bauer, Ph.D.*

University of Maryland Hospital

Thomas Kenny, Ph.D. University of Maryland Hospital

Interest in the concept of "minimal brain dysfunction," orMBD, has led to major efforts to identify the characteristics of the syndrome. The use of the so-called medical model has resulted inan emphasis on diagnosis as a step in planning effective management. The neurologic emphasis of this model has been less than satisfactory probably because patterns of behavior and learning are determined by the complex interaction of numerous factors: genetic, neurolog- ical, psychosocial, and environmental [1]. A unitary approach, that is, neurological or psychosocial, may be practical only in the ex- treme cases where clear etiologies are demonstrable. Such examples would more realistically constitute neurologic dysfunction, or emo- tional disturbance as a diagnosis rather than the label "minimalbrain dysfunction," which clearly implies less obvious clinical find- ings. The inability to replicate or correlate these minimal clinical characteristics stresses the need for a broader approach to the un- derstanding of MBD.

It is the premise of this paper that the identification of MBDis essentially a phenomenological diagnosis based on observable im- pairments of ego functions rather than on assumptions concerning dynamic structure or other causative criteria [2]. The ultimate goal of an ego disturbance approach to psychopathology is to establish normative procedures for the diagnosis of ego strength and weak- ness and patterns of variation. Certain ego functions and patterns may be regularly or more crucially involved in the various diagnos- tic syndromes. The diagnostic issue from the ego frame of refer- ence is the degree to which a specific ego function is impaired in

*Dr. Bauer is in the Department of Pediatrics, School of Medicine, Univer- sity of Maryland Hospital, Redwood and Greene Streets, Baltimore, Maryland 21201.

2 3 8 ChildPsychiatryand HumanDevelopmentVol. 4(4), Summer 1974

Rudolph Bauer and Thomas Kenny 239

the context of impairment or lack of impairment of other ego functions. Such an approach allows one to clearly specify and understand the deficit in relation to other forms of ego disturbance without a presumption of etiology [3: pp. 3-63].

The purpose of this paper is to present the MBD syndrome from the ego disturbance frame of reference describing those ego functions that may be regularly or characteristically involved in the MBD syndrome. In this way, an attempt will be made to define. the syndrome in a clear and less diffuse manner, to distinguish, on the basis of both history and behavior, between the MBD child and other diagnostic entities [4].

For assessment purposes it is useful to divide the functions of the ego into the following five categories [2] :

1. Autonomous functions: those intellectual skills that are a function of language and perceptual motor organization and the corresponding skill that reflects language and perceptual motor or- ganization-learning [2].

2. Relation to reality: a perceptual process with two major components, the capacity to test reality and the capacity to main- tain an adequate sense of reality.

3. Thought processes: consist primarily of cognitive focusing, reasoning, and concept formation.

4. Object relation and defenses: the mode of handling impulses, social skills, and interpersonal relations.

5. Synthetic functions: the ability to synthesize experience and integrate functioning effectively.

Previous attempts to conceptualize MBD have resulted in systems that contained many features of these five ego functions. The lackof focus on the ego model resulted in an emphasis on one or two functions without clearly integrating all or differentiating the inter- relationships of MBD and other childhood disorders.

Table 1 presents a summary in terms of an ego disturbance model of the MBD syndrome by previous workers.

An analysis of the data in table 1 suggests several important areas of disturbance regularly associated with MBD. All of the auth- ors note disturbance in the three areas of "autonomous function," and all agree on a normal "relation to reality." In the area of though processes, all agree about the deficit in cognitive focusing and the normal area of reasoning. There is no clear consensus about the effect on concept formation. Object relations are usually affect- ed, but in a variable manner. Synthetic function has not been con- sidered in previous reports.

To facilitate a differential diagnosis based on an ego model,

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Child Psychiatry and Human Development

TABLE IA COMPARISON OF THE DISTURBANCE OF EGO FUNCTION IN THREE SYSTEMS

EGO FUNCTION

1. Autonomous Functiona. Deficiencies in Global Functioningb. Deficiencies in Specific Academic Area c. Impairment in Perceptual-Motor and/or

Language2. Relation to Reality

3. Thought Processes

1. Cognitive Focusing

2. Reasoning

3. Concept Formation

4. Object Relation and Defensesa. Passive Dependent Character Style

b. Impulsive Character Style S. Synthetic Function

WENDER CONNOR

WEINER

Code: + = Disturbance in ego function.- = No disturbance in ego function,+ = Ambiguous reference or questionable disturbance in function.

0 = No reference tothe function.

these areas of dysfunction should be contrasted with other typesof childhood behavior or organic disorders. Considering the possi- bility of a continuum of causality ranging from severe organic im- pairment to serious emotional disturbance, MBD may represent a variable point between these two poles. The point in the continuum can fluctuate depending on which of the ego functions is involved. Figure 1 represents a hypothesis based on the ego disturbance by function in relation to the extremes of organic or schizophrenic disorders.

Autonomous Function

Autonomous functioning impairment is the primary dysfunc- tion experienced by the MBD subject. Autonomous ego functioning impairment will be evidenced in three interrelated modalities: (a) deficiencies in those global intellectual functions that reflect learn- ing, such as general knowledge, word knowledge, memory, sequenc- ing skills, and imitative skills; (b) deficiencies in specific academic

+ + + + + +

+ + +

+ + +

+ + ~ + + +

0 0

Rudolph Bauer and Thomas Kenny 241

areas, such as reading, spelling, or arithmetic; and (c) specific im- pairment in perceptual motor organization and language processes. It is suggested that impairment in these three modalities is a neces- sary and sufficient condition for the phenomenological diagnosis of MBD.

An intellectual evaluation is necessary to rule out mental retar- dation which would indicate overall limited ego development. If a subject's overall intellectual functioning is low average (80 IQ), it is expected that his autonomous ego functioning should reflect the corresponding level of skill. It is the discrepancy between overall functioning and autonomous areas that suggests the MBD syndrome without other etiological implications.

The second criterion is a failure to learn despite adequate gen- eral intelligence. Therefore, if a subject has low average intelligence and above and is functioning academically well below chronological and grade expectations, then he is experiencing academic deficiency.

'1.

2

Autonomous Function

R e l a t i o n . t oR e a l i t y

Thought Processes (Cognitive Focusing)

(Reasoning)

(Concept Formation)

Ob)ect Relation

a. b. c.

a . b. c.

a b. c.

a. b c.

a, b. c.

a. b. c,

a.

b. c.

MBD

Organic Schizophrenic

M B D

Organic Schizophrenic

MBDO ganic Schizophrenic

M B D

Organic Schizophrenic

4

Organic

Schizophrenic

MBD

O r g a n i c Schizophrenic

MBD

Organic Schizophrenic

Besides indications of impairment in global intellectual func-

A COMPARISON OF THE LIMITS OF DEGREE OF IMPAIRMENT OF EGO FUNCTIONS IN MBD, ORGANIC IMPAIRMENT, AND SCHIZOPHRENIA

5. SyntheticFunction

Degree of Impairment

No Impairment

::::::::::::::::::::::

Mild Severe Impairment

..................

I

]

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L I ! ! ! ! i ! i i ! i ! i i i i i ! i i ! i i i i i i i i i ~ i i i ! i ~i i i i l i l i i i i i i ! ! : ~ : ~ : ~ : ~ : ~ : ~ : ~ : ~ : i : ~ : ! : ! : ! : i : i : i : i : i : i : i : i : i : ! : ! : ! : ! : i : i : i : i : i : i : i :

::::::::::::::::::::::::::::::::::

. . . .~ i : : : ::;:;i;~;!!~~:~:~:~:~:!:!:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:i:i:!:!:~:~:~:i:~:~

MBD :::::::::~:i:!:!:~:~:~] !

FIGURE 1: A comparison of the limits of degree of impairment of ego func- tions in MBD, organic impairment, and schizophrenia.

242 Child Psychiatry and Human Development

tioning, and impairment in academic skills, specific impairment in perceptual motor and/or language functioning ought to be manifest in order to clearly indicate autonomous functioning impairment. The pattern of such deficits is likely to vary from one child to an- other. When there is perceptual motor impairment, evidence of central pathology is not necessary for the manifestations of MBD syndrome nor should it be presumed. Hence a Bender scored ac- cording to the Koppitz system might indicate a developmental lag and is important in the phenomenological diagnosis even if individ- ual errors are not clearly associated with brain injury.

Relation to Reality

Reality testing consists of accurate perceptions of the environ- ment, and its impairment is identified by autistic perceptions, poor judgment, and inability to recognize conventional modes of re- sponse [2]. Reality sense is based upon a person's perception ofhis body, and its disturbance is reflected in indefinite ego boundar- ies and distorted body imagery [2]. A review of the syndrome sug- gests that subjects who experience autonomous functioning impair- ment (MBD) generally have intact reality testing and sense of reality

[4, 5]. To the degree that an MBD subject's percepts are not deter- mined by the realistic qualities of the stimuli that elicit them there is the possibility that the subject has moved toward schizophrenic or severe organic impairment.

Thought Processes

In terms of thought processes, the MBD subject is not expected to show reasoning impairment. If disturbed thinking is manifest, one should consider that the child may be experiencing a schizoid or possible schizophrenic adjustment.

The failure to establish and maintain focus indicates that a per- son is having difficulty selecting the most relevant aspects of a stimulus field and adjusting his attention to changes in the situation to which he is responding [2].

Clinical experience indicates that severe focusing disturbance such as unusual location choice, or figure ground blurring on un- structured tasks such as the Rorschach, is indicative of extensive organic and/or schizophrenic dysfunction. However, perseveration and figure ground deficiency on more structured tasks such as the Bender would suggest minimal cognitive deficiency and would re- flect the characteristic MBD dysfunction.

Rudolph Bauer and Thomas Kenny 243

Behavioral distractibility and hyperactivity are reflective of cog- nitive focusing difficulties. Support of this hypothesis is found in the positive focusing effects of stimulant medication [6]. The im- pulse difficulties associated with MBD subjects are not specifically a problem of controlling primitive aggressive and sexual impulses but of organizing and experiencing stimuli in a focused manner. The impulse problem that seems to be associated with MBD is a nonprimitive, non-id-imbued quality and is not a question of weak defenses. The specific impulse problem of the MBD subject is phe- nomenologically a problem of focusing and reflected behaviorally as distractibility and hyperactivity. It depends on a child's defen- sive style whether primitive asocial characteristics predominate.

Concept formation in the normally functioning person is marked by the capacity to interpret experience at appropriate levels of ab- straction [2]. At one time concrete thought was deemed to be characteristic of both brain-injured and MBD children. Work by Birch [7] and Gallagher [8] does not confirm this simple dichot- omy as characteristic but suggests great variability among these children in concept formation, In terms of phenomenological diag- nosis it is not necessary that there be a clear manifestation of con- crete concept formation.

Object Relations and Defenses

The psychologically healthy individual is able to establish and maintain satisfactory relationships with people, which in terms of ego functioning indicates satisfactory object relations [2]. Object relations in the MBD syndrome differ from schizophrenic ego dis- turbance in that basic object relations are present but dysfunction occurs in the more developed level of object relations, the secondary level. Indicators of problems of secondary object relationships are dependency, lack of flexibility, lack of reflectivity, and lack of ca- pacity to inhibit impulsive behavior [9]. A review of the literature

[4] suggests that MBD subjects show various and divergent typesof secondary object impairment. This includes the more passive dependent type of adjustment in which objects are experienced ina passive, overwhelming way, suggesting passive dependent character development, and/or the interpersonal style in which objects are experienced in an avoidance manner, suggesting impulse disturbance and possible delinquent character development.

The differentiation between these two modes of characterolog- ical adaptation and neurotic adaptation is a question of ego defense development. The neurotic is seen as utilizing a developmentally

244 Child Psychiatry and Human Development

higher level of defense in the sense of using either repression (hys- terical) or intellectualization (obsessive compulsive). The use of avoidance either into fantasy or into activity is considered to be more primitive and shows less delay and reflective ability. It should be noted that the difference between MBD character styles is often reflected in the defensive use of avoidance. The passive dependent ~voids by retreat into fantasy and the impulsive character by re- treat into activity.

Synthetic Function

The final ego function to be discussed is synthetic function.The normal person is able to organize and integrate his thought pro- cesses, relation to reality, interpersonal skills, defensive resources, and intellectual capacities in the service of a stable and rewarding life pattern [2]. Such integrating and organizing activity constitutes the synthetic function of the ego. Schizophrenia involves severe im- pairment of synthetic functioning while the MBD syndrome does not reflect such severe ego impairment. If an MBD subject does ex- perience such disorganization, then he has phenomenologically pro- gressed beyond MBD toward schizophrenia.

Summary

In this paper the MBD syndrome has been interpreted in terms of impairment of ego function. This focus allows for differentiation of MBD from other childhood disorders, and facilitates an under- standing in terms of a continuum of severity of impairment in spe- cific ego functions that reflect specific childhood disorders.

Differential diagnosis is facilitated by comparison of those im- pairments of ego function that are associated with MBD and those that are associated with schizophrenia and with organic impairment.

The MBD child is characterized by mild disturbance in the areas of autonomous function, cognitive focusing, and concept formation. The child's reasoning skills, reality testing, and synthetic function are normal. A variation in this pattern of findings could suggestthat the child's problem was either more organic or schizophrenic, or a combination of one of these factors in addition to MBD.

It is the degree of impairment in each function that raises the possibility of the type of disorder the child experiences. In this approach, the disorder is understood by the particular pattern of ego strength and impairment. An appropriate therapeutic regimen

Rudolph Bauer and Thomas Kenny 245

might concentrate on areas of deficiency and be more effective than current approaches.

References

1. Kenny T, Clemmens R: Medical and psychological correlates in children with learning disabilities. J Pediat 78:237-77, 1972.

2. Weiner I: Psychodiagnosis in Schizophrenia. New York, John Wiley & Sons, 1966.

3. Bellak L: The schizophrenic syndrome: A further elaboration of the unified theory of schizophrenia. In L Bellak (Ed), Schizophrenia: A Review of the Syndrome. New York, Logos, 1958.

4. Wender P: Minimal Brain Dysfunction in Children. New York, John Wiley & Sons, 1972.

5. Conners K: The syndrome of minimal brain dysfunction: Psychological aspects. Pediat Clin North Amer 14:749-62, 1967.

6. Freedman D (Chmn): Report of the conference on the use of stimulant drugs in the treatment of behaviorally disturbed young school children.

   Newsletter Soc Pediat Psychol 1(1):6-10, 1972.

7. Birch NG (Ed): Brain Damage in Children. Baltimore, Williams & Wilkins,

1964.8. Gallagher JU: The Tutoring of Brain Injured Mentally Retarded Children.

Springfield, Ill, Charles C Thomas, 1960.9. Kaplan M: The Structural Approach in Psychological Testing. New York,

Pergamon Press, 1970.