Guidance by Understanding
Dr. Gerard J. Nijhof
• Orthopedagogue / clinical psychologist
• Master and PhD, Free University Amsterdam
• Current occupation at Amsta, Amsterdam,
department for people with intellectual disabilities
• [email protected]
Multiple complex Developmental Disorder
 Case: Pierre
 McDD: symptoms
 McDD and Autism: differences and
 McDD and Schizophrenia
 Treatment
Case: Pierre
Pierre - 1
Pierre is a boy of 18 years old.
Very anxious, he wants to stay at home.
Sometimes he is flooded with fear and panic.
Often he is in a good mood, but this can rapidly
change into a state of high irritation.
• He fears people who (in his fantasy) ‘have a gun.
behind their back’, he avoids other people.
Pierre - 2
• He doesn’t have friends – ‘friends do not
understand what is really happening’.
• He doesn’t understand the nature of social
interactions very well.
• For him his ‘men with guns’ fantasy is a reality.
• He thinks he is the only person who can save
his family.
Pierre - 3
• Pierre has to learn how to handle
- his mood swings
- his anxiety
- his fantasies
• When he can master his mood swings, anxiety
and fantasies, his outlook is much better.
• McDD: no separate DSM-IV entry;
• McDD is classified as PDD-NOS most of the
McDD: developmental disorder.
Symptoms - three different groups:
1. Regulation of affective state
2. Social behaviour and sensitivity
3. Cognitive processing
Regulation of affective state
Regulation of affective state - 1
• Intense generalised anxiety, diffuse tension, or
• Unusual fears an phobias that are peculiar in
content or intensity.
• Recurrent panic episodes, extremely frightened,
or flooded with anxiety.
Regulation of affective state - 2
• Episodes of behavioural disorganisation or
regression - with immature and primitive
behaviour (sometimes self injurious), lasting
from minutes to days.
• High amount of mood swings, often out of line
with a certain cause.
• High frequency of idiosyncratic anxiety.
reactions. This means anxiety reactions which
are strange, bizarre and very individual.
Social behaviour and sensitivity
Social behaviour - 1
Impairments in sensitivity to social signals
Impairments in social reciprocity.
Social disinterest.
Detachment, no emotional involvement.
Avoidance or withdrawal of social engagement,
particularly with adults.
Social behaviour - 2
• Attachments may seem friendly and cooperative,
but are very superficial, aimed primarily on
receiving material needs.
• Inability to initiate or maintain peer relations,
leading to isolation.
• Disturbed attachments displaying high degrees of
ambivalence, particularly to adults (parents /
caregivers). This is manifested by clinging, overly
controlling and wanting behaviour.
Social behaviour - 3
• ‘Shifting’ or aggressive behaviour. Oppositional
behaviour towards parents, teachers and
• Profound limitations in empathy.
• Profound limitations to ‘read’ or understand
others thoughts and feelings.
Cognitive processing (thinking
Cognitive processing, thinking disorders - 1
• Thought problems out of proportion with
mental age.
• Irrationality, sudden intrusions on normal
thought processes.
• Magical thinking.
• Neologisms (new words) or nonsense words,
often repeated over and over again.
• Bizarre ideas, intentional or non intentional,
without worrying what others think of it.
Cognitive processing, thinking disorders - 2
• Very typical: confusion between reality and
• Perplexity, easily being confused. Trouble with
understanding social processes and keeping one’s
thoughts straight.
• Delusions (something a person believes to be true
because they want it to be true, when it is
actually not true).
Cognitive processing, thinking disorders - 3
• Fantasies of omnipotence. Thinking they can do
the impossible.
• Paranoid preoccupations (i.e. ‘everybody is
looking at me’).
• Over engagement with fantasy figures.
• Grandiose fantasies (i.e. having special powers).
McDD and Autism
Differences and similarities
McDD and Autism - 1
• McDD: characterized by anxiety and reactions to
anxiety (= affective part of the disorder).
• Autism: shows a perseverative way of thinking
and acting.
• McDD: rapid mood swings and extreme reactions
(sudden temper tantrums).
• Autism: this is less recognizable.
McDD and Autism - 2
Both Autism and McDD are characterized by many
problems in the social realm, especially when
more people are involved.
McDD: it can be confusing that people with McDD
sometimes function quite well in individual
interaction with a doctor or a psychologist.
Autism: we do not find this in the same way with
McDD and Autism - 3
Both in McDD and Autism there are problems with
inadequate social behaviour.
McDD: People with McDD can show adequate and
inadequate social behaviour. This depends on the
intensity of the flooding of thoughts and emotions.
Autism: People with autism are continuously
embarrassed in the social domain which can cause
anxiety that leads to aggression.
McDD and Autism - 4
McDD: For people with McDD social behaviour is
restricted by interferences of
- thought disorders
- intensity of emotions
- lack of regulation of emotions
Autism: People with Autism can be characterized by
having ‘theory of mind’ problems. It is one of the
reasons for their restricted social functioning.
Theory of mind
• The ability to take into account own and others
mental state in understanding and predicting
• Attributing ideas and feelings to another person
and (re)acting accordingly: giving direction.
• By accessing the mental processes of other
persons we can predict and understand their
McDD and Autism - 5
• McDD: In general language development is normal
with McDD. However communication is poor and
without reciprocity.
• Autism: There is more variability.
• McDD: In children with McDD fantasy can be
excessive and sometimes bizarre and frightening.
• Autism: Children with autism have difficulties with
their fantasies. Their play is poor and stereotyped.
McDD and Autism - 6
Both have problems in the behavioural repertoire.
• McDD: Behaviours of people with McDD are highly
variable and of short duration. The thinking
disorders are impressive: highly associative,
illogical, not allowing for reality.
• Autism: People with autism are restricted in their
behavioural repertoire. It is marked by obsessions,
stereotyped behaviours and restricted interests.
McDD and Schizophrenia
McDD and Schizophrenia - 1
• Unlike autistic children some children with
McDD develop Schizophrenia in adult life.
• Sometimes it is very difficult to distinguish
psychotic behaviour from fantasies of
omnipotence and other fantasies.
• The main difference: with McDD the irrational
ideas are correctable (this may be difficult).
McDD and Schizophrenia - 2
• With McDD I sometimes observe episodes
which I call: ‘mini psychotic moments’.
• It is important to acknowledge the difference
between symptoms of Autism, McDD and
• Persons with McDD do need a same climate of
guidance as persons with autism do.
• There are special items in the treatment and
guidance of persons with MCDD.
• Special items: Help ego, Master of mood,
Master of anxiety , Master of fantasies
Treatment – 1: the Help Ego
• Other persons can become a ‘help ego’ in an
ongoing process of clarifying ambiguous situations,
they can also be of help in regulating emotions.
• This system is very vulnerable, because without a
help ego offering explanation and correction life is
too complicated.
• A ‘help ego’ is a central element in the treatment.
Treatment – 2: Master of Mood
• People with McDD need help learning to
regulate their emotions and mood swings.
• They can be trained to perform a ritual when
the emotions are too strong:
- Rotating one’s body in some way
- Thinking of their birthday
- Softly saying: ‘I am the master of my
Treatment – 3: Master of Anxiety
• Psychotherapy: therapists can help to remove
the anxiety.
• Therapist can try to ‘level out’ anxiety…
‘Sometimes all people are anxious. You are
anxious, I am anxious. But we know that it is not
necessary. You are the master of your anxiety.’
Treatment- 4: Master of Fantasies
• Therapists (parents) can help to correct the
ideas (fantasies). Confrontation with reality in a
friendly way can help, i.e.: ‘Look, there really is
no man with a gun.’
• Therapist can help to correct the grandiose
fantasies. Confrontation with reality may be
useful. Sometimes it is necessary to
communicate that: ‘nobody is almighty, we are
all normal people’.
Thank you for your kind attention
This lecture is based on my own experience and on the
research and practical work of many colleagues. We are
beginning to gain insight in the complex world of McDD, but
a lot still needs to be clarified.