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Current Affairs Psychology in Pakistan

Tax Kum Karo: Analyzing the Relationship Between Income, Taxes and Mental Health in Pakistan

Written by Abdullah Qureshi

“If money is the bond binding me to human life, binding society to me, connecting me with nature and man, is not money the bond of all bonds? Can it not dissolve and bind all ties? Is it not, therefore, also the universal agent of separation?”

Karl Marx

Pakistan has entered its 5th unofficial year of economic turmoil. While the steep decline seems to have become lesser so, the decline still continues.

An Introduction to Pakistan’s Economic Woes

The National Accounts Committee (NAC) said that the average income per person went up a little from $1,551 in fiscal year 2023 to $1,680 in 2024. For reference, it was $1,766 in 2022 and $1,677 in fiscal year 2021.

On top of that, the Pakistani government is planning to raise direct taxes by 48% and secondary taxes by 35%.

This indicates an overall level of decline in the per capita income and a stark increase in taxes. To top it off, this decline is also in the midst of economic and political turmoil.

As a response to the proposed budget, many salaried people have resorted to protests. Banners are held high of #taxkumkaro (lower the taxes). These protests are still not as rage-filled as the table talk in Pakistani households.

What brews at the domestic and psychological level is far more debilitating than one can imagine.

These are the bare figures of the problem.

In this essay, I will attempt to assess how income and taxes impact mental health. I will also discuss what this means in the context of Pakistan.

Income and Mental Health

‘Tax Kum Karo’ is not just about taxes.

It is also about the shockingly low income of the salaried class that has to now pay additional taxes.

Low-income populations usually live under stressful situations. These chronic stressors ratchet up the risk of worsening mental health problems. Economic turmoil has long been linked to dissatisfaction with life. Poverty is associated with greater risk of common mental disorders (Adler et al., 2016).

According to the World Bank, 40% of Pakistanis are already living below the poverty line, with another 10 million hovering just above it.

This is a colossal figure. I argue here that it is far more pernicious than just a matter of sustenance.

It is a matter of psychological and philosophical devastation of an entire nation.

First, let us do a bit of groundwork and understand how the economy interacts with psychology.

How does Income Affect Mental Health?

Shields-Zeeman (2021) conducted a study on the linkage between income and mental health. They found that income is associated with reduced psychological distress and improved health.

So, combing this research with the fact that poverty exacerbates psychological issues, this presents us with an ugly cocktail.

How does Mental Health Affect Income?

A decline in mental health has a significant cost in the productivity of a country.

A decline in physical health also has a substantial cost on the economy.

In fact, Poverty is thought to lower people’s ‘cognitive bandwidth,’ which can change how they make decisions and lead to dangerous health behaviors (Schilbach et al., 2016). Knapp and Wong (2020) wrote an entire essay detailing where economics and mental health meet. They cited productivity costs and the cost of illness (COI) as coming through both direct and indirect means.

Moreover, Marcotte & Wilcox-Gök (2001) conclude that 5–6 million workers in the US between the ages of 16 and 54 lose their jobs, don’t look for work, or can’t find work every year because of mental illness. Researchers think that people with mental illness make between $3,500 and $6,000 less a year compared to those who don’t have mental illness.

However, this relationship is even more complex when both directions are considered.

The Complexity

A review by Shields-Zeeman and Smit (2022) found that increases in income were associated with a small improvement in mental health. However, a drop in income had a larger negative influence on psychological well-being.

These findings suggest that the effect of income loss is more detrimental to mental health than an increase in income is for improving mental health.

This has important implications for those living just above or below the poverty line.

Why?

Because a very short drop in income can present these people a substantial risk to income security and mental health.

In Pakistan’s context, these findings have serious implications. This is because a significant amount of people were pushed to a lower socioeconomic class in the last 5 years (Ali, 2022). In fact, many of these crises featured political turmoil and polarization.

Link to Suicide

Another crucial bit of information is that domestic and financial problems are the two most significant reasons for suicide (Naveed et al., 2023). This, in some ways, solidifies a link between financial problems and severe psychological issues.

In fact, it is even more illuminating as the political polarization effects family leadership (Rashid & Rashid, 2024). This in turn could cause many domestic issues. Thus, the economic crisis and the political polarization have both a direct and indirect effect on mental health in Pakistan.

Taxation and Mental Health

Rawls’ (1971/1999) theory of justice says that countries with more progressive taxation had higher ratings of well-being. Meanwhile, countries with less progressive taxation had more negative daily experiences.

This was corroborated by a study conducted by Oishi et al. (2012).

However, in Pakistan, the current taxation is not progressive. This is because, according to the proposed budget, the people who fall inside the ‘middle class’ are also slapped with very similar tax bracket of the more affluent class.

Moreover, many of the taxes actually target the classes which are underprivileged.

The Pakistani Finance Bill was recently changed to raise taxes on business dairy farms and fuel. Builders and investors’ earnings are also taxed at a rate of 10% to 12%. Besides that, there is now a 10% sales tax on office supplies such as notebooks, pencils, pens, ink, staplers, and more.

MNAs’ trip allowances, on the other hand, has gone up from Rs10/km to Rs25/km.

There are also some seemingly ‘soft’ attempts to recover money from those who d o not pay their taxes.

These policies can be seen as pernicious for the people who they do not benefit.

The problem is that the people who do not benefit from this are also the people who no longer possess financial stability.

Another very important finding indicated by Oishi et al. (2012) was that in low income countries, even progressive taxation does not improve well-being.

Trust

It is no secret, however, that these tax demands are not the government’s own policy.

Most of the tax demands arise from the International Monetary Fund’s camp.

The IMF’s key demands include an increase in the tax revenue target, withdrawal of subsidies, taxes on the agriculture sector, increase in levy and taxes on power, gas and oil sectors, privatisation of sick government organisations and units and improving administration, a ministry official was quoted as saying.

The problem here is that this reduces the utility of government action. Once the utility is lowered, so is the level of trust in the population.

Nations are built on philosophical principles. A nation-state that cannot protect its citizens fails to justify its utility.

This can have an even more grievous impact on the national perception of the government. Rothstein and Uslaner (2005) argue that the social trust of a government is in itself a different dimension.

If social trust is lower, many people in the population reject even the better policies. Thus, if the current party in power has any interest in continuing its service in this fragile democracy, their way of handling the economic crisis is failing.

Conclusion

It appears as if the government of Pakistan has yet to understand basic principles of building trust. This trust is not built by documentation on social media about the work trips of chief ministers. Rather, trust is built based on policies which positively affect the people. One could argue that higher taxation is the way to go.

However, when allowances of government officials are increased at the same time, one can question:

Who is the state protecting?

So far, the tentative budget favors the people who are privileged. It allows room for tax evaders. But unfortunately, it strangles those who are already living below reasonable means.

 But the protests of ‘tax kum karo’ rage on. One can only hope that at some point, the middle class could find a way into the power corridors of Pakistan. Perhaps, the people who are suffering the most deserve a chance at ruling.

References

  • Adler, N. E., Glymour, M. M., & Fielding, J. (2016). Addressing social determinants of health and health inequalities. Jama, 316(16), 1641-1642.
  • Knapp, M., & Wong, G. (2020). Economics and mental health: the current scenario. World Psychiatry, 19(1), 3-14.
  • Marcotte, D. E., & Wilcox-Gök, V. (2001). Estimating the employment and earnings costs of mental illness: recent developments in the United States. Social Science & Medicine, 53(1), 21-27.
  • Naveed, S., Tahir, S. M., Imran, N., Rafiq, B., Ayub, M., Haider, I. I., & Khan, M. M. (2023). Sociodemographic characteristics and patterns of suicide in Pakistan: an analysis of current trends. Community mental health journal, 59(6), 1064-1070
  • Oishi, Shigehiro & Schimmack, Ulrich & Diener, Ed. (2011). Progressive Taxation and the Subjective Well-Being of Nations. Psychological science. 23. 86-92. 10.1177/0956797611420882.
  • Rashid, Z., & Rashid, S. (2024). Political Instability Causes & Affects. Pakistan Journal of Humanities and Social Sciences, 12(1), 294-303.
  • Rawls, J. (1999). A theory of justice (Rev. ed.). Cambridge, MA: Harvard University Press. (Original work published 1971)
  • Rothstein, B., & Uslaner, E. M. (2005). All for All: Equality, Corruption, and Social Trust. World Politics, 58(1), 41–72. doi:10.1353/wp.2006.0022
  • Schilbach, F., Schofield, H., & Mullainathan, S. (2016). The psychological lives of the poor. American Economic Review, 106(5), 435-440.
  • Shields-Zeeman, L., Collin, D. F., Batra, A., & Hamad, R. (2021). How does income affect mental health and health behaviours? A quasi-experimental study of the earned income tax credit. Journal of epidemiology and community health, 75(10), 929–935. https://doi.org/10.1136/jech-2020-214841
  • Shields-Zeeman, L., & Smit, F. (2022). The impact of income on mental health. The Lancet Public Health, 7(6), e486-e487.
Categories
Psychology in Pakistan

History of Psychology in Pakistan

Written by Najwa Bashir

The formal history of psychology in Pakistan dates back to the 1960’s. In Pakistan, psychology was recognized as a distinct academic discipline over 59 years ago (Zadeh, 2017). According to Michal J. Stevens, Wedding Danny, Dr. Nosheen Khan Rehman, and Taylor and Francis (2004), Pakistan had two universities in 1947. The psychology department was first set up in 1887 at the University of Punjab in Lahore (West Pakistan) and again in 1921 at Dhaka (East Pakistan; now Bangladesh). The University of Karachi, Sindh was founded in 1946, and the psychology school has been running since 1951.

Further psychology departments were set up in Peshawar in 1950 and in Rajshahi (East Pakistan) in 1953. Pakistan’s oldest psychology labs can be found at University of the Punjab, Government College University Lahore, and Dhaka University, which is now in Bangladesh but used to be in East Pakistan. In the 1960s, only the academic and theory parts of psychology were up and running. Experimentation was not a big focus.

In 1964, there were only 250 teachers working, no national psychological association, and no study magazine. However, later on, a psychological laboratory was set up at Punjab University in Lahore to study applied psychology. Universities were also encouraged to do experiments and research in psychology, and more journals for psychological research were published by Michal J. Stevens, Wedding Danny, Dr. Nosheen Khan Rehman, and Taylor and Francis (2004) (Firdous, 2010).

Up until 1960, one of the places where psychology was taught as part of the philosophy curriculum was the Government College in Lahore (Rafiq et al., 2022). GC Lahore used to teach psychology as part of the philosophy curriculum up until the 1960s. Psychology became its department at GC Lahore in 1962, thanks to the strong direction of Dr. Muhammad Ajmal. He became the department’s founder and head (Zadeh, 2017).

Forman Christian College, Lahore, was the second school that taught psychology. At Karachi University, the first separate school of psychology was set up. It was led by Qazi Muhammad Aslam, whose main area of study was philosophy. While Sindh University became its own thing in 1960. Syed Muhammad Hafeez Zaidi was seen in Frontiers of Psychological Research in Pakistan in 1975.

The main goal was for philosophy teachers to become involved in the field of psychology. Due to this, traditional indigenous people started studying psychology, which was mostly based on theory. There were early works in Pakistani psychology written by Hafeez Zaidi and a few others.

After 1960, many psychology schools sprung up. But at first, these departments couldn’t get many students, usually only three to seven. The reason was an opening in the job market. Before 1991, there were more than 10 universities in Pakistan that mostly offered M.A. and M.Sc. degrees in Psychology. Today, in 2018, about 12 universities have started to offer BS (Hons), MS, and Ph.D. studies in clinical psychology.

From the start until now, psychologists have needed a governing group, but the idea hasn’t fully grown yet. The University of Punjab and the University of Karachi both set up the Center for Clinical Psychology because President Zia Ul Haq was very interested in the field (Rafiq et al., 2022).

From 1960 to the present day, the field of psychology in Pakistan has been progressing slowly, but steadily. The growth can be seen in the fact that full-fledged psychology schools have been set up at the universities in Karachi, Sind, and Peshawar. Several associated schools began offering M.A. programs in psychology, and it became a separate subject to study at the Inter, B.A., and BSc levels. In 2007, HEC started a four-year BS Psychology program, which changed the way psychologists are trained at the college level in a big way.

In 1983, two schools of clinical psychology opened in Karachi and Lahore, two of Pakistan’s biggest metropolises. This was a big step forward for clinical psychology. At first, both schools gave people with a Master’s degree a one-year diploma in clinical psychology. After a while, both schools added graduate programs in clinical psychology. Dr. FarrukhZahor Ahmad started the Institute of Clinical Psychology in Karachi. He is a clinical psychologist who first learned his craft at the University of Stanford in Pakistan(Zadeh, 2017).

When the National Institute of Psychology, Islamabad opened in 1976, it added another important milestone to the history of psychology (Zaman, 1991). In 2000, Bahria University in Karachi opened the Institute of Professional Psychology. Several universities in Pakistan offer bachelor, graduate, and postgraduate programs in psychology and clinical psychology. These include the International Islamic University in Islamabad, NUST in Islamabad, and Beacon House in Lahore. The Pakistan Psychological Association (PPA) was founded in 1968, and the Pakistan Association of Clinical Psychologist (PACP) was founded in 1988. Both of these events were major turning points in the field. These are two national groups for psychologists, with the third one being just for professional psychologists(Zadeh, 2017).

Psychological journals can also be used to see how psychology has changed over time. The first psychology magazine came out in 1965, and there were five more until 1991 (Zaman, 1991). The Government College, Lahore’s Journal of Psychology, now called the Psychology Quarterly, has been out since 1962. In 1978, an Urdu journal called “Zehan” started coming out. From 1992 to 1995, the Institute of Clinical Psychology at the University of Karachi put out the Pakistan Journal of Clinical Psychology every other year. Journal printing stopped from 1995 to 2005, but it started up again in 2006 and has been going strong ever since (Zadeh, 2017).

The eleven years from 1995 to 2006 marks the time when the field of psychology grew incredibly in Pakistan and a huge number of people got PhDs in psychology. During this time, a culture of research grew, and as a result of rules set by the Higher Education Commission (HEC), research papers were required for academic job openings and raises (HEC, 2019). These requirements led to a rush of research papers being published in Pakistan, and many new research magazines were also set up. Back then, from 1995 to 2006, the internet wasn’t very common, and even where it was, there weren’t many places where you could get free papers. Many researchers in Pakistan relied on the research magazines that were available in their university libraries. Due to this, these studies were mentioned hundreds of times and were the easiest to find examples of published studies. Also, most of the people who wrote these studies were professors working at both public and private colleges. These professors also oversee MPhil and PhD studies, and most of the research done at that time was for MPhil or PhD theses (Kamrani et al., 2022).

References

  • Firdous, N. (2010). Historical Perspective of Psychology in Balochistan: Depiction, Dynamics and Development. Bi-Annual Research Journal “Balochistan Review”,23(2), 93-111. Available at: http://www.uob.edu.pk/Journals/Balochistan-Review/data/BR%2002%202010/93-111%20HISTORICAL%20PERSPECTIVE%20OF%20PSYCHOLOGY%20IN%20BALOCHISTAN%20DEPICTION,%20DYNAMICS%20AND%20DEVELOPMENT,%20Neelam%20Firdous.pdf
  • Higher Education Commission (2019). Quality Assurance. https://hec.gov.pk/english/services/universities/QA/Pages/faculty-appointment-criteria.aspx
  • Kamrani, F., Kamrani, N., &Kamrani, F. (2022). Eleven Years of Psychological Researches in Pakistan (1995-2006): What Titles Reveal About Pakistani Research. Journal of Professional & Applied Psychology, 3(2), 319-326. https://doi.org/10.52053/jpap.v3i2.117
  • Rafiq, M., Zareen, G., Khalid, A., Chahal, F. M., Maqbool, T., &Hadi, F. (2022). Clinical and neuropsychology in pakistan: challenges and wayforward. Pak-Euro Journal of Medical and Life Sciences, 5(1), 119-128. Available at:https://readersinsight.net/PJMLS/article/view/2442
  • Zadeh, Z. F. (2017). Clinical Psychology in Pakistan: Past, Present and Future. International Journal of Humanities and Social Science, 7(11), 26-28. Available at: https://www.ijhssnet.com/journals/Vol_7_No_11_November_2017/4.pdf Zaman,R.M. (1991). Clinical Psychology in Pakistan. Psychology and Developing Societies. Sage Publication. Available at: http://www.sagepublication.com?content/3/2/221.
Categories
Commentary

Analysis: “95 percent of Women in Pakistan are ignorant”

Written by Abdullah Qureshi

In the last days of June, 2024, an episode of Mukalma with Khalil-ur-Rehman Qamar aired on Samaa TV. This show caused ripples of conversation all over the Pakistani internet. Mukalma with Khalil-ur-Rehman is a show which features discussions on various topics. These conversations are usually between the titular writer, Khalil-ur-Rehman, and one or more guests. In this particular episode, the guest was Sahil Adeem.

Sahil Adeem is known as a religious scholar and a psychologist. Over the years, he has publicly appeared in multiple forums. His debate tactics are quite provocative. They often employ derogatory commentary on branches of religious scholarship. However, much of his commentary seems to resonate with many people. I would not deny that he has bits and pieces of information about many different subjects – even if they are misleading.

Sahil Adeem is also a very creative person. He tries to connect scientific discoveries with the Ayat in the Quran. This is not the first time that public figures in Pakistan have tried to do so. Adeem’s own research appears to be limited to anecdotal evidence and pop science.

So, to say that Adeem’s grip, even over pop science or pop psychology, is substantial could be incorrect.

The episode of Mukalma with Khalil-ur-Rehman in question is an example of this.

In this article, I would go over three pieces of evidence highlighting cognitive biases.

Evidence 1: The Validity of the Claim ‘95 Percent of (Muslim) Women in Pakistan are ignorant’

In the most highlighted part of the episode, Sahil Adeem claims that 95% of women in Pakistan are ignorant about Taghut. Taghut in Islam is the concept of focusing on some other being as opposed to Allah (Ahmad, 2009). All in all, Ahmad (2009), drawing on Maududi’s teachings, explains that this concept encompasses the entirety of the state. If any person in the state holds anything ‘above’ Allah in his priorities, he is falling under the ambit of Taghut.

Sahil Adeem claims that most Pakistanis (around 40% of men and 95% of women) do not understand this concept. However, one thing that Adeem fails to mention is that he has no evidence to back this claim.

He has cited no polls. He has cited no studies.

Hence, this claim is a perspective. Perhaps a better way of stating this claim is that it is his hypothesis.

However, even the hypothesis is poorly constructed.

The Issue with Invalid Claims

The entire episode of Mukaalma with Khalil-ur-Rehman has multiple invalidated claims. For example, at a certain point, Khalil-ur-Rehman indicates that 99% of the top brass of media executives are feminists.

This is the demonstration of overgeneralization. Overgeneralization is a cognitive error which is based on incorrectly counting the number of instances. Then, the individual inductively reasons that this is the case for a large population of instances (Franceschi, 2009).

The issues with overgeneralization are multifold.

When you do not operationally define ‘feminists’ or ‘taghut’, you are not clear in what you are measuring. Hence, Sahil Adeem is unlikely to calculate the number of people who understands various levels of this concept.

Secondly, the claims are misleading. They are not proven to be representative of the population. Thus, there is a high risk that your claims are incorrect.

This is particularly harmful if the claim is uttered by people of influence. The opinion-setters of a culture could thus be misleading their audience. Especially in matters of emotional value.

Evidence 2: Intellectual Dishonesty

Not knowing the word ‘taghut’ does not mean one is ignorant about the concept.

While Maududi opposed this, many religious scholars do limit taghut to obeying and/or worshipping of tyrannical authorities or idols. Indeed, in classical Islam, taghut is used in the context of those who consider themselves above the commands of Allah.

“See how they fabricate lies against Allah—this alone is a blatant sin.

Have you ˹O Prophet˺ not seen those who were given a portion of the Scriptures yet believe in idols and false gods and reassure the disbelievers1 that they are better guided than the believers?” (4:50-4:51)

So, are Muslim women and men ignorant about the consequences of holding equals or superiors to Allah?

By claiming that 95% of women are ignorant of this concept, Sahil Adeem is displaying an inability to understand the other person’s arguments.

Issues with Intellectual Dishonesty

Intellectual dishonesty could be defined as willfully tempering with logical arguments. The problem with this is that it indicates biases. When bias is introduced into an intellectual debate, there is a high probability of misrepresenting the core arguments. For example, Adeem’s claim of ‘jahiliyat’ or ignorance in women is substantiated by the argument that his understanding of ‘taghut’ is not already understood by others.

As I have explained earlier, not knowing the word ‘taghut’ is not indicative of ignorance of the concept.

In Sahil Adeem’s case, the most likely bias to cause this is the illusion of explanatory depth. The Illusion of explanatory depth is a cognitive bias in which Adeem could believe that his explanation of ‘taghut’ has more depth than another individual’s concept (Rozenblit & Keil, 2002). This makes him disregard the fact that many muslims already have the idea or even a more substantiated idea of taghut.

This is why I would want to properly represent the opposition’s arguments.

I would have to understand the other perspective. If one does not understand the other perspective, he/she cannot argue with logic. This makes the debate less productive and insightful.

Evidence 3: Focus on Provocation  

Focus on provocation compromises scientific and intellectual validity in a debate. Provocative statements, however, can be reinforced more heavily.

To claim that 95% of (muslim) women in Pakistan do not understand a major sin in Islam can be reinforcing.

It is reinforcing because people respond more to these claims. Whether people rebut or agree, it seldom matters as long as it gets an emotional reaction.

Unfortunately, there are seldom any checks put on shows in the Pakistani context. Political commentary is fact-checked in a somewhat bipartisan manner. However, the religious commentary is not. Social commentary is also not fact-checked as rigorously as it should be.

This allows commentators to give out provocative statements regularly.

The female host of the show provided some pushback. But these rebuttals were not about the validity of the information that both Khalil-ur-Rehman and Sahil Adeem handed out. Moreover, the panelists seemed to agree on the point that Aurat March featured placards that were ‘obscene.’

At one point, Khalil-ur-Rehman eluded that these cards were made for prostitutes. While my perspective on sex work remains largely amoral, I understand that remarks like these could be considered derogatory. 

But the writer faced no pushback on this claim.

Issues with Provocative Statements

While Khalil-ur-Rehman does not consider himself to be a scientist, Sahil Adeem does. Adeem has claimed at multiple points that he is a psychologist. Psychology is a behavioral science and thus to pose as an authority in that could give credence to certain claims.

The issue with scientists using certain provocative statements is that this compromises their neutrality. A provocative statement can often misconstrue certain facts. In fact, a focus on provocation could even ‘create’ false facts.

Conclusion

The interview reflected the state of television, its regulation, standards of content and reliance on sensationalism. One particular point that really stuck with me was the ease by which this show allowed misinformation by the guests and the hosts. At the end of the day, the ratings and views stacked up. One question remained:

What did we really learn about women’s rights?

Perhaps at a certain point of the future, this issue would be addressed. However, looking at the current specimen, I am not optimistic. Sensationalism is a powerful tool of journalism. But I believe that sensationalism in scholarship, as demonstrated by Sahil Adeem, is indicative of poor standards.

One can still hope that new standards could be set. I, for one, have hope even if it is in futility.  

References

  • Ahmad, I. (2009). Genealogy of the Islamic state: reflections on Maududi’s political thought and Islamism. Journal of the Royal Anthropological Institute, 15, S145-S162.
  • Franceschi, P. (2009). Theory of Cognitive Distortions: Over-Generalization and Mislabeling.
  • Rozenblit, L., & Keil, F. (2002). The misunderstood limits of folk science: An illusion of explanatory depth. Cognitive science, 26(5), 521-562.

Written by Abdullah Qureshi

Categories
Psychiatric Disorders

Diagnostic Features of Autism Spectrum Disorder

Written by Najwa Bashir

Autism spectrum disorder (ASD) is a neurodevelopmental condition marked by problems communicating with others, limited hobbies, and doing the same things over and over again (American Psychiatric Association, 2013). Autism spectrum disorder, or ASD, is a group of brain disorders. Patterns of behavior, hobbies, activities, and social problems that happen over and over again are what define this range. Some kids with ASD have behavior and mental health issues. This is because ASD is a difficult neurodevelopmental disease. Unfortunately, these kids get upset when things change around them because they aren’t very good at adapting. The signs start in early childhood and make it hard to do normal things. Language problems, brain challenges, and epilepsy happen more often in children with ASD than in the general population (Mughal et al., 2022).

The World Health Organization (WHO) reports that 0.76 percent of children around the world have ASD. However, this only includes about 16 percent of all children in the world (Baxter et al., 2015). The Centers for Disease Control and Prevention (CDC) says that about 1.68% of 8-year-old children in the US (or 1 in 59 children) are identified with ASD (Biao, 2018; Palinkas et al., 2019). Parent-reported ASD findings in the US in 2016 were 2.5% on average (Kogan et al., 2018). Autism and Developmental Disabilities Monitoring Network (ADDM) data shows that the number of people with ASD in the US more than doubled between 2000–2002 and 2010–2012 (Biao, 2018). It might be too early to say anything about trends, but in the US, the number of people with ASD seems to have leveled off, with no statistically significant rise from 2014 to 2016 (Xu et al., 2018). No changes have been made to the DSM-5 diagnostic standards yet, so it’s too early to say what effect they will have on frequency (Palinkas et al., 2019).

ASD can happen to people of any race, ethnicity, or income level, but not everyone with ASD is diagnosed the same way. It has been shown that ASD is more common in white children than in black or Hispanic children (Baio, 2018). Even though the differences seem to be going down, they may still be there because of shame, limited access to healthcare services, or the fact that a patient’s first language is not English (Hodges et al., 2020).

People all over the world who have ASD have a lot of health problems. Finding ASD early can lower the number of children who have developmental problems and help them communicate better (Salari et al., 2022). The following text mentions the diagnostic criteria and features of autism spectrum disorder according to DSM 5 TR (American Psychiatric Association, 2022).

Diagnostic Criteria for Autism Spectrum Disorder

A. Consistent problems with social contact and interaction in a variety of settings, shown by any or all of the following, either now or in the past (examples are meant to show, not list all of them; see text):

  1. Problems with social and emotional exchange, such as an odd social approach and an inability to have a normal back-and-forth talk; less sharing of interests, feelings, or affect; or failing to start or respond to social interactions.
  2. Lack of skills in nonverbal communication behaviors used for social interaction, such as not combining verbal and nonverbal communication well, having problems with eye contact and body language, not understanding and using gestures properly, or not using any facial expressions or nonverbal communication at all.
  3. Problems with making, keeping, and understanding relationships, such as having trouble changing how they act in different social situations, having trouble making friends or sharing pretend play, or not being interested in their peers.

B. Limited, recurring patterns of behavior, hobbies, or activities, as shown by at least two of the following, either now or in the past (examples are provided for reference only; see text):

  1. Movements, objects, or words that are patterned or repeated, such as simple motor stereotypies like lining up toys or spinning objects, echolalia, or using unique phrases.
  2. Insisting on things staying the same, not changing, or speaking or acting in a certain way over and over again (for example, being very upset by small changes, having trouble with transitions, having rigid thought patterns, welcome practices, or having to take the same route or eat the same food every day).
  3. Very limited, fixed interests that are intense or focused in a way that isn’t normal (for example, a strong connection to or preoccupation with strange items, interests that are too limited or that last too long).
  4. Being overly or underly sensitive to sensory input or showing an odd interest in sensory parts of the environment (for example, not caring about pain or temperature, being sensitive to certain sounds or textures, smelling or touching things too much, or being visually interested in lights or movement).

C. Symptoms must be present in the early stages of development, but they may not show up fully until social demands are too much for the person’s limited abilities, or they may be hidden by tactics learned later in life.
D. The symptoms make it hard to act normally in social, professional, or other important areas of life.
E. Intellectual developmental disorder (also called intellectual disability) or global developmental delay are not better ways to explain these problems. A lot of the time, intellectual developmental disorder and autism spectrum disorder happen together. To identify both of them at the same time, a person’s social speech skills must be below what is normal for their age.

Note: People who have a sure-fire DSM-IV diagnosis of autism spectrum disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise defined should be given that label. If someone has major problems with social communication but doesn’t otherwise meet the standards for autism spectrum disorder, they should be checked for social (pragmatic) communication disorder.
Specify the current level based on problems with social contact and limited, repeated patterns of behavior:
Requiring very strong strength
Requiring a lot of help
Needing help:
Specify if:
Whether there is intellectual disability along with it
Together with or without language problems
Specify if:
linked to a known genetic or other health problem or external cause (Note on the code: add more code to find the genetic or other medical problem that goes with it.)
linked to a mental, behavioral, or neurological issue
Specify if:
With catatonia

Diagnostic Features of Autism Spectrum Disorder

  • As per criteria A and B, people with autism spectrum disorder have limited, repetitive patterns of behavior, hobbies, or activities and chronic problems with reciprocal social contact and social interaction. These signs show up early in life and make it hard to do normal things (Criteria C and D).
  • Core diagnostic features are clear during the developmental stage, but problems may not be seen in some situations because of assistance, compensation, and present supports.
  • The disorder also shows up in very different ways based on how severe the autism is, the person’s level of development, their chronological age, and maybe even their gender. This is where the word “spectrum” comes from.
  • People who don’t have intellectual or language impairments may have more minor signs of deficits (e.g., Criterion A, Criterion B) than people who do have intellectual or language impairments and may be working hard to hide these deficits.
  • Lack of social communication problems will be less obvious if a person has better communication skills in general (for example, speaks clearly and doesn’t have any brain disabilities). In the same way, Criterion B weaknesses (limited patterns of behavior and interests) might not be as clear if the interests are more in line with what kids their age normally like (like trains or Ancient Egypt instead of moving a string).
  • The problems with social contact and conversation that are listed in Criterion A are widespread and last a long time.
  • Verbal and unconscious communication problems in social situations show up in different ways based on the person’s age, level of intelligence, language skills, and other things like past and present care and support.
  • Lack of speech, language delays, trouble understanding speech, repeated speech, or speech that is too precise or stilted are just a few of the language problems that many people have. Autism spectrum disease makes it hard to use language for social contact, even when formal language skills like vocabulary and grammar are fine.
  • Lack of social-emotional exchange, or the ability to interact with others and share thoughts and feelings, can be seen in young children who don’t initiate social interactions or share emotions, and who also don’t copy other people’s behavior closely or at all.
  • Languages that do exist are often one-sided and don’t involve social reciprocity. They are used to ask for things or name things instead of to talk, share thoughts, or make comments. When it comes to older kids and people who don’t have intellectual disabilities or language delays, problems with social-emotional reciprocity may show up as issues with understanding and responding to complicated social cues like learning when and how to join a chat and what not to say.
  • Individuals who have come up with ways to deal with some social challenges still have trouble in new or uncontrolled situations and find it hard and stressful to consciously figure out what is socially natural for most people. Researchers think that this behavior may make it harder to diagnose autism spectrum disorder in these people, maybe especially in older women.
  • People who have problems with nonverbal communication skills for social interactions may not make eye contact, make eye contact less often, or use movements, facial expressions, body language, or speech intonation in ways that are not normal for their culture.
  • Impaired joint attention is an early sign of autism spectrum disorder. This can show up as not pointing, showing, or bringing things to share an interest with others, or as not following someone’s eye look or pointing.
  • People may learn a few useful gestures, but their collection is smaller than other people’s, and they don’t always use expressive motions when they’re talking to others. Teenagers and adults who speak more than one language may have trouble matching their body language with their speech, which can make their relationships seem strange, awkward, or over the top.
  • In some situations, impairment may be pretty subtle (for example, someone may make good eye contact when talking), but it will be clear if they can’t combine eye contact, gesture, body posture, prosody, and facial expression when they’re talking to other people, or if they have trouble keeping these things up for long periods of time or when they’re stressed. People who have trouble making, keeping, and understanding relationships should be rated by how well they meet age, gender, and cultural norms.
  • It’s possible that there isn’t any, very little, or normal social interest, which can show up as rejecting others, being passive, or approaching them in a way that seems hostile or annoying. These issues are especially clear with young kids, who don’t get enough shared social play and imaginative play (like age-appropriate, open pretend play). Later, they become very set in their ways when they play.
  • Older people may find it hard to understand what behavior is acceptable in some settings but not others (for example, being relaxed during a job interview) or the various ways that language can be used to communicate (for example, comedy, white lies). There may be a clear desire for doing things by yourself or with people who are much younger or older than you.
  • Many times, people want to make friends without having a full or accurate picture of what friendship really means (for example, bonds that only involve shared hobbies). It’s also important to think about your relationships with peers, coworkers, and providers (in terms of reciprocity).
  • As stated in Criterion B, someone with autism spectrum disorder also has limited, repetitive patterns of behavior, hobbies, or activities. These patterns can look different depending on the person’s age, ability, intervention, and present supports.
  • Some examples of stereotyped or repetitive behaviors are flapping the hands or flicking the fingers, using the same objects over and over (like spinning coins or lining up toys), and talking in the same way over and over (echolalia, which is the delayed or immediate repetition of heard words; using “you” when talking about oneself; using stereotyped words, phrases, or prosodic patterns).
  • Too much adherence to routines and limited patterns of behavior can show up as resistance to change (e.g., distress at what seem like small changes, like taking a different route to school or work; insisting on following rules; rigidity of thought) or ritualized patterns of speaking or acting (e.g., asking the same questions over and over, pacing a perimeter).
  • People with autism spectrum disorder often have very narrow, fixed interests that aren’t focused or intense enough. For example, a baby who is very attached to a pan or piece of string; a child who is obsessed with vacuum cleaners; an adult who spends hours making schedules.
  • Some interests and habits may be caused by an apparent over- or under-reactivity to sensory input. This can show up as strong reactions to certain sounds or textures, touching or smelling things too much, being fascinated by lights or spinning objects, or sometimes not caring about pain, heat, or cold.
  • Extreme reactions or routines about the way food tastes, smells, feels, or looks, or limiting food too much, are common and may be a sign of autism spectrum disorder.
  • A lot of people with autism spectrum disorder who don’t have problems with their intelligence or speaking learn to control their repeated behaviors in public. For these people, doing the same thing over and over, like rocking or moving their fingers, may help them relax or calm down. Special hobbies can be fun and inspiring, and they can also help you get an education and a job later on.
  • Limited, repeated patterns of behavior, hobbies, or activities may have been present as a kid or in the past, even if the symptoms are not present now. This means that the diagnostic criteria were met.
  • Criterion D says that the traits must make it clinically significant harder to do important things in social, occupational, or other areas of present performance.
  • Criterion E says that the person’s social communication problems, which may be joined by an intellectual developmental disorder (ID), are not in line with their developmental level; the problems are worse than what would be expected based on their level of development.

Conclusion

Individuals all over the world who have ASD have a lot of health problems. Diagnosing ASD early can lower the number of children who have developmental problems and help people communicate better. So, health officials need to know how common ASD is and how it’s getting worse so they can plan and carry out the right steps to lessen its effects.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
  • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (2022). Washington, DC, American Psychiatric Association.
  • Baio, J. (2018). Prevalence of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2014. MMWR. Surveillance Summaries, 67. http://dx.doi.org/10.15585/mmwr.ss6706a1
  • Baxter, A. J., Brugha, T. S., Erskine, H. E., Scheurer, R. W., Vos, T., & Scott, J. G. (2015). The epidemiology and global burden of autism spectrum disorders. Psychological medicine, 45(3), 601-613. https://doi.org/10.1017/S003329171400172X
  • Hodges, H., Fealko, C., & Soares, N. (2020). Autism spectrum disorder: definition, epidemiology, causes, and clinical evaluation. Translational pediatrics, 9(Suppl 1), S55. https://doi.org/10.21037/tp.2019.09.09
  • Kogan, M. D., Vladutiu, C. J., Schieve, L. A., Ghandour, R. M., Blumberg, S. J., Zablotsky, B., … & Lu, M. C. (2018). The prevalence of parent-reported autism spectrum disorder among US children. Pediatrics, 142(6). https://doi.org/10.1542/peds.2017-4161
  • Mughal, S., Faizy, R. M, Saadabadi, A. (2022). Autism Spectrum Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525976/
  • Palinkas, L. A., Mendon, S. J., & Hamilton, A. B. (2019). Innovations in mixed methods evaluations. Annual review of public health, 40(1), 423-442. https://doi.org/10.1146/annurev-publhealth-040218-044215
  • Salari, N., Rasoulpoor, S., Rasoulpoor, S., Shohaimi, S., Jafarpour, S., Abdoli, N., … & Mohammadi, M. (2022). The global prevalence of autism spectrum disorder: a comprehensive systematic review and meta-analysis. Italian Journal of Pediatrics, 48(1), 112. https://doi.org/10.1186/s13052-022-01310-w
  • Xu, G., Strathearn, L., Liu, B., & Bao, W. (2018). Prevalence of autism spectrum disorder among US children and adolescents, 2014-2016. Jama, 319(1), 81-82. https://doi.org/10.1001/jama.2017.17812
Categories
Psychiatric Disorders

Diagnostic Features of Social (Pragmatic) Communication Disorder

Written by Najwa Bashir

In the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a new condition called Social (Pragmatic) Communication condition (SPCD) was added. Individuals with this disorder have problems with their pragmatic communication skills (Amoretti et al., 2021). Individuals with this condition, which is a type of Communication Disorder (CD), have a major issue with their functional skills in a broad sense. Sometimes people with SPCD have trouble communicating with others, can’t change what they say depending on the situation, and have trouble following the rules of speech (American Psychiatric Association, 2013, p. 47).

Children who don’t meet the standards for an autism spectrum disorder may have social problems when they talk to others. This is referred to as social (pragmatic) communication disorder (Flax et al., 2019). In the past, before DSM-5, three types of behavior were needed to diagnose ASD: interacting with others, communicating, and restricted, repetitive, or stereotypical behaviors. Communication and social interaction have been combined into a single criterion called “Social Communication,” with structure language used as an additional descriptor. The RRB criteria have stayed mostly the same, with the addition of sensory problems and behaviors that were not in DSM-IV. The term “Social Pragmatic Communication Disorder” (SPCD) was created to include kids who didn’t meet the new criteria for ASD but might have met criteria for DSM-IV, and PDD-NOS in the past, such as having limited hobbies and doing the same things over and over again (Swineford et al., 2014). ASD 299.00 (F84.0) or Language Disorder 315.39 (F80.9) are not the only problems that kids with SPCD have when it comes to communicating with others. As Flax et al. (2019) say, SPCD is a developmental condition that causes problems with social, vocal, and nonverbal communication.

Prevalence

Not much is known about how common SPCD is in the general population using DSM-5 criteria right now. Also, there isn’t much known about what functional effects come from weaknesses in certain types of social-pragmatic communication (Adams et al., 2015). South Korean kids ages 7 to 12 who were evaluated for autism had SPCD in 0.5% of the cases (Kim et al., 2014). A clinical group of kids with autism was screened, and only 8% met the standards for SPCD. Most of these kids had major behavior problems (Mandy et al., 2017). The structure language skills, on the other hand, were not reviewed independently (Saul et al., 2023).

Functional Impairment

Many kids who have problems with social and pragmatics also have issues with their behavior and emotions (Mandy et al., 2017). Gemillion and Martel (2014) also say that kids who have behavior problems often have issues with speaking, social skills, and everyday life skills. Some people have said that social-pragmatic skills help connect structured language to behavior, especially in poor areas (Law et al., 2014). It has also been said that social and functional communication skills are important for getting ready for school (Pace et al., 2019). These skills play a big role in how well kids do in reading and math at a young age and in their ability to control their emotions (Ramshook et al., 2020). As expected, kids with SPCD have trouble with schoolwork, especially reading (Freed et al., 2015), because they need to use their social cognitive and inferencing skills to understand what they read. So far, research has shown that social-pragmatic deficits are linked to other developmental issues that raise the risk of bad outcomes. This shows how much SPCD might cost the public health system and how important it is to plan good health and education services for kids who have these problems (Saul et al., 2023).

Diagnostic Criteria for Social (Pragmatic) Communication Disorder

According to DSM 5 TR (APA, 2022), the following are the diagnostic criteria for social (pragmatic) communication disorder:    

A. People who have persistent problems with social verbal and unconscious interactions show it in the following ways:

  1. Problems making friends and communicating in a way that fits the social situation, like saying hello and sharing information.
  2. Being unable to change the way you talk depending on the setting or the person you are talking to includes not using too much serious language, talking differently in a classroom than on the field, and talking differently to a child than to an adult.
  3. Problems following the rules for talking and sharing stories, such as being patient, asking questions when something isn’t clear, and knowing how to use spoken and silent hints to manage interactions.
  4. Difficulty understanding subtext (like making conclusions) and unclear language (like puns, jokes, metaphors, and words that can mean more than one thing depending on the context).

B. The problems make it hard to communicate, meet new people, form relationships, do well in school, or do well at work, either on their own or together with other problems.
C. The signs start in the early stages of development, but the problems might not show up fully until they have to deal with social situations that are too hard for them to handle.
D. The symptoms aren’t caused by another neurological or medical condition or by not being good at grammar and word structure. They also don’t fit better with autism spectrum disorder, intellectual developmental disorder (ID), global developmental delay, or another mental disorder.

Diagnostic Features of Social (Pragmatic) Communication Disorder

Drawing on DSM 5 TR (APA, 2022), here are the signs  that someone has  childhood fluency disorder:

  • Finding it hard to understand pragmatics, which is the social use of words and conversation. This shows up as problems understanding and following the rules of both spoken and unspoken communication in real-life situations, as well as changing their language to fit the listener’s needs or the situation, and following the rules for conversations and telling stories.
  • Due to problems with social communication, people can’t communicate effectively, participate in social activities, make friends, do well in school, or do their jobs successfully. There is no better way to understand the problems than by having low skills in structural language, cognitive ability, or autism spectrum disease.

Associated Features

Below-mentioned are some associated features of social (pragmatic) communication disorder:

  • Language impairment, which means falling behind in language stages and having structured language problems in the past or present, is the most common social (pragmatic) communication disorder trait.
  • People who have trouble communicating with others may avoid social situations.
  • People who are affected are also more likely to have attention-deficit/hyperactivity disorder (ADHD), mental and behavioral problems, and certain learning issues.

Looking at the prevalence scores of this disorder, it appears that the condition is not diagnosed much and there have not been enough studies on it. However, the aforementioned diagnostic criteria and features can help spot individuals with SPCD so professional treatment can be sought in time.

References

  • Adams, C., Gaile, J., Lockton, E., & Freed, J. (2015). Integrating language, pragmatics, and social intervention in a single-subject case study of a child with a developmental social communication disorder. Language, Speech, and Hearing Services in Schools, 46(4), 294-311. https://doi.org/10.1044/2015_LSHSS-14-0084
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
  • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (2022). Washington, DC, American Psychiatric Association.
  • Amoretti, M. C., Lalumera, E., & Serpico, D. (2021). The DSM-5 introduction of the Social (Pragmatic) Communication Disorder as a new mental disorder: a philosophical review. History and Philosophy of the Life Sciences, 43(4), 108. https://doi.org/10.1007/s40656-021-00460-0
  • Flax, J., Gwin, C., Wilson, S., Fradkin, Y., Buyske, S., & Brzustowicz, L. (2019). Social (pragmatic) communication disorder: Another name for the broad autism phenotype? Autism, 23(8), 1982-1992. https://doi.org/10.1177/1362361318822503
  • Freed, J., Adams, C., & Lockton, E. (2015). Predictors of reading comprehension ability in primary school-aged children who have pragmatic language impairment. Research in developmental disabilities, 41, 13-21. https://doi.org/10.1016/j.ridd.2015.03.003
  • Gremillion, M. L., & Martel, M. M. (2014). Merely misunderstood? Receptive, expressive, and pragmatic language in young children with disruptive behavior disorders. Journal of Clinical Child & Adolescent Psychology, 43(5), 765-776. https://doi.org/10.1080/15374416.2013.822306
  • Kim, Y. S., Fombonne, E., Koh, Y. J., Kim, S. J., Cheon, K. A., & Leventhal, B. L. (2014). A comparison of DSM-IV pervasive developmental disorder and DSM-5 autism spectrum disorder prevalence in an epidemiologic sample. Journal of the American Academy of Child & Adolescent Psychiatry, 53(5), 500-508. https://doi.org/10.1016/j.jaac.2013.12.021
  • Law, J., Rush, R., & McBean, K. (2014). The relative roles played by structural and pragmatic language skills in relation to behaviour in a population of primary school children from socially disadvantaged backgrounds. Emotional and Behavioural Difficulties, 19(1), 28-40. https://doi.org/10.1080/13632752.2013.854960
  • Mandy, W., Wang, A., Lee, I., & Skuse, D. (2017). Evaluating social (pragmatic) communication disorder. Journal of Child Psychology and Psychiatry, 58(10), 1166-1175. https://doi.org/10.1111/jcpp.12785
  • Pace, A., Alper, R., Burchinal, M. R., Golinkoff, R. M., & Hirsh-Pasek, K. (2019). Measuring success: Within and cross-domain predictors of academic and social trajectories in elementary school. Early Childhood Research Quarterly, 46, 112-125. https://doi.org/10.1016/j.ecresq.2018.04.001
  • Ramsook, K. A., Welsh, J. A., & Bierman, K. L. (2020). What you say, and how you say it: Preschoolers’ growth in vocabulary and communication skills differentially predict kindergarten academic achievement and self‐regulation. Social Development, 29(3), 783-800. https://doi.org/10.1111/sode.12425
  • Saul, J., Griffiths, S., & Norbury, C. F. (2023). Prevalence and functional impact of social (pragmatic) communication disorders. Journal of Child Psychology and Psychiatry, 64(3), 376-387. https://doi.org/10.1111/jcpp.13705
  • Swineford, L. B., Thurm, A., Baird, G., Wetherby, A. M., & Swedo, S. (2014). Social (pragmatic) communication disorder: A research review of this new DSM-5 diagnostic category. Journal of neurodevelopmental disorders, 6, 1-8. https://doi.org/10.1186/1866-1955-6-41
Categories
Psychiatric Disorders

Diagnostic Features of Childhood-Onset Fluency Disorder (Stuttering)

Written by Najwa Bashir

Stuttering

Sometimes called stammering and more generally disfluent speech, stuttering is a speech condition marked by repeating sounds, syllables, or words; sound delay; and speech breaks called blocks (NIDCD, 2017). The childhood-onset fluency disorder is a chronic change in the normal flow and timing of speech that is not proper for the person’s age (American Psychiatric Association, 2013 as cited in SheikhBahaei et al., 2022).

Individuals who stutter know exactly what they want to say but struggle to organize it smoothly. People with trouble speaking may also show signs of stress, like blinking their eyes quickly or trembling their lips. People who stutter may find it hard to talk to others, which can impact their quality of life and ties with others. Stuttering can also make it harder to get a job which can negatively impact your chances of getting hired, and treatment can cost a lot of money. People who stutter can have very different symptoms at different times of the day. Most of the time, stuttering gets worse when someone speaks in front of a group or on the phone. On the other hand, singing, reading, or speaking in unison can briefly make stuttering better (NIDCD, 2017).

Differences in the structure, function, and control of dopamine in the brain have been linked to stuttering. These differences are thought to be genetic. It is important to make sure that the right evaluation or recommendation is made for children because more and more people agree that starting speech therapy early for kids who stutter is very important. For adults, stuttering can be linked to a lot of mental and social problems, like social nervousness and a low quality of life. Recently, pharmacologic treatment has gotten a lot of attention, but there isn’t a lot of clinical evidence to back it up. Speech therapy is still the most common way to help kids and adults (Perez & Stoeckle, 2016). The number of people who have DS depends on their age and the exact meaning of stuttering that is used. The most common number given is a lifetime frequency (chance that a person will ever stutter) of 5%. However, new information suggests that the total frequency is more like 10% (Yairi & Ambrose, 2013), with kids being most affected. Up to 90% of kids who stutter (CWS) will get better on their own as kids. Persistent DS is when an adult did not heal from DS as a kid. This happens to less than 1% of the population (Yairi & Ambrose, 2013). Stuttering that is thought to be caused by mental stress or brain damage is less common, but no one knows how common it is (Theys et al., 2011). According to Yari and Ambrose (2013), men are four times more likely than women to have DS, and men are also more likely to have it last longer than women. Other things that can help you tell if someone will continue with stuttering are a late start age, longer length of stuttering, a family history of persistence, and lower language and nonverbal skills (Yairi et al., 1996). It is very important to diagnose children right away because early treatment has the best results (Weir & Bianchet, 2004).

Diagnostic Criteria for Childhood-Onset Fluency Disorder

According to DSM 5 TR (APA, 2022), the following is the diagnostic criteria for childhood-onset fluency disorder:

A. Disturbances in the regular flow and timing of speech that aren’t acceptable for the person’s age or language skills, last a long time, and are marked by one or more of the following happening often and clearly:

  1. Repetition of sounds and syllables.
  2. Sound expansions of vowels and consonants.
  3. Broken words (e.g., stops within a word).
  4. Audible or silence blocking (filled or unfilled breaks in words).
  5. Circumlocutions are word changes that get rid of troublesome words.
  6. Words that are spoken with too much physical stress.
  7. Whole words that repeat on one syllable, like “I-I-I-I see him”

B. The problem makes people nervous about saying out loud or makes it harder for them to communicate, interact with others, or do well in school or at work, either on its own or in combination with other problems.
C. Symptoms start in the early stages of growth. Note: cases that start later are called F98.5 adult-onset speech disorder.
D. It’s not caused by a problem with speech, movement, or senses; it’s not slurred speech from a brain injury (like a stroke, tumor, or trauma); it’s not caused by another medical condition; and it’s not better explained by another mental disease.

Diagnostic Features of Childhood-Onset Fluency Disorder

In the light of DSM 5 TR, the following are the diagnostic features of childhood-fluency disorder:

  • A main feature of childhood-onset fluency disorder (stuttering) is a change in the usual flow and timing of speech that isn’t proper for the person’s age.
  • This disorder is marked by repeated or prolonged sounds or syllables and different kinds of speech problems, such as broken words (like pauses within a word), audible or silent blocking (like filled or unfilled pauses in speech), circumlocutions (like changing words to avoid problematic ones), words made with too much physical tension, and repeated monosyllabic whole-words (like “I-I-I-I see him”).
  • The problem with speech could make it harder to do well in school or at work and to talk to other people.
  • Situationally, the level of disturbance changes, and it’s usually worse when there’s extra pressure to talk (like when you have to give a report at school or talk about a job).
  • Most of the time, dysfluency doesn’t show up when reading out loud, singing, or talking to pets or inanimate objects.

Associated Features

The associated features are as follows (APA, 2022):

  • Individuals may start to fear the problem before it happens.
  • Disfluencies can be avoided by changing the rate of speech or ignoring certain words or sounds. The speaker may also try to avoid certain speech situations, like talking on the phone or in public.
  • Not only do worry and anxiety make dysfluency worse, they are also symptoms of the disease.
  • Motor movements may happen along with a childhood-onset fluency disorder. These can include eye blinks, tics, twitches of the lips or face, jerks of the head, breathing movements, and tightening of the hand.
  • There are different levels of speaking skills in kids with speech disorders, and it’s not clear what the link is between the two. Studies have shown that kids who stutter have differences in both the structure and function of their brains. Estimates vary based on age and the possible cause of stuttering, but men are more likely than women to stumble.
  • Stuttering has many causes, some of which are genetic and some of which are neurological.

Conclusion

The childhood-onset fluency disorder is a serious concern as it can cause trouble in communication, academics, and overall functioning of the children, either directly or indirectly. Therefore, it is important to take the signs and symptoms of stuttering seriously and seek treatment immediately.

References

  • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (2022). Washington, DC, American Psychiatric Association.
  • NIDCD (2017). Stuttering. Available from: https://www.nidcd.nih.gov/health/stuttering#:~:text= Stuttering%20is%20a%20speech%20disorder,a%20normal %20flow%20of%20speech.
  • Perez, H. R., & Stoeckle, J. H. (2016). Stuttering: clinical and research update. Canadian family physician, 62(6), 479-484. Available from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907555/
  • SheikhBahaei, S., Millwater, M., & Maguire, G. A. (2023). Stuttering as a spectrum disorder: A hypothesis. Current Research in Neurobiology, 5, 100116. https://doi.org/10.1016/j.crneur.2023.100116
  • Theys, C., Van Wieringen, A., Sunaert, S., Thijs, V., & De Nil, L. F. (2011). A one year prospective study of neurogenic stuttering following stroke: incidence and co-occurring disorders. Journal of communication disorders, 44(6), 678-687. https://doi.org/10.1016/j.jcomdis.2011.06.001
  • Weir, E., & Bianchet, S. (2004). Developmental dysfluency: early intervention is key. Cmaj, 170(12), 1790-1791. https://doi.org/10.1503/cmaj.1040733
  • Yairi, E., & Ambrose, N. (2013). Epidemiology of stuttering: 21st century advances. Journal of fluency disorders, 38(2), 66-87. https://doi.org/10.1016/j.jfludis.2012.11.002
  • Yairi, E., Ambrose, N. G., Paden, E. P., & Throneburg, R. N. (1996). Predictive factors of persistence and recovery: Pathways of childhood stuttering. Journal of communication disorders, 29(1), 51-77. https://doi.org/10.1016/0021-9924(95)00051-8
Categories
Current Affairs

The Establishment: A Pakistani Archetype

Written by Abdullah Qureshi

“The power of a popular delusion lies in its ability to tap into the deepest fears, desires, and insecurities of a society, offering a false sense of security or hope in the face of uncertainty.”

Charles Mackay (1832)

Over the course of Pakistan’s history, many institutions have been critiqued. Zulfiqar Ali Bhutto laid much of the blame on bureaucratic corruption. As soon as Bhutto took power, he fired 1,300 civil servants without a hearing. This is testament to his disdain for the CSP cadre (Ansari & Bajwa, 2019).

Then, the Shareef brothers have at multiple times put the blame on impartial judicial processes. More recently, Imran Khan (and much of the military presidents) blamed politicians for Pakistan’s dire economic straits.

Many of these critiques are fair.

However, there is one institution, universally lambasted since the beginning of this country.

The establishment.

The Evergreen Villain

The establishment is considered to be the ultimate boogieman. It is an organization which topples powerful governments, controls politics from the barracks and eats up all the resources. Politicians seem to fear the establishment. Those who seem to go against their plans are ousted from office on bogus charges. Worse, they are often exiled and some are killed.

Here are some questions for people who prop up this image of ‘the establishment’:

Do the cases against politicians hold merit?

If the person you oppose was charged with a similar crime, would it still be as unbelievable?

Do you believe the establishment should be neutral?

Has your ‘political favorite’ committed acts that undermine the security of your country?

Is the government machinery free of corruption, in general?

If you genuinely take the time to answer these questions you will realize one very important thing.

Human beings are biased. According to Lawrence Kohlberg (1963), a renowned developmental psychologist, humans start adhering to a moral view of the world, fairly early in their lives. By the early adolescence, they start developing the conventional morality. They subscribe to societal norms because they allow them to function. This social teaching predisposes us to have certain biases.

It is very easy to stay at the conventional stage. It is very easy to label things as ‘good’ or ‘bad’. In fact, doing so would allow you to stall cognitive dissonance for a long time.

Until, you are forced to encounter reality.

The reason why the ‘establishment’ is the villain, is because it is easy to consider them so.

If we accept that the establishment is to blame for everything, we allow ourselves freedom to not think.

Why would anyone want to think about their own sins? Sins that they can be held accountable for.

The Establishment vs the Innocents

Often in Pakistan, when someone talks about the establishment, they refer to the military. They think back to the 3 decades of military regimes in Pakistan’s history. There is no question that such breaks in democracy do make governance difficult.

However, is it not true that political actors have played a fair share in impulsive decision-making? Is it not true that counterproductive policies, like the creation of the Federal Security Force in the 1970s, did more harm than good?

A sitting prime minister decided to head to the streets because a new army chief was being instated. If this is the regular behavior of a prime minister, many political idiocies can be justified.

One also has to wonder whether prime ministers are afforded license to kill. If not, then how can anyone justify a Prime Minister’s orders to stop a plane in mid air, carrying the chief of the army?

While the prime minister is the top official, he is not allowed to have someone killed. Just letting you know, in case we have forgotten basic values at this point.

Philosophical Suicide of the Intellectuals

More educated and aware journalists and academics also talk about the role of the judiciary and/or the bureaucracy. However, in some ways, they commit philosophical suicide when they still use the word ‘the establishment’.

The Sapir-Whorf hypothesis argues that the language we speak determines our experience (Sapir, 1836). There is also the psychological concept of self-fulfilling prophecies. If you keep repeating to yourself that something will happen, that something eventually does happen.

‘The establishment’, has unfortunately become a part of our language. We have accepted the complete dominance of one institution. The establishment has been the boogieman for too long a time.

Reality Check

To find a solution to the political instability in Pakistan, it is important to break the archetype of the establishment. Are we sure that civilian governments have delivered what was required of them? Are we sure that the red tape in the bureaucracy is justified? Are we sure that the judiciary is impartial?

Statistics point towards one single answer: no.

In 2023, Transparency International Pakistan (TIP) conducted a National Corruption Perception Survey (NCPS). The results are very telling.

According to the National Corruption Perception Survey 2023, the police are still the most corrupt department (30%). Tendering and Contracting came in at number two (16%), and the judiciary came in at number three (13%).

None of these sectors consider themselves part of the establishment. 

Yet, they are infringing upon the boundaries of their professions which are specifically meant for justice.

Has the establishment pointed a gun to their heads and made them glutton down resources?

It Wasn’t Me, It Was Them!

The establishment is the altar where we wash our sins as a nation. It does not exist.

Political power does. The prime minister does, and so do the other two heads of the three arms of the state. Military influence on governance is undeniable. As undeniable as the forfeiture of responsibility demonstrated by officials involved in corruption.

By assigning the establishment the responsibility of corruption, poor governance, we allow many people to be free of accountability. For they too blame the establishment on one hand, and slacken their own responsibilities with the other. Sadly, the very beneficiaries of the status quo lambast those who they consider more powerful than them.

The Way Forward

Politicians and officials cannot remain within conventional morality. They might blame others for the debacles we are in, but they did choose to be in this position. Hence, we cannot blame the establishment.

We can only blame ourselves.

However, I am not optimistic about the people of Pakistan relinquishing their archetype of the establishment. As a practicing clinical psychologist, I believe we as people can improve. Warped beliefs are difficult to treat.

References

  • Ansari, S. H., & Bajwa, F. (2019). HIGHER BUREAUCRACY IN PAKISTAN: AN HISTORICAL ANALYSIS OF PRAISE AND BLAME. ISSRA Papers, 11(I), 73-96
  • Kohlberg, L. (1963). Moral development and identification.
  • Mackay, C. (1932). Extraordinary popular delusions and the madness of crowds. Noonday Press. 
  • Sapir, E. (1836). Sapir–Whorf Hypothesis.
Categories
Current Affairs

Psychosocial Analysis of Mob-Lynching in Pakistan

By Abdullah Qureshi

Recently, a 40 year old male tourist was lynched by a mob after allegations of blasphemy. According to reports, the hotel management had discovered a few burnt pages of the Quran from the victim’s room. Following this, the subject was detained by the police for investigation. During the ordeal, announcers of some mosques disclosed the information of where the subject was held. A mob gathered and demanded the police entry into the police station. When it was refused, the mob broke in, found the subject in the servants’ quarters and subsequently killed him.

Lynchings are regrettably becoming more common in Pakistan. In May (2024) a Christian man was lynched in Sargodha. The failure of the state to provide some protection to these victims is striking. However, I argue in this article that mob lynching is a product of many psychosocial issues.

Mob lynching has three major facets. The first is cognitive dissonance, wherein an event in the external world clashes with a personal, widely held belief (Festinger, 1962). Secondly, there is group action, unified by certain characteristics or beliefs. The third is use of violence, a product of aggression and the circumstances the group has or is in.

In the following sections, a social model of mob-lynching compiled by Baig and Ahmad (2020) would be used to understand this recent incident. I will look at this model through the psychosocial facets described earlier.

The Psycho-social Model of Mob-Lynching in Pakistan

Baig and Ahmed (2020) argue that there are 4 levels of analysis of mob-lynching. These are:

  • Individual
  • Process
  • Society
  • State

Individual Level

The tourist was lynched by human beings. They were of the locality of Madyan. They had human motifs. Plus, they lynched at an individual level. So, the first level of analysis has to be at the individual level. Baig and Ahmed (2020) discuss that human actions have two categories:

  • Reflective
  • Reflexive

Reflective Actions

The reflective actions are where the character knows ahead of time what he wants to achieve. It could be a means to an end (instrumental). Or it could be an end in itself (value).

Reflexive Actions

The acts that are reflexive do not involve the person thinking ahead of time. Emotional actions are rapid bursts of certain behaviors, like when someone is angry or excited. Another thing is that the character does some things automatically, without giving them much thought.

Psychological Aspect

Swat is inhabited by many people. Religious extremism, while found across the country, is more weaponized in some areas. Since Swat has been a focal point of major security issues, this weaponization is obvious.

Beliefs. When popular beliefs are challenged the result is often emotional distress in many individuals. Groupthink by the members of the mob allows the mob to be cohesive in beliefs.

Circumstances. The staff of the police station refused entry to the mob. However, the mob disregarded this refusal and forcefully entered the establishment. If the culture of the area is permissive of popular beliefs, this allows the group more moral freedom to act. At an individual level, the circumstances allow more autonomy to a mob rather than the actions to one single person.

Violence. After breaking in, the mob forcefully found out the accused blasphemer and murdered him. The community at large did not rally to punish this mob. So, it could be seen that the circumstances were favorable to lynching. Extreme actions thrive in communities with extreme beliefs.

The Process Level

Randal Collins (2012) broke down the process of a mob killing into 4 steps:

  • Find a weak target, preferably one who is emotionally controlled.
  • Aim for an audience that supports a small group of violent artists.
  • Stay far away so that weapons can be fired without having to face the enemy
  • A secret motif that acts like there is no conflict until the very end;

Psychological Aspect

Collins’ model, while insightful, cannot be perfectly mapped to the Madyan lynching. For example, there was no attempt by the mob to mask their intentions of violence. They broke in to the police station and lynched the person fairly quickly.  Thus, the process could be better understood using a psychological framework.

The beliefs of the group along with the precipitating incident dictate the possibility of violence. On the other hand, the circumstances – including the culture, strength of law enforcement and cohesion of a group – affect the intensity of the violence. So, the causal event, beliefs of the mob, and circumstances allow violence. As a result, both the possibility and intensity of the violence increase

The Society Level

Max Weber came to some very interesting conclusions about modernity (Weber 1979; as cited in Baig & Ahmed, 2020). Weber says that modernity is made up of three main currents: rationalization, disillusionment, and bureaucratization.
In effect, after detention, the police send justice problems to the courts, where they are settled based on “merit.”

Traditional justice, on the other hand, did not have fixed officials to understand and implement it. Most of the time, it happened quickly. When deciding what was fair, people usually looked at the masses of the time. In this way, it was a group effort based on agreement. In these kinds of structures, everyone felt like they had to take part in the process of sentencing and justice.

According to this view, the lynching at Madyan could be viewed as an expression of justice by a traditional society. A traditional society is not simply a conservative society. A traditional society is a pre-modern society that does not follow the rational and bureaucratic model of authority.

So, one could conclude that lynching occurs more when at a societal level, bureaucratic processes are not followed.

Psychological Aspect

The lynching of the 40 year old tourist could be facilitated by the societal traditions. Swat has a conservative culture and the valley is situated in an area which has a tribal history. Located in the province sharing a volatile border with Afghanistan, the place also has had security issues. Indeed, in an earlier historic account, Stein (1942) admitted that the area was deeply tribal.

Unfortunately, these security issues, along with poor socio-economic prowess mean that trust in the state is low.

So, one common assumption that could be inferred is that authorities are not trustworthy. This allows the tribal system of justice to override the legal system. I would argue that mobs gather to build the strength of force to challenge the legal system. The reason, I argue is the erosion of trust in the legal system.

The State Level

Thomas Hobbes (1985, quoted in Baig & Ahmed, 2020) says that the main reason people want peace is because they are afraid of dying. In order to stop this deadly possibility, people make states, which are a single power hub where people can’t use their own. The only valid group that can use violence against people is the state. That’s why Hobbes called the state “a monopolizer of violence in a territory.” This description is at the heart of modern nation-states, and it’s now a part of almost every meaning of politics (Weber, 1979).

Hobbes said that if a state doesn’t take control of violence, people’s lives will become “short, nasty, and brutish.” If there is no government, other people and groups will use violence for their own reasons, which will lead to a society where everyone works together.

Psychological Aspect

For the lynchers at Madyan, the ego ideal seems to be in clash with the state’s procedures. The ego ideal is a complex of ideals that one has (Rosenfeld, 1962). For example, one could say that personal responsibility is the ego-ideal that trumps ideal of state responsibility. It could also be the case that the mob’s ideals were specifically different in the area of religion.

Whatever the case might be, it appears that the ego-ideals of a mob are not in alignment with the state’s ideals. The mob wanted the accused to be dealt with regardless of the legal process. The state, on the other hand, desires to be held responsible for dealing with the accused.

This appears to be a major psychological conflict of the collective mob with the state.

Solving the Issue of Mob Lynching

Mob lynching is a tricky phenomenon. There are multiple people in a mob. Plus, this group of people has an aggressive stance. It is very easy to see examples of how even the writ of the state does not contain collective anger.

So, to deal with the issue of these mass demonstrations of violence, one has to tackle multiple levels. As offered by this essay, corrective action and awareness has to occur at all the levels of analyses:

  • The Individual Level
  • Process Level
  • Society Level
  • State level

I propose that the individual and process levels could be targeted through better engagement between the residents of the area, and the state. If this is done, the locals could trust the authorities more to conduct due process.

To target the society and state levels, opinion-makers could be addressed. They could be briefed about how to behave in a particular situation. The Imams of the mosques could be educated by like-minded religious scholars about due process. Furthermore, they would have to be assured that the state is there to help.

To target the state level is the job of the policy makers and implementers. This would involve maintaining a healthy socioeconomic status and literacy rate so that these incidents could be prevented from the get go.

Conclusion

What happened at Madyan was condemned by many people. The Human Rights Commission of Pakistan (HRCP) took almost instantaneous notice of this tragedy. Furthermore, Pakistan Ulema Council (PUC) also condemned this attack. This shows that religious and human rights leaders in contact with the state oppose what has happened.

However, I argue that the issue is much deeper. If the socioeconomic and psychosocial conditions of various areas of Pakistan are not improved, distrust of the state will continue to prevail.

References

  • Baig, K. A. S. T., & Ahmad, M. A. (2020). Mob lynching in Pakistan: an integrated conceptual model. Pakistan Social Sciences Review, 4(1).
  • Collins, R. (2012). Entering and leaving the tunnel of violence: Micro-sociological dynamics of emotional entrainment in violent interactions. Current Sociology, 61(2) , pp.132–151.
  • Festinger, L. (1962). Cognitive dissonance. Scientific American, 207(4), 93-106.
  • Hobbes, T. (1985.) Leviathan, Harmondsworth: Penguin Books
  • Stein, A. (1942). From Swat to the Gorges of the Indus. The Geographical Journal, 100(2), 49-56.
  • Rosenfeld, H. (1962). The superego and the ego-ideal. The International Journal of Psycho-Analysis, 43, 258.
  • Weber, M. (1978). Economy and Society: An Outline of Interpretive Sociology. London: Univeresity of California Press.