Understanding the Logic

Parent Education Group Starting in Boise!

Tue, 22 May 2012 23:00:00 GMT

Understanding the Logic of "Meltdowns"

Dr. Nilsson and his staff would like to invite you to our new "Parent Education Group. " This will be an informal gathering of parents and the staff of The NeuroDevelopment Resource Center. Dr. Nilsson will present information about understanding the cause of meltdowns and provide strategies to prevent and manage meltdowns.

When: Tuesday June 5th, 6:30pm - 8:00pm
Where: 950 W. Bannock St., Banner Bank Building 11th Floor
RSVP: 208-947-5368 or info@neurodevcenter.com
Cost: FREE!

Refreshments Provided

To Test or Not to Test: What should I do?

Tue, 22 May 2012 18:04:00 GMT

A parent on Facebook raised the question that virtually every parent of every child experiences at one time or another, the indecision of whether “to test, or not to test” their child. I wanted to address the question in greater detail than space allowed on Facebook. This is a particularly important consideration for any parent of a child struggling in school, whether for learning, socially, or for development generally. The question often asked is whether the parent should have their child do the group testing administered at school, what we used to call the “cafeteria tests.” The answer is always “yes,” particularly since you “paid” for it anyway with your taxes. The critical consideration is to make time to go over the results with a teacher, counselor, or someone who can explain it to you.

The main questions to ask are: “At what level is my student performing?” “Is the test profile consistently high, low, or in the middle compared to classmates?” “What does my child need to perform at his/her best?” With variability, the student may be high in one area, and low in others, requiring more specialized support in some classes. Parents should allow child with apparent learning disability or neurodevelopmental disorder to be tested.

The primary reason for considering testing, is to “Understand the Logic” of the behavior, learning and development of the individual child. Each child is truly unique relative to genetic, medical, and educational history, in combination with their unique personal experience. “Understanding the Logic” of the individual child is critical for accessing a broad range of support. Given the perceived (and potentially practical) need to “quantify” (behavior, development, disability), testing should be a particularly valuable contribution to educational progression, but also to parenting.

Back to the consideration of “to test, or not to test.” I strongly encourage parents to gather as much information as possible about their child, in considering educational and social support, medication, and behavioral considerations. The information provided by the school is at no cost and could avoid expenses later. In order to provide optimal educational, neurodevelopmental, and treatment support, it is critical to “Understand the Logic” of the presenting behavior/symptoms of the individual. Specific interventions can be identified and implemented. For some, remedial interventions (e.g., learning to read, write) may be of benefit. For others, it is unlikely that they will ever read or write productively, but fortunately with technology, they have options available to facilitate and optimize their learning! The most basic reason to administer neuropsychological testing is to add to your understanding of your child, to facilitate identifying and adjusting educational/intervention strategies, but particularly in making parenting decisions.

I am a little biased, but a well done neuropsychological test battery by an experienced, well- trained neuropsychologist should evaluate functional capacity, but more importantly provide parents with the specific logic of their child’s brain. Many clinicians administer neuropsychological testing, but not all are well-trained. I know a school psychologist who does “neuropsychological testing” but administers the same tests that would be done in a school/educational evaluation. The expectation should be that the evaluation will explain the logic of your child’s brain and offer specific recommendations. I encourage parents to talk to other parents who have had neuropsychological evaluations, ask who did them, and how useful they felt the evaluation was in benefitting the educational experience of their child. The consideration of remediation versus adaptation/ accommodation for some children with prominent developmental/learning problems should be central to identifying educational strategies. Neuropsychological testing will help in that process.

Another issue is that of responsibility. I have heard many parents express the expectation that “It is the school’s responsibility to educate my child.” While that is in part true (we pay taxes!), if the parent isn’t actively involved in the educational process, including working with the child at home, the outcome will most likely be less than optimal. There is truth in the old expression “It takes a village to raise a child.” Everyone needs to be on the same page, having the same understanding, and expectations. The parent/parents are the constant in the child’s life (or should be) and as such, it is critical that parents accept that responsibility, using the “supporting cast” as necessary.

A well-trained, experienced pediatric neuropsychologist is potentially a valuable member of the child’s team. Look for credentials, board certification, and references to guide your decision.

Understanding the Logic - Moving Beyond the Diagnosis

Mon, 07 May 2012 20:25:00 GMT

The foundation for an accurate diagnosis and complete knowledge of any disorder is that of “Understanding the Logic” of the symptoms. That includes a complete understanding of the patient’s history - genetic, medical, developmental - in combination with specific observation of the patient and interview with parents, spouse, etc. Most psychiatric diagnoses are a label for a group of symptoms, not necessarily explaining the specific combination of symptoms leading to the diagnosis. Involvement of parents, teachers, the patient, and others are important to the process of explaining the logic of the individual’s behavior. By understanding the logic of symptoms, a more specific treatment plan can be provided in combination with educational support and other interventions to optimize outcomes.

A diagnosis is frequently perceived as the important foundation of health care, defining the process of “now what do we do?” It is required by insurance carriers for reimbursement of services. The routine assumption is that a diagnosis should define treatment. However, majority of mental health diagnoses are “labels” for groups of symptoms. Perhaps the most prominent mental health diagnosis is Attention Deficit Hyperactivity Disorder (ADHD). This diagnosis includes a group of symptoms, with the common assumption that the group of symptoms has a specific, singular “cause”. However, there are multiple reasons why a child, adolescent, or an adult may be inattentive or hyperactive. A child with vision or hearing problems may be inattentive. Patients having anxiety may be inattentive, but for a variety of reasons. Children having experienced traumatic brain injury, recognized or not recognized, experience symptoms commonly diagnosed as ADHD.

For example, a mother brings her child into Clinic, reported by teachers at school to be “inattentive.” The teachers are confident that the child should be diagnosed Attention Deficit Hyperactivity Disorder, diagnosed formally and prescribed medication. An important part of the diagnostic process is to not just observe inattention, but also to understand WHY the patient is inattentive. Children with hearing or language disorders can be inattentive. Children presenting with high levels of anxiety are also often diagnosed as ADD or ADHD. For such individuals, when prescribed a stimulant, often their symptoms can become worse. They are likely to require medication more consistent with treating symptoms of anxiety. Is an individual easily over-aroused (i.e., over-stimulated) in their environment, and as such, their ability to attend disrupted?. It is easier to identify a specific treatment plan if we understand the “logic” of the specific behavior. Treating Attention Deficit Hyperactivity Disorder will be very different than treating someone for anxiety, a hearing problem, traumatic brain injury, etc.

Moving beyond the diagnosis, facilitating a more complete understanding of the logic of the behavior and symptoms, then initiating a specific treatment program will be of greater benefit to parents, teachers, and others interacting with the patient. When a family member or other adult understands the logic of behavior, it is easier for them to understand the individual’s behavior, to have compassion for the frustration and discomfort of the patient, to participate in applying appropriate treatment recommendations, and to facilitate long-term success and well-being of the individual.

What is the Significance of Poor Eye Contact?

Tue, 17 Apr 2012 00:02:00 GMT

Vision is the most “hard-working” of our five senses, virtually processing information non-stop, even as we sleep. The volume of information it processes is truly remarkable, other sensory systems having more “down time.” You may remember in grade school or even junior high school having “staring contests”. We would stare into each other’s eyes; the first to look away “lost the competition.” What was the logic behind the response? Why did we look away? The most basic answer is “because it became uncomfortable.” Persistently staring into another person’s eyes over-stimulates the sensory system, creating the discomfort experienced in the form of neurogenic irritability or anxiety.

For human beings, eye contact is a particularly critical means of gathering information from people we encounter, for monitoring safety, obtaining information about the individual (e.g., mood, safety, trust), which then contributes to our decision-making socially, etc. Eye contact is a behavior that is critical to our interaction and communication with others perceived differently across cultures. For some, sustained eye contact is socially inappropriate or rude. In our culture, poor eye contact is associated with everything from shyness, lying, discomfort, to neurodevelopmental disorders, such as Autistic Spectrum Disorder.

Poor eye contact is a significant observation in understanding the logic of an individual’s behavior, potentially contributing to diagnosis and treatment. For an individual experiencing high levels of “over-stimulation” (e.g., anxiety, stress, neurogenic irritability), eye contact is particularly overwhelming. Accordingly, patients with high levels of “over-stimulation” have a difficult time initiating and maintaining eye contact, tending to look away most of the time. In more extreme forms, diagnosis of autism or autistic spectrum disorder is suggested for limited or absent eye contact. For those individuals, eye contact can become uncomfortable emotionally or psychologically, some even describing it as “painful.”

With this understanding, it is unsettling to hear of therapists suggesting to parents that they need to prompt eye contact to the point of forcing it. Such intervention should be considered very carefully. Limited eye contact most commonly reflects an “over-stimulated” nervous system (i.e., brain), suggesting a need to reduce that level of stimulation. Environmental control, anti-anxiety medication, sensory integration therapy and neurofeedback are all options of consideration. Reducing the arousal level, along with high levels of positive reinforcement, eye contact will likely improve, approaching what might be perceived as “normal” eye contact.

What will a Neuropsycholgist do for my child?

Thu, 26 Jan 2012 17:03:00 GMT

Parents are often referred to clinical neuropsychologists by their neurologist, neurosurgeon, primary care physician, friends, or family member but with no specific explanation as to what to expect a neuropsychologist will do. I was speaking at a conference when parent in audience asked the question, “What should I expect from a neuropsychologist providing care for my child? I do not recall how I began my response, but I do recall that it was not progressing well. The mother of one of my patients happened to be in the audience and came to my rescue. Raising her hand, she asked if she might help in answering the question. I gladly shared the microphone.

The mother explained briefly to the audience the symptoms her son was experiencing that prompted the initial referral. Not sure exactly sure how she would respond, I was relieved to have her speak positively of my interaction with the family. Expecting that she would report the benefit to the school, the “well written evaluation” but her response was somewhat unexpected. She reported that the greatest benefit provided was explaining to her the “logic” of her son’s behavior and symptoms, which she reported answered her questions of why he behaves the way he does, and by understanding that, her ability to advocate for him was much improved. She was better able to communicate with the school, asking questions, requesting services, etc. Prior to that time, she reported having been perceived as an overly protective, and controlling mother. It had been perceived that “he just needed more discipline”, not recognizing that he required more structure.

The mother’s description was reassuring, of benefit to the group, myself included, and consistent with my professional goals in providing treatment support. Understanding the “logic” of a child’s behavior post-acquired brain injury was a very helpful foundation to beginning treatment. Unfortunately, the tendency is to base our opinion of the child who struggles or the parents’ ability to parent the struggling child on what we see, without understanding the logic of the child individually. This logic becomes the foundation of how they learn most productively, why they behave the way they do, etc. Our assumption always is that the parent “should know better” and be able to control their child. All children are not created equal…

My goal is to provide a greater understanding to parents for how a disruption (e.g., acquired brain injury, genetics, brain tumors, seizures, neurobehavioral disorder) in the developmental progression can impact regulation of behavior, emotion, and learning, disrupting the process of neurodevelopmental progression. With that understanding, we can optimize educational opportunity and maximize developmental outcomes. And therefore, by understanding the “logic” of a child’s behavior and / or learning difficulties, we are in a better position to successfully access and develop optimal support for the individual child.

For suggestions of questions to ask your clinical neuropsychologist, click here.

What is a Neurodevelopmental Disorder?

Wed, 11 Jan 2012 23:58:00 GMT

When an infant, child, or young adolescent experiences an acquired brain injury, it is much different than when an older adolescent/adult experiences brain injury. For the latter, they have completed or are in the process of completing physical development and neurodevelopment (e.g., brain). They have acquired the basic skills needed to function as a “mature organism”. If they experience an acquired brain injury, depending upon the severity of the injury, they will lose functional capacity of the brain, the degree of loss dependent upon the severity, location, and type of injury. When an infant/child/young adolescent experiences a brain injury, it not only affects the skills that they have acquired, but also disrupts their developmental/neurodevelopmental progression. That is to say, they are not acquiring the functional foundation of skills we all depend upon to progress from childhood to adulthood. “My husband just hasn’t grown up!” is not what we are talking about.

From birth on, the brain is growing and developing the networks of neurons, developing structure for specific skills, language being a notable example. When the brain is injured, that progression of development is disrupted or in some cases lost, meaning that treatment/developmental support must go back and begin the process of “rebuilding”. That is the foundation of what is called a “neurodevelopment disorder”. The basic definition is one of there being a disruption (i.e., disorder) of developmental progression. Examples include Autism, ADD / ADHD, Non-Verbal Learning Disorder, Sensory Processing Disorder, Fetal Alcohol Syndrome etc. Many learning disorders are fundamentally neurodevelopmental disorders.

It is critical that treatment begin early and aggressively; early intervention is key. Parents need to receive the tools and resources to participate in treatment, but also be “empowered” in the treatment process as participants (e.g., observers/reporters, historians, co-providers). I encourage parents to be assertive in asking to participate and to receive the information and tools they require. The process is really one of “all the kings horses, and all the men” working together, the similarity of putting “Humpty Dumpty all together again”. Very few parents can afford paying someone to provide all treatment support and intervention. I consider part of my role being that of helping to organize and train the parents, clinicians, educators, and even grandparents. It is a little unsettling how often the expectation of families is just to take the child home “and love them”.

Neurodevelopment is the foundation of virtually everything we are or will become. A disruption of that process is devastating, but should receive the greatest level of effort we can muster as parents, grandparents, educators, health care providers, and others.

Your comments and questions are welcome and encouraged!!

An Interesting Demonstration of Reading

Tue, 10 Jan 2012 14:41:00 GMT

We take reading for granted, having done it for as long as we can remember. Not only does the brain process letters into words, and words into sentences, it allows us to visualize the content of what we are reading, comparing the content of what we have read before, saving it in memory. It contrasts what we have heard and what we have seen relative to what we have read. The brain’s ability to pull information together, to comprehend, evaluate, organize, and store the information is difficult to monitor because it happens without conscious awareness.

Reading is a particularly impressive example of the brain’s functional capacity. We are the only species on the planet (that we know of), that can use complex visual language symbols. Chimpanzees to a limited degree recognize very simple language symbols, but nothing remotely comparable to what we are able to do as human beings. As humans, we read printed material, not only convenient to our learning and education, it is an amazing demonstration of the brain’s functional capacity, particularly in its ability to process detailed information, putting it all together.

Some time ago, an interesting “demonstration” of the complexity and speed of printed language processing skills crossed my desk. Please read the following paragraph to yourself:

Aoccdrnig to a rscheeahrcr at an Elingsh uinervtisy, it deosn’t mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht frist and lsat ltteer is at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae we do not raed ervey lteter by itslef but the wrod as a wlohe . How auobt taht?

The paragraph demonstrates the brain’s ability to not only recognize and process single language symbols, but also language concepts, predicting the logical sequence of letters, but also words and sentences with the ability to generate simultaneous comparisons, contrasted with memory of higher probability associations, allowing us to recognize a word even with the letters scrambled. The suggestion is that “we do not read every letter in isolation, but the word as a unit.” Our brain looks for patterns and the predictability of the text is based upon “groups of letters,” but is also highly dependent upon words and letters previously presented. It is also dependent upon the content and the subject matter. Successfully performing the task (e.g., reading accurately) is highly dependent upon our ability to conceptually organize all of the information (i.e., symbols), making thousands of simultaneous comparisons, drawing upon our previous experience.

The “researcher” referenced in the paragraph actually is incorrect. The brain does not process just the first and last letter. The brain processes everything, all the individual letters, the number of letters in the words, what words come before and after each word. It is a great demonstration of our amazing “simultaneous multi-processor,” the brain! Given the complexity of processing visual language, it takes really very little to disrupt the process of reading. The diversity and magnitude of different types of reading disorder are heavily dependent upon the nature of the disability and how the brain is compromised (e.g., genetically, brain injury).

Applications of Self-Calming Strategies for Children

Mon, 30 Apr 2012 15:28:00 GMT

One of the things I enjoy most about a website/blog is that of interaction with parents, learning from the front lines! I find that I learn a significant percentage of my knowledge professionally from interactions with parents!

Children early begin to experience self-calming with specific activities. They learn early that rocking is calming. It is observed across a spectrum of development, particularly for children with more severe developmental disorders. At least one of our children had a “blankie” that in combination with a thumb, could not be beat! A favorite toy, stuffed animal, or other familiar object generated self-calming. Kids recognize at some level the increased level of arousal (e.g., fear, anxiety, stress) and seek out their preferred object. In a comment to the Blog “Learning from Each Other”, mom introduced herself as the “object of calming”, an excellent strategy, placing her in a position of observing the increased levels of arousal and facilitating calming. Not only is she able to observe, but she can model, direct, orchestrate, etc. the progression of awareness and strategies.

The challenge is in the developmental progression!! As our children mature, they spend more and more time away from us, providing less opportunity for observation or for participating in the calming process. The most critical basic skills are in identifying and understanding over-arousal and then identifying the most appropriate productive strategies to self-calm. A lesson I learned early in my career was that a GREAT strategy for one patient, was totally unproductive for another. Observing and “understanding the logic” of behavior is critical to successful intervention. Even many healthcare professionals get caught up in THE ANSWER, but it is different for every child, adolescent, and adult.

At the risk of being redundant, the basic principles are in recognizing/understanding the logic of the arousal when it occurs, identifying those strategies that are most successful to the individual in facilitating self-calming and self-regulating, understanding our own logic. That may mean a combination of strategies, including medication, self-hypnosis, environmental modifications, neurofeedback, all means of facilitating self-regulation of arousal.

Understanding / Recognizing Acquired Brain Injury in Pediatric Populations

Fri, 11 Nov 2011 16:48:00 GMT

I was recently consulting at a regional school for children with learning disorders, traumatic brain injury, autism, neurodevelopmental disorders, etc. As we were reviewing patient records, the question was raised whether a young teenager had experienced early acquired brain injury. One of the staff commented “No. She had a scan and it was negative”. I inquired as to what type of scan, the magnification available for the scan, and what was the medical history suggesting a scan. The expectation was that if there had been a brain injury of any type, it would have been identified by the scan. Myth #1

Another discussion evolved around the “physical” manifestations of acquired brain injury. The expectation was expressed that there would be obvious physical signs of such an injury – hemi-paresis, physical anomalies (e.g., “drag a leg and drool”), severe developmental delays, disruption of motor movement, mental retardation. The expectation was that such a patient is likely to be easily recognized. Myth #2

In the course of review of children identified for consultation, one child, roughly age six or seven, was observed to be aggressively attacking a peer who had taken their book away. He was hitting, kicking, and even biting. It was obviously necessary to restrain the child physically, two aides having a difficult time, even given their size and strength. “He is just “MEAN”! He is one of the children with severe psychiatric problems!” I asked to see the child’s chart, finding a history I had expected likely the case. A review of the medical history reflected a particularly traumatic delivery, the boy “stuck” in the birth canal for an extended period of time, but other than some scratches “looked fine” post delivery. Mom was reassured that he “was fine and would have no problems”. Myth #3

At the end of the consultation, walking out to the car, the director of the program thanked me for coming, and shared with me the experience her own daughter had experienced. She was riding her bike in the neighborhood (without a helmet), when she lost control, into a utility pole, striking her head. “She was crying but did not get knocked out. She was just cried, got up, and walked her bicycle home! Thank heavens she didn’t have a brain injury. She didn’t lose consciousness.” Myth #4

Undoubtedly, more than any generation before us, we have more opportunity to experience brain injury. Beginning with transportation, cars, planes, bicycles, followed by toys that create the opportunity, including Big Wheels, trampolines, skating, etc., we generate an amazing number of traumatic brain injuries. As reported by the American Associations of Neurological Surgeons (AANS.com), at least 21% of traumatic brain injuries in children were a result of recreational or sports related activities. There are statistics that surprised me! Even with our technology of air bags, seat belts, helmets, injury to the brain still occurs, but the severity decreases, the brain injury less obvious. On one hand, as a clinical neuropsychologist it is job security, there is plenty of work to go around! The depressing thought, in looking at the statistics for known brain injuries, with the exception of an Emergency Room visits, is how many brain injuries are not recognized as significant, and did not receive optimal support. Another story, another time!

Probably the most basic function of the brain is that of being an impressive “regulator/organizer”, at least when it is working properly! It regulates and organizes EVERYTHING we do. Truly, the brain gets a lot of help from its “friends”, such as the heart, the lungs, stomach, and others, all of which have specific basic functions to perform. The brain is the “organizer” of ALL functional capacity. Even when we are asleep, the brain is “on the job”. When the brain is injured, there are functional changes that are common, predictable, and often obvious, if you know what you are looking for. The symptoms are similar for children and adults, but given often adults hide “symptoms” better than kids. Adults have better control of their nervous systems by virtue of their age and physical maturity, and as such, symptoms are not usually as obvious. A concern for children is that brain injury can disrupt developmental progression, children potentially not keeping up developmentally.

Aside from the most extreme pathology or injury (e.g., severe TBI, brain tumors, physical manifestations (e.g., appearance, motor, function), the most prominent symptoms are emotional/behavioral, often diagnosed as “psychiatric disorders”, not particularly extreme in their manifestation. Parents may describe a “change in personality. Any of the following can be seen in normal kids, but when the numbers of behavioral characteristics increase, the potential for neurologic injury increases. Infants with early brain injury are often described as unable to negotiate the nipple, having a poor “suck”, not feeding well. Some exhibit extreme “colic” (but not really colic), becoming easily over-stimulated (e.g., noise, being held, bright lights, noisy environment). As kids develop, the demands increase. Sometimes they are late in developing (e.g., walking, talking), sleep may become more disrupted. Loud noises become disruptive, the child startling easily, and possibly to an extreme degree. Self-calming behaviors become more prevalent (e.g., “rocking” themselves), or other repetitive movement. Language delays may be observed. Slow developing motor function (e.g., not coordinated), multi-tasking, delays walking, poor coordination) are all potential contributors.

As the children get older, problems become to show up in decreased social awareness, not reading social cues. Inability to read social cues is often a problem; kids not making friends or not keeping friends. Computational math is a frequent prominent weakness in academic progression, slow in developing. Anger and related behavior problems become more pronounced, more reactive, more likely to seek a “physical’ solution (e.g., increased aggression, biting, kicking, hitting). Emotional volatility, confrontation, volatile temper, and generally poor mood regulation can be observed to varying degrees in children. This group of children often becomes lost, exhibiting poor visual/spatial skills. They do not keep up developmentally with their age mates.

All said and done, no child has all of these, normal children will have some. There is much be done to help the child and facilitate developmental progression. Early intervention is always suggested. The constellation of behavior is always somewhat unique.

Questions are invited for discussion within the group.

Responses to Myths:

Myth #1 – Scans are a very valuable tool but not capable of identifying all brain injury, especially in the more mild range. Some scans are not capable of picking up the subtley.

Myth #2 – Physical appearance, while perhaps obvious in some extreme forms of acquired brain injury, is never a particularly universal or reliable marker.

Myth #3 – Hypoxia is a potential consequence of some birth complications or trauma, injuring the brain, but not readily obvious in more mild to moderate injuries.

Myth #4 – Loss of consciousness (LOC) is not necessary nor is it always present for some brain injury, particularly for birth complications.

Is it Mental or Physical Health? YES!

Thu, 20 Oct 2011 21:00:00 GMT

In our culture, the assumption is that if you have brain injury, it is obvious. “The patient drags a leg and drools!” Not so. An overwhelming majority of individuals having sustained acquired brain injury would not be recognized as having a brain injury. The most common consequences of acquired brain injury are “neurobehavioral” or “neurocognitive”, evident in more subtle emotional/behavioral or neurodevelopmental disorders (e.g., anxiety, inattention, reactive attachment disorder, learning problems, impulsive behavior, problems with socialization).

Possibly the most disruptive event in the progression of health care was the division of Mental Health and Physical Health in the 1800’s. At the time, it seemed like a good idea. Sigmund Freud was actively diagnosing patients as having “mental illness” as opposed to being “possessed by demons”. Patients with extreme emotional/behavioral disorders (e.g., psychosis, schizophrenia) were at that time being placed in institutions or “insane asylums”, treatment focused upon driving demons from the body. Psychiatry as a professional discipline evolved, advocating for this population, dramatically improving their medical care. Further underscoring the separation, psychiatry developed their own diagnostic system Diagnostic and Statistical Manual, now in the 5^th edition. There has been “good news” and “bad news” in the progression of health care with that division!

Mental (behavioral/emotional) health has never really achieved the respect that it deserved in health care. “Oh, that’s just a mental problem!”, “The problem is all in their head!” The assumption has been that if the individual truly wanted to change, he/she could. The brain is as much part of the body as the lungs, heart, etc. In today’s health care, why is lung disease treated as health care, but consequences of injury to the brain, another organ in the body, treated as “mental health”? In the treatment of acquired brain injury, once rehabilitation is complete, the long-standing problems, commonly dysregulation of mood and emotion, now are behavior disorders (e.g., inattention, anxiety, depression, reactive attachment disorder, reactive extreme anger, cognitive disorders), often referred to Psychiatry. As time passed, insurance companies discovered that by dividing health care, they could isolate “mental health”, the coverage not as comprehensive. The challenge currently is that we are recognizing more than ever before, that the same brain is the foundation for physical medicine and psychiatric medicine.

In current society; transportation (e.g., cars, walking, bicycles), sports (e.g., football, hockey, boxing), and medical consequences (e.g., seizures, strokes, complications of childbirth, alcohol/drugs) are all potential contributors to acquired brain injury. When the brain is injured, the most prominent, persistent, and disruptive symptoms are often “behavioral” or “psychiatric”, evident in disruption of the brain's ability to regulate mood and emotion, increased irritability, reactivity, and emotional volatility. The patient is potentially less inhibited, more easily aroused, inattentive, anxious, more easily over-stimulated and more prone to extreme anger.

I remember as a graduate student in clinical psychology learning diagnostic classifications. In mental health, a majority of the diagnoses are symptoms, hence Attention Deficit Disorder, closely followed by Attention Deficit Hyperactivity Disorder (two symptoms). Anxiety Disorder is another symptom. Reactive Attachment Disorder, Oppositional Defiant Disorder, and Depression are other examples of “symptom” diagnoses. The diagnoses are descriptions of behavior, not related to basic etiology. This allows focus on the symptom/behavior, distancing from the underlying etiology, potentially a problem in considering treatment. The division of physical and mental health continues to confuse health care.

Mental health or physical health? In our culture, there is often considerable shame over a “mental health” diagnosis, to the point that many do not seek appropriate care. Frequently, a patient would benefit from both mental health and physical health care, but there is a tendency to identify either/or. My hope is for an evolving healthcare system that recognizes the intimate relationship between the mental health and physical health, recognizing that many of our disorders are "diseases" are a direct function of injury to the brain.

Your observations and comments regarding your experience in health care are welcome and encouraged!

Inside your Teen's Head

Mon, 18 Jul 2011 20:42:00 GMT

In Parade Magazine, November 28, 2010, there was an article published by Judith Newman, providing a valiant effort at communicating the logic, or apparent lack thereof, of the teenage brain. We have always considered teenagers to be different from adults, most frequently attributed to hormonal influences, lack of experience, poor parenting, and a variety of other less accurate or incomplete explanations. However, the foundation of the article was explaining the contribution of adolescent brain development as a primary contribution to explaining teenage behavior. As a clinical neuropsychologist, it makes intuitive sense, especially more pragmatically in observing their behavior, as they are very different from not only adults, but also from older peers. The brain regulates EVERYTHING we do, and clearly, having been the father of three teenagers, the behavior appears to be unique to the individual, but not as unique as it appears across individuals. Teenagers are in fact very different, by virtue of their experience and their development. There is a specific underlying “logic” to teenage behavior that may be helpful in parenting, specifically and generally.

The teenage brain is clearly a work in progress; it is far from having achieved the level of development enjoyed by adults, hence our struggle understanding our teenager! Certain functions, particularly those responsible for motor control or hand/eye coordination, are as well-developed early in adolescence as they will ever be, hence the ability to demonstrate their superiority for computer games! “The teenage brain is like a Ferrari: It is sleek, shiny, sexy, and fast, and it corners really well. But it also has really crappy brakes (and steering)! Unfortunately, some of the more important functions are dependent upon a nervous system that slowly improves over time, depending not only upon the stimulation and experience available, but also on the neurodevelopmental progression of the brain.

In an infant, each neuron (e.g., nerve cell) has around 2500 synapses (e.g., connections to other nerve cells). From birth to roughly age 3, that number increases to around 15,000, more or less. That allows our brain to process a greater volume of information, much more complex in nature, and process it more rapidly. That allows us to conceptually integrate and organize large volumes of information from multiple sources and to respond as necessary and appropriate. For teenagers that is not guaranteed! That increase in numbers of connections allows us to gradually process increasingly greater volumes of information, requiring much greater speed and complexity. With that in place, that level of complexity allows us to reason and problem-solve more complex information, more rapidly and efficiently. This explains the frequent problems observed in teenagers not “getting it all together”, not fully completing access to the information required. At times they appear to be so “clueless”, but at the same time very bright.

The brain experiences “a surge in brain wiring” early, originally thought to occur only once. We now know that there is another surge just before adolescence, and probably several others. As we mature, we go through a process of refining specific skills, reflected in anatomical changes in the brain (e.g., additional branching of nerve cells). There is also a process of “pruning” those connections. It is true, to a degree, that “if we don’t use it (nerve cell connections), we lose it”. Our brain adjusts to learning experience and to that which is of particular interest or value to us. Some areas will continue to progressively grow and develop; other areas influenced by activities/skills of lesser interest, may actually fade away. Some areas of the brain, such as the frontal lobes, particularly the pre-frontal cortex, responsible for organizing complex plans/ideas, forming strategies, and controlling impulses, may not become fully developed until the late 20’s. This explains, at least in part, why the teenage brain struggles to see “the big picture”, to understand the complexity of some tasks, and makes impulsive, often poor decisions.

There are other differences. Beginning in puberty and into young adulthood, an adolescent/young adult requires much more sleep than younger peers or than older adults. The adolescent brain is less able to regulate or control stresses, such as feeling ostracized, wanting to get even, and feeling enraged. As such, extreme behavior may be observed (i.e., Columbine). This uncontrolled mood and anger 50 years ago was less of a problem than now, automatic weapons, explosives, and other weapons available. Given the developmental differences in adolescent brains, their lack of perspective also fails to inhibit some choices or actions. Adolescent perceptions of emotion are frequently inaccurate and incomplete, the adolescent failing to integrate all of the information necessary/helpful in making decisions, sometimes life-and-death decisions.

Take an adolescent to lunch!!

"Brain Freeze" and Brain Injury

Wed, 25 May 2011 18:33:00 GMT

The cover story of Newsweek (March 7, 2011) describes an interesting but easily recognized phenomenon becoming more prominent in our daily routine. The article, titled “I Can’t Think!” (pp. 28-34), describes “brain freeze”, a reported consequence of individuals being bombarded by extreme levels of stimulation. The brain becomes over-stimulated and over-whelmed by the volume of information we process and information we consciously seek out. I remember a time when there were five or six channels on TV, and except a movie on Saturday night, there was not much going on. In stark contrast, in a world of Twitter, FaceBook, Smart Phones, iPads, and iPods, 60 or more TV stations, not to mention radio, TV, movies, CD’s, DVD’s, etc. we are dramatically over stimulated! Although the brain does an impressive job of suppressing excessive levels of stimulation, researchers are demonstrating an upper limit to what our nervous system can manage. It appears that we are now beginning to recognize that upper limit, choices necessary for quality of life. Persistent excessive levels of stimulation are demonstrating a negative consequence to our quality of life.

Although there are more, three prominent characteristics of brain function are frequent contributors to the problem. First, the brain works very hard to identify what information is important to keep and what we should disregard. The greater the volume of information available, the brain works harder under increasing conditions of stress on the system. Second, in addition to the volume of information presented, the rate the information presented potentially “knocks the brain for a loop”! The greater the speed at which the information is directed at us, the more aggressive the demand for the brain to make processing decisions. Third, the brain is wired to recognize and orient to changes in the environment. When there is limited or no change, our brain relaxes; with rapid changes from multiple sources, our brain becomes over-stimulated, subsequently over-aroused, and begins to shut down. When there are multiple changes, from multiple sources, occurring simultaneously (e.g., e-mail, Twitter, FaceBook, phone, conversation) the brain begins to lose its ability to process, control, and use the information. This process generates a condition of “extreme fatigue”, leading to deteriorating loss of function, apparently a problem for many.

Reading the article, I was struck by the similarity of functional consequences of “Brain Freeze” and brain injury. The article cites research demonstrating that “under an onslaught of information”, the brain becoming over-whelmed, the prefrontal cortex (PFC) of the brain “waves a white flag” and shuts down, functional capacity deteriorating as though a “circuit breaker had popped”. There are reported demonstrated changes in blood flow to the PFC. When an individual is faced with an over-whelming number of choices (e.g., over-aroused), there is greater likelihood the individual will become immobilized, unable to make choices, and shutting down. When the brain is injured, the processing speed and efficiency becomes significantly reduced, a result of damage to the nervous system. The resulting consequence is that the brain does not function optimally or even malfunctions, often as a result of over-stimulation leading to excessive arousal. Under conditions of excessive levels of arousal, the brain begins to react defensively, behavior becoming much more extreme (e.g., rage, anger, emotional volatility.

Another finding reported in the Newsweek article was that of the benefit of “pulling back” from the constant influx of information, “taking a break”. There are potentially major consequences of “persisting at high levels of stimulation, with subsequent excessive levels of arousal, resulting in compromised functional capacity. Speed, efficiency, and accuracy begin to decrease. “Over-whelming and distracting the brain, makes it more difficult to tap into the specific core information you require” (Newsweek). In contrast to speed, it would appear that pace and balance is critical to cognitive strategies to maintain optimal levels of neurological and cognitive performance (e.g., thinking, problem-solving). There is a definite limit to our working memory. When it stops functioning, our ability to think, reason, and problem-solve is negatively impacted, adversely affecting our memory and learning.

Although it is of interest that “Brain Freeze” is similar to what happens to individuals experiencing acquired brain injury, the mechanisms are different. In contrast to “Brain Freeze”, where there is a pathologically increasing level of stimulation, with acquired brain injury, for children, adolescents, or adults, the ability to regulate is lost, at least temporarily, but with more severe injury the loss can be permanent. The brain is particularly vulnerable to becoming over-stimulated and over-aroused, the brain less able to regulate function. It requires much less to “shutdown”. Patients with brain jury usually avoid the high levels of stimulation of crowds, such as K-Mart and similar stores, athletic events and other high stimulation environments because the individual with acquired brain injury tend to shut down as a result of the over-stimulation, the individual unable to “self-calm”. For a patient having experienced an injury to the brain, the situations of over-stimulation described in the article would be even more dramatically over-whelming and unproductive. Individuals having experienced acquired brain injury experience particularly extreme “brain freeze”, but at much lower levels of stimulation than the healthy brain. Most of my patients, in recognizing their tendency to become so easily over-whelmed (i.e., “brain freeze”, they learn to actively avoid environments or situations characteristic of extreme arousal.

The article is a good read to become more aware of individual limits and boundaries in balancing our daily routine, finding comfortable limits, and maintaining them to the degree possible. Check out the article online.

What is in a Diagnosis?

Thu, 12 May 2011 17:14:00 GMT

I am always fascinated overhearing mothers in the waiting room talk about their children’s diagnoses, what they had to go through to get that diagnosis, and what they anticipate they must do to “fix” it. Mental health (psychiatric) diagnoses are often descriptors: anxiety, depression, inattention, reactive attachment disorder. Clearly there are some more visible “designer diagnoses” that go around, Attention Deficit Hyperactivity Disorder being one of those! Autism and Asperger’s are close behind. Complicating the diagnostic process is the division of mental health and physical health. There is no good reason for the division, but in 1880 it made sense and insurance companies now are using it to their advantage, reimbursing at different fee schedules for mental and physical health.

Many “mental health” diagnoses are as brain-based as any physical disorder! ADHD is a malfunction of the nervous system (i.e., brain) “not doing its job”. For patients having acquired brain injury, subsequent symptoms of anger, depression, inattention are not “behavioral” or “psychiatric disorders”, they are arguably neurological disorders. And the list goes on. . . .

Identifying a diagnosis is an interesting phenomenon in mental health. There is frequently the expectation, conscious or unconscious, that having “named it”, we can now fix it! After all, in general medicine, isn’t that the way it works? The problem is identified, medicated, excised, exercised, massaged, and then fixed or at least improved! If only it were that simple! The diagnostic process begins with the problem being named, a mother often offering an opinion, in combination with word of mouth from other mothers. They identify a clinician they believe they can trust. Often a health care provider, having earned the trust of the primary care physician or other health care providers, receives referrals of patients or their mothers, having had a positive experience with that care provider.

I am embarrassed to admit that it took me a while before I REALLY understood the complexities of the diagnostic process. Prior to that, diagnoses had a basic functional value; if I didn’t provide a diagnosis, I didn’t get paid by the insurance companies! I know. It was a little self-centered of me! The more embarrassing part was I still didn’t understand the emotional/psychological significance for mothers in identifying a diagnosis. I hope mothers of my previous patients aren’t reading this!

However, having a system divided into mental health and physical health doesn’t consistently make sense. Individuals having experienced brain injury, experiencing emotional/behavioral symptoms are diagnosed and treated under “mental” health. Illness or injury to the body, is “physical” health. For some patients it is a greater problem than for others. Unfortunately, identifying a diagnosis is not that simple in behavioral health! A child diagnosed with Attention Deficit Hyperactive Disorder can be inattentive or hyperactive for many different reasons. Impulsivity, reactivity, inattention, hyperactivity, anxiety, low stress/frustration tolerance, are all considered “behavioral” but in reality are commonly observed in patients having medical or neurological (i.e., brain-based) problems!

As a result, the diagnostic process is a little more complicated that it appears, not particularly precise, and doesn’t always accurately direct treatment considerations. A majority of my patient population experience known or suspected brain injury. They have often received a neurologic diagnosis, but also have been diagnosed with emotional/behavioral disorders. My office staff bounces back and forth between mental health and physical health benefits, because different carriers provide different coverage.

We struggled in naming our website, seeking to identify in as few words as possible our goal in producing a Website. “Understanding the Logic! – Moving Beyond the Diagnosis” summarizes succinctly that goal. Don’t get me wrong; diagnoses can be a good thing. However, when the day is done, beyond the reimbursement process, there is little to show for it beyond having the treatment service partially reimbursed. As a clinical neuropsychologist, the diagnosis helps pay the bills, but I do not believe it necessarily does anything for the patient. My goal in the process of testing/evaluating a child is not to just identify a diagnosis for the child, but rather to understand the logic of the behaviors observed. That may contribute to or modify the diagnosis, but most important helps the parent, educator, or primary care physician to “Understanding the Logic” of the individual child. That logic should facilitate the parents’ and others’ understanding of the child, addressing their needs, and adjusting what we do to optimize and facilitate their developmental progression.

Success is the consequence of a collaborative effort of neuropsychology, education, physician, and parent, with a few others thrown in. It would be nice if the clinician could do it all. The bottom line is that the parent, usually the mom, must be the “choir director” for the group, especially in using a clinical neuropsychologist (my bias), if she has confidence in him. I have seen many patients complete the process. While I did my part, moms made the difference, using the clinicians and educators optimally.

We would love to hear your experiences, good or bad, in better understanding your experiences and resources you have accessed.

Should I Let My Son Play Football?

Sat, 25 Feb 2012 16:26:00 GMT

The mother of one of my patients came in recently carrying the alumni magazine “On Wisconsin” from the University of Wisconsin. Such articles are increasing awareness of brain injury, changing the way the game is played. Rules are in place to prohibit more extreme impact, especially for professional football, but still not sufficient. The article in question “Head on Collision” was addressing the violence in football and the consequences, most notably potential for traumatic brain injury. It was not the first article; it won’t be the last. As a good mother, she was concerned for consequences of her son playing football in junior high.

Mike Webster, an alumnus of the University of Wisconsin, was one of my favorite players. He played seventeen years for the Steelers, playing Center, not considered a high impact position, as for a wide receiver or running back. After hiking the ball, his job was to charge into the defensive line, initiating contact with defensive players, play after play. He retired in 1990, after 17 years, hooked on pain killers. By 2002, Mike was dead, but not before suffering chronic pain, amnesia, depression, and dementia. At autopsy, his brain showed the signs of his football career, multiple indications of traumatic brain injury.

There is growing interest in the risk for concussion in football and the consequences. Many football players are donating their brains at death, to better understand the consequences. Roughly six months ago, a former NFL player, stabbed himself in the heart, thus preserving his brain for autopsy to demonstrate the basis of the symptoms he was experiencing. He was struggling with major problems associated with the consequences of brain injury, including extreme fluctuations of mood and emotion, memory problems, and anger to the point of rage. His desire was to help/warn others of the unseen consequences of repeated blows to the head.

Players from the NFL are arguably extreme examples. Should the young man mentioned above play football, in high school? Some would argue yes; others, no. As Americans, we cheer our gladiators. Football and hockey are particularly violent, players prone to acquire brain injury. It is becoming more obvious that repeated blows to the head are not a good idea. In high school, is a student at risk for major injury? Depends! What is the “job description” of the position, level of aggression, level of competition (i.e., Pee Wee, high school, college, professional). As players move up the competitive ladder, violence increases. Risk factors (i.e., concussion, physical injury), with bigger, stronger, faster athletes, create greater risk for physical injury, including repeated concussion.

High school football is not the same level of risk of college or professional football. However, there is the risk of unfortunate injury, generating permanent neurologic injury. The problem is most often not a consequence of a single blow, but with repeated blows to the head and the cumulative consequence of such. Equipment is dramatically much improved in protecting the player but the player is still at some risk. Perhaps the Latin expression “caveat emptor”, or “let the buyer beware” says it best…..

New Blog Format

Fri, 06 May 2011 16:21:00 GMT

In the next week, we will be introducing a new blog format. I feel like the blog is becoming hard to navigate and want to make it easier for people to find the information they need. We will be dividing my individual blog into two separate blogs.

"Understanding the Logic"
This blog will focus on my goal of helping parents, teachers, spouses and others understand why the individual does what they do. What is the logic of the individual’s behavior? By understanding the logic of symptoms, a more specific treatment plan can be provided in combination with educational support to optimize outcomes.

"Working to Achieve Balance"
This blog will focus more on the next steps to take once we understand the logic. This will include therapy tools, parenting tools, educational tools and accommodations etc. Our ultimate goal of our blogs is to help people to find and achieve balance in their lives.

As always, it will be a work in progress. You input is always welcome and appreciated!