Brain Evaluation

The low fliers

What to do about the low fliers; the ones who are clearly out of sync with their environment, at home and at school? They are unhappy, alternating between poor behaviors and upsetting everyone, then feeling badly and asking if they are still loved or are they still going to get the treat that was promised to them or are they okay. They are reactive emotionally, often intolerant of everyday situations; their behavior is impulsive and the first thing everyone thinks is ADHD and they certainly fit the characteristics of this disorder.

But here is the problem, you test them and they have symptoms of executive reasoning.  Attention problems that seem to follow the pattern of ADHD inattentive type suggests a genetic disorder that has been exacerbated. So what is the problem of labeling ADHD when we see characteristics that are more related to executive processes? Because the label leaves them at risk for a lifetime of medication and no resolution; tired parents, low self esteem in the child and continuing unresolved problems. You refer them for a sleep study with all the symptoms of apnea and they come back okay and you ask the question, well, how close were they to sleep apnea? Or how well was this measured; or was the CAP scoring used or were other methods used to determine sleep disordered breathing? You can’t question the professional especially if they are a big deal in their field so what to do? You ask the treating physician about an EEG which comes back normal: But how normal? The pediatric neurologist is well known.  How dare you question his read on things, but you can’t help but think there has to be some differentiating factor that creates this unmanageable kid who is so difficult for himself to deal with along with his parents and everyone else. So now you begin to treat and you do what you can with many of the causal factors remaining untouched. You are criticized for thinking critical thoughts about other professionals when your only concern is that something was missed that could be treated and could make a huge difference now:  But all you can say to the parents is, “well there does not appear to be anything but lets do some treatment of the symptoms we know are clearly there and maybe discuss with your treating physician repeating these tests in a year”.

 

Testing For Autism

It appears that schools have finally agreed to the consensus that the autism spectrum is a group of neurodevelopmental disorders with a multitude of causative factors.  The brain is clearly involved in this disorder spectrum and considered the reason for the red flags of a lack of language development, formally seen at 12 months when the child is not babbling or gesturing, at 16 months when not using single words meaningfully, and at 24 months when not using two word spontaneous phrases accompanied by a problem socializing.  It is becoming accepted knowledge that the common denominator between the social and behavioral difficulties as well as language losses is the frontal, executive reasoning processes. 

Agreed upon general characteristics are the following:

·       Cognitive: Uneven development of cognitive skills,

·       Social skills: Difficulty understanding social rules, turn taking, sharing, being aware and correct perceiving and interpreting nonverbal facial expressions and emotions of others, ability to be empathetic and aware of the feelings of others

·       Communication: Difficulty responding to verbal information, multiple step commands and lack of expression of needs and wants, organization and self direction, difficulty screening out distractions, completing activities independently, initiating work activities, organizing free time, stopping one activity and moving on to the next, being flexible, and shifting attention

 

Does this not sound like executive reasoning deficits?

So, I have to question why the schools do not routinely refer out for neuropsychological evaluation to diagnose the autism spectrum given that this is not their area of expertise nor, generally speaking, have they received essential in it.

Why do the schools insist upon using self report measures and preschool language tests; measuring what is already obvious to diagnosis this disorder? A parent is not always made aware of the difference in diagnosis by a school professional versus a neuropsychologist, maintaining that their child has already been diagnosed. They do not understand that the “testing” received from the school, consisted of the completion of self-report measures that they filled out regarding the symptoms they observed in their child and that no testing was actually done.  Thus the diagnosis was based upon the opinion of the parents and their view of their child as well as what was observed in the classroom by the teacher or members of the study team. 

 Because the school insists that they are able to diagnose Autism spectrum, Asperger’s and a variety of disorders, the insurance companies will not pay for testing outside of the school system, insisting that the interpretation of the new school laws are such that they are responsible for any and all testing that a child needs.  Schools who are struggling financially have inadvertently created a problematic situation for everyone involved.  School psychologists who are not licensed psychologists insist upon instructing parents that they should not have “outside testing” done by a professional neuropsychologist, that it is not needed. Should the schools really  be responsible for all of this: For a neurodevelopmental disorder, from diagnosis to treatment?

Autism spectrum, might I remind the reader is a brain disorder not a behavior disorder. So why is it being diagnosed as a behavior disorder?  When the school  receives a neuropsychological evaluation instead of being grateful that someone in the community took the time to identify the child’s learning needs and to work synergistically with the school, they denounce the evaluation, discredit the professional, and/or ignore the report all together:  Such a waste when the schools already admit that autism spectrum is a brain disorder. As always the child and the parents suffer.

Driving: When to Give Up the Wheel because it is Not Safe for Others

Driving skills deteriorate with increasing dementia severity.  High risk drivers are those with unidentified or identified mild cognitive decline.  It is important that a physician trained in the aged population be the person to direct their patient to stop driving to relieve that duty from family. Physicians may need the help of a neuropsychological evaluation to provide assessment to help diagnose their decision. It is important to pay attention to the following warning signs:

·       Decreased miles being driven

·       Collisions

·       Moving violations

·       Avoiding certain driving situations, driving at night or in the rain

Aggressive or impulsive personality traits

The presence of routine helps sleep quality in the Aged

Maintenance of daily routines in the elderly was found to be associated with a reduced rate of insomnia.  This study found in Sleep, (Vol 33, 4, 2010) highlights the need for routine in the elderly population and the importance of preserving routines even as changes are made in dwelling and living conditions.  Treatment would benefit from interventions that are structured and built into the individual’s already established routine.

TNF levels are a mechanism behind the Apnea-Stroke Link

TNF, the inflammatory protein tumor necrosis factor was identified as being significantly higher in OSA patients.  Authors think that the inflammation is the origin of vessel damage resulting in stroke.  (Neurology Today, July 1, 2010). TNF alpha levels were found to be increased in children diagnosed with OSA driven primarily by sleep fragmentation and body mass index, closely associated with the degree of sleepiness. Surgical treatment for OSA (tonsillectomy and adenoidectomy) was found to result in significant reductions in the TNF alpha levels as well as prolonged sleep.

TBI associated with Major Depression

Traumatic brain injury may lead to major depression. Finding of new study that half of those diagnosed with TBI had a major depression (Neurology Today, July 1, 2010).  The patients also reported a high level of anxiety.  Both of these issues affected their quality of life and contributed to more functional impairment one year post injury.  The study suggests that major depression is very common after traumatic brain injury and associated with significant disability. There can be a brain triggered depression following TBI that is too deep and too severe for psychotherapy and/or medication to make a tremendous difference which needs to be recognized as a treatment variable.  Treatment should involve the whole family as a result, in the recognition that the brain injured person does not have a great amount of control over their depressed thoughts and as such cannot make changes on their own without support.  Cognitive therapies are very critical in the need to establish open communication to address the internal thinking processes of the brain injured person that are often not reality based.  The tendency is to think that things are far, far worse than they actually are or need to be. Recognize that you may or may not be able to talk the person out of their thoughts or dark beliefs and be ready to be creative in offering alternative treatments such as brain training and other methods to address the “crooked thinking”.

Spouses of Dementia have a six fold increased risk of dementia onset with husbands at higher risk than their wives.

A large population of 2,442 participants were studied for up to 12 years showing that dementia was significantly associated with older age and having a spouse with dementia.

The Benefit of Reading and Hobbies to lower the risk of Dementia

Dementia is now recognized as a chronic disease affecting 35.6 million with the expectation of increasing to double that amount over the next twenty years.  There is scientific interest that older adults may alter their risk of dementia by keeping their brain active.  The MoVIES project was a study initially enrolling 1,681 participants from a blue collar rural area of southwestern Pennsylvania who were at least 65 years of age with at least a 6^th grade education beginning in 1987.  They were followed at two year intervals through 2002.  They were asked to self report their leisure activities and dementia assessment was completed.  942 people were used for follow-up, ruling out variables of reading ability and participation.  The result of this study (American Journal of Alzheimer’s Disease & Other Dementias, 25, 5) found that engaging in hobbies for one or more hours per day was protective against developing dementia in later life and associated with a lower risk to develop dementia.  Research points to the benefit and need to remain active in your life and to keep your brain active.

Executive Functioning Deficits in Parkinson’s Disease, Amnestic (Memory) Mild Cognitive Impairment

Studies are suggesting that mild cognitive impairment or MCI appears prior to the onset of dementia associated with PD or Parkinson’s.  A recent study (American Journal of Alzheimer’s Disease & Other Dementias, 25,5) assessed patients diagnosed with MCI and PD finding significant executive reasoning deficits using tests of distractibility, fluency, cognitive flexibility, sequencing and new and novel learning.   The suggestion is the presence of attention/executive reasoning deficits and the need to focus upon examination of memory and executive reasoning deficits in this population. 

Depression is a Problem, An Independent Risk Factor for Dementia and a number of Illnesses

Depression is not longer something to ignore.  Those individuals who have been depressed since childhood with what we call endogenous depression or depression throughout their life (often present in the family history) are likely at more risk for all kinds of problems with graceful aging.  Recent research (Neurology 7-6-2010) shows that depression is associated with an increased risk of dementia and Alzheimer’s disease seen in women in a study spanning 17 years.  949 participants from the Framington heart study were assessed for depression and during the 17 year follow-up period, 164 developed dementia and 136 of the cases were Alzheimer’s dementia.  Lifestyle factors associated with longstanding depression such as diet, physical activity and social engagement may be some reasons for the increased risk of dementia.  Research reports that depressed patients are 1.5 times more likely to develop dementia than those who are not depressed.  Each depressive episode resulted in a 14 percent increased risk for dementia. One depressive episode results in a significant 87 percent increased risk of dementia.  The suggestion is that depressive symptoms create a wear and tear on the brain making it more vulnerable to common pathologies of Alzheimer dementia. Doesn’t that make you want to address any symptoms of depression today?