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Pediatric Brain Injury: Applications of Clinical Neuropsychology - featured May 23, 2011

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Pediatric Brain Injury: Applications of Clinical Neuropsychology

By: David E. Nilsson Ph.D ABPP/CN

Appropriately, the brain is described as the functional “center” of any individual, unique to the individual from conception on, shaped by our genetic endowment, and experience in our neurodevelopmental/neurobehavioral history. The brain directs what we do, how and when we do it, processing every thought, sensation, or motor function we experience. It regulates all body function, our sensory systems (e.g., visual, auditory, tactual, gustatory (taste), and smell), and becomes the foundation of our personality, moderating all our interaction with our environment. The brain integrates and organizes information central to our reasoning, judgment, and problem-solving, facilitating communication, learning, and socialization. Perhaps most important to our discussion is that of the brain’s role in regulating and managing our exposure to stimulation and our response to that stimulation (i.e., arousal). Unfortunately, not all brains are created equal! No one recognizes this more than clinicians and educators working with such individuals day-to-day. However, there remains a lack of consensus for the “logic” of behavior of the individual. The most basic consequence of injury to the brain is to disrupt the “logic” of learning, behavior, and function of the individual, as they were and as they will become. As educators and clinicians, it is our role to identify and understand that “logic” to direct our efforts.

The science of Clinical Neuropsychology, the study of neurocognitive and neurobehavioral function of the brain and the consequences of injury, in collaboration with other disciplines, has become a more productive resource to health care providers over the last thirty to forty years, contributing to a progressively enriched understanding for function of the brain, the consequences of an acquired brain injury, and foundations for directing clinical care of brain injury patients. For me personally, applications to a pediatric population have been of particular interest. Understanding the “logic” of function of the brain, the “logic” of acquired brain injury, and the “logic” of the course of recovery of function and continuing neurodevelopmental progression, is critical to the well-being and the developmental progression of the individual. Unique to a pediatric population is not just an interest in the consequences of the injury at the time of injury, but most importantly to understand the likely developmental and neurodevelopmental consequences of the injury and the specific needs for intervention in a clinical population.

The contributions of clinical neuropsychology to the individual patient and to the rehabilitation process have become progressively more available, contributing to a more complete understanding of the individual brain, the consequences, both general and specific, of brain injury, and identifying specific interventions to facilitate optimal physical, neurocognitive, and neurobehavioral recovery. The last ten to fifteen years have been particularly productive in considering specific applications of clinical neuropsychology, more critically, interfacing with other disciplines. Unfortunately for pediatric populations, the applications of clinical neuropsychology to education have been slower in developing more specific understanding of the neurodevelopmental consequences to date, relatively limited to date. The foundation for the understanding of learning, neurodevelopment, and neurobehavior in education has not been consistently based in neuroscience, leaving some gaps in our understanding and application. Not unlike other disciplines, education has been slow in integrating clinical and educational applications for neuroscience. Differing opinions or observations are welcome for discussion!

I have been invited from time to time to write or talk about applications of clinical neuropsychology, always welcoming the opportunity to discuss acquired brain injury, the consequences of such, and specific applications for intervention. I have also attended many presentations by colleagues sharing potentially valuable information. It has occurred to me, albeit slowly, that many presentations, my own included, have been limited in specific practical application. The content routinely is predominantly factual information. Those receiving information often do not acquire specific information facilitating application of the material presented. It does not necessarily contribute to better understanding the underlying logic of how we consider treatment applications for those we serve, identifying specific logic or applications addressing clinical/educational needs of the individual. It should facilitate “understanding the logic” of the central nervous system, the brain specifically, using that logic to contribute to the process of recovery, recovering lost function, and protecting ongoing neurodevelopmental progression. My goal here is not to train clinical neuropsychologists, but rather to use what is known from the study of clinical neuropsychology and to facilitate identification of successful applications to treatment, education, and clinical management of patients generally.

The general consensus of our culture is that if you have a brain injury, you “drag a leg and drool”. While that can be observed with very severe brain injury, it is infrequent across the spectrum of brain injury. When we think of brain injury rehabilitation, we think of that patients having experienced severe brain injury. However, they are the clear minority in the population of brain injured individuals. Many walk among us, potentially presenting as having some problems; others are “invisible” until they are recognized, often not until a complete medical and developmental history is available. Only then is the underlying “logic” of the brain injury of an individual available. Some are obvious, a disruption to language, expressive and/or receptive; functional motor deficits, gross and fine motor, are more available to observation, but often are more limited in their disruption in the overall constellation of symptoms! The most disruptive functional losses resulting from traumatic brain injury are not readily visible. A child having a hemi-paresis experiences multiple other consequences of the injury to the brain, much less obvious, both short-term and long-term, but creating major disruptions to developmental progression and functional capacity. Yet commonly, the focus of treatment is upon the motor function.

In considering a child with presenting history of acquired brain injury of any type, few children present with all of the potential symptoms. Children, as a rule, are less likely to verbalize the full spectrum of symptoms, are able to recover more quickly, and as such be over-looked for specific intervention. As such, it becomes critical that those working with children, educators, physical therapy, occupational therapy, speech/language therapists, and school psychologists, watch for the spectrum of potential consequences of brain injury, identifying those children at risk, considering treatment applications, initiating optimal educational, developmental, and other interventions to minimize the potential consequences, especially those less than obvious.

The list of potential consequences of pediatric brain injury below does not list all potential problems but rather the more commonly observed and reported. These are not presented in the order of greatest significance; for each child the constellation of symptoms is unique, an interaction of their genetic, developmental, and personality characteristics interacting with the consequences of traumatic brain injury. The following are presented for your consideration:
  1. Self Regulation – a primary function of the brain is in the regulation of multiple systems of the body, physical responses to heat and cold, body temperature, light/dark, heart rate, respiration, regulation of arousal and the list goes on. The most prominent and obvious disruption to self-regulation in children is that of behavior; adults are not exempt. The brain’s ability to regulate mood and emotion, inhibiting more extreme emotional response is disrupted. A spectrum of anger may be observed (irritation to rage), increased aggression, impulsivity, inattention, difficulty inhibiting inappropriate behavior, and limited self-monitoring. Changes in “personality” are often reported, a reflection of the behavioral change.
  2. Conceptual Integration – the brain has the ability to pull information together from multiple sources and multiple senses, allowing us to conceptually integrate information. For example, a child with brain injury can often read material very well but is unable to integrate the letters/words into concepts, visual representations; as such comprehension is less than optimal. It allows us to remember and assimilate what we learn. It directs our behavior in the context of the situation, the environment, individuals, etc.
  3. Speed of Processing – when healthy, the brain processes information rapidly, without a conscious effort, assimilating information rapidly and efficiently. With brain injury, functional capacity is potentially slowed considerably, creating problems for learning and processing information generally. Problem-solving may be slower and less fluent.
  4. Attention/Concentration – the brain is actively involved in directing the attention of our senses to learn, for safety, for security, and multiple other activities. When the brain is injured, that process is disrupted and consideration for educational and developmental support should include evaluating the loss and making treatment recommendations and accommodations.
  5. Disruption to Ongoing Development – It is not uncommon in monitoring children presenting with history of traumatic brain injury or other neurologic injury, to discover that they do not keep up with their peers. It is CRITICAL to monitor educational and developmental progression of such children, intervening as necessary to optimize progression in acquiring skills and being able to apply those skills. Children who fall progressively further behind are likely to have greater difficulty in catching up with peers, less likely to finish school, and more likely to under-achieve.

It is critical to consider not only loss of function, but also to identify difficulty keeping up, intervening early post-injury, relearning skills, or identifying adaptive and compensatory strategies. Interventions to facilitate self-regulation of moods/emotions (e.g. medication, NeuroFeedback) improve attention/concentration (e.g., medication, NeuroFeedback).

Featured Author and Organization: David E. Nilsson Ph.D ABPP/CN and the NeuroDevelopment Resource Center

David E. Nilsson Ph.D. ABPP/CN is a clinical neuropsychologist having offices in Salt Lake City, UT and Boise, ID (long story). Although he sees children, adolescents, and adults, his practice is more predominantly pediatric, having begun his career as a pediatric neuropsychologist at Primary Children’s Medical Center in Salt Lake City. He has been committed not just to neuropsychological testing but to identifying and implementing aggressive early neurodevelopmental treatment and support, a critical contribution of pediatric neuropsychology in collaboration with other clinical disciplines.

The NeuroDevelopment Resource Center was organized as a means of sharing information, educating parents, educators, and clinicians, and “Understanding the Logic”, the title of his website/blog (http://www.neurodevcenter.com). The Center provides diagnostic and clinical support to patients and their families, identifying and implementing traditional and novel strategies (e.g., NeuroFeedback).




Tags: Article TBI School Psychology Newsletter 27 May 2011