Einstein’s Relativity

“I am a foster parent. My (foster) child appears angry with periods of rage and depression along with acting out, aggression… he can’t sleep at night, can’t sit still… and has basically no friends because he plays too rough. His family background is a mess… father is incarcerated, mother has a long drug history with multiple paramours, alcohol abuse, domestic violence. We have been told that he as ADHD, ODD and bi-polar disorder. He has "failed" trials on three different psychostimulants and now is taking some kind of cocktail that includes three medications at one time. Are his problems biological or environmental?” Hmmmm…

… this may take a minute to formulate a theoretical background… but please be patient with me… Einstein’s “Theory of Relativity” boiled down to its child-like essence goes something like this. As a boy, young Einstein would sit along the railroad tracks and watch the trains go by. In his book, Relativity, he recalls wondering what would happen if someone threw a ball up in the air while riding on a moving train. What would it look like? Well, if you were on the moving train the ball would travel in an arc … and one could actually construct a mathematical equation that would define the arc. But, if you were sitting beside the train tracks, the ball would travel straight up and down in a line and you could construct a mathematic equation that would define the line. Both are mathematical truths! So, which is true? Does the ball travel in an arc or line? The answer… it depends on the relative position of the observer.

Hmmmm… what does that have to do with neuropsychology in general or your child, in particular? Is a symptom/problem related to a physiological disorder (mass) or a psychological disorder (energy)? The answer? Yes… it is both… any symptom/problem will have both physiological (brain/body) and psychological (energy/spiritual) components. The implication is that a holistic approach that seeks to understand both physiological and psychological contributions to symptoms is critical… and that interventions must necessarily consider both physiological and psychological factors. The physician who treats only the body is a fool as equally as the psychologist who only treats the psyche… the mind and body are simply two aspects or perspectives of the same person… and treatments must consider both avenues.

What does this have to do with your child? It means that your activities, relationship, home environment, emotional tone, etc. are as critical to your child’s healing as the medication. Oftentimes we look to wizards (ie., physicians, psychologist, etc.) to treat the body and feel powerless or impotent to affect outcomes. Your efforts are central to healing!!!

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

Autism Part 2

So, what causes autism? The person who answers that question wins the Nobel Prize in Medicine! Unfortunately, my best guess is that there will not be an answer, but multiple answers since there is no autism, but multiple autism spectrum disorders each of which may have its own unique etiology (cause) and biological features.

The research on the causes of autism appears to bear out this hypothesis. In an article, entitled “Neuropathological Findings in Autism”, (Brain 2004 127(12):2572-2583; doi:10.1093/brain/awh287), that extensively reviewed the research on autism spectrum disorders Saskia J. M. C. Palmen, Herman van Engeland, Patrick R. Hof and Christoph Schmitz conclude that “the majority of the neuropathological data (on autism) remain equivocal” with studies variously relating autism spectrum disorders to: (a) a decrease in the number of Purkinje cells throughout the cerebellar hemispheres without significant gliosis, (b) features of cortical dysgenesis, (c) increased cell packing density of smaller neurons in the limbic system, (d) age-related abnormalities in the cerebellar nuclei and the inferior olive, (e) abnormalities in nicotinic and muscarinic cholinergic neurotransmitters/neurons and (f) abnormalities in the GABAergic system.

While neuroimaging and neuropathology studies have yielded equivocal (and occasionally polar opposite) findings, several functional features of autism spectrum disorders remain constant and implicate involvement of several brain functions.

• Studies have consistently demonstrated abnormal fear (ie., “fight or flight”) responses among individuals with autism spectrum disorders with references to social anxiety, poor eye contact (avoidance), sleep disturbances, obsessive-compulsive features, anger, poor impulse control, depression and paranoia… and these abnormalities in behavior coincide with research showing abnormalities in the size and function of the amygdale which is a relatively small almond-shaped region embedded within the limbic system, the same limbic system that govern “fight or flight” distress responses. This brain (amygdala) – behavior (fight or flight) connection appears to account for a cluster of symptoms/problems associated with autism spectrum disorders. Unfortunately, the cause of amygaloid abnormalities is not clear. While it is possible that the amygdaloid abnormalities reflect a breakdown in the blueprint (genetic/DNA), it remains quite possible that this abnormality is related to a breakdown in other brain regions connected to the amygdala (ie., other regions whose input to the amygdala spurs development). The possible role of a breakdown of the myelinated axons that connect brain regions (ie., limbic-frontal lobe connections) has been suggested.
  
• Research has consistently demonstrated the presence of abnormal sensory gating (ie. inhibition, selection, direction, etc.) among individuals with autism spectrum disorders with references to no pain responses, exaggerated pain responses, needs for deep pressure/touch, avoidance of touch, ear guarding under high stimulation settings, limited visual searches, … and these abnormalities in behavior coincide with research showing abnormalities in the size and function of the thalamus. The thalamus is located deep within the subcortical region and has been described as being the Grand Central Station of the brain with a primary function of routing sensory information (ala passengers) to their appropriate locations. Poor routing may account for sensory over-load along with failure to attend to some relevant stimuli… along with the bizarre symptoms of sensory contamination (see Born on a Blue Day in which the author reports seeing numbers in color). This brain (thalamus) – behavior (sensory routing) connection appears to account for a cluster of symptoms/problems associated with autism spectrum disorders. Unfortunately (does this sound familiar… see the amygdala above) the cause of thalamic abnormalities is not clear. While it is possible that the thalamic abnormalities reflect a breakdown in the blueprint (genetic/DNA), it remains quite possible that this abnormality is related to a breakdown in other brain regions connected to the thalamus (ie., other regions whose input to the thalamus spurs development). The possible role of a breakdown of the myelinated axons that connect brain regions (ie., cortico-thalamic and upper brainstem-thalamic connections) has been suggested.
  
• Research has consistently demonstrated the presence of abnormal social responses among individuals with autism spectrum disorders with references to poor eye contact, limited initiation of reciprocal play, limited attachment/empathy, failure to follow the gaze of others and failures to maintain social relationships… and these abnormalities in behavior coincide with research showing abnormal “mirror neuron” activity. “Mirror neurons” have been named due to the fact that the neurons appear to be activated when an animal performs an action and when the animal observes the same action performed by another animal. These “mirror” neurons have been implicated in observational or social learning, social interest and language development. “Mirror neurons” have been identified within the prefrontal cortex….and the “frontal lobes” tend to function as our executive or coach with functions of organization, planning, use of feedback to adapt/change, observer functions and internalization of social rules. This brain (frontal) – behavior (poor executive function) connection appears to account for a cluster of symptoms/problems associated with autism spectrum disorders… including disorganization (ie., lining up is not organization), poor planning (ie., inability to utilize the future for present decision-making), failure to use feedback (ie., perseverative responses), poor observer functions (ie., difficulties seeing the world through the eyes of others) and deficient internalization of social rules (particularly unwritten rules). Unfortunately (does this sound familiar… are you getting the picture?) the cause of frontal abnormalities is not clear. While it is possible that the frontal abnormalities reflect a breakdown in the blueprint (genetic/DNA), it remains quite possible that this abnormality is related to a breakdown in the myelinated axons that connect the frontal lobe to other brain regions.

So, what causes autism? We do not know but several lines of evidence appear to implicate a disruption in the development of the myelinated axons that connect various brain regions and that there may be a multitude of etiologies or causes that result in this final common pathway and then again, maybe there are simply a variety of etiologies and that our decision to group these disorders into a single category reflects our tunnel vision or narrow view. But the bigger question is…. WHAT DO WE DO? Hmmmm… maybe another time we can start that.

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

Autism Part 1

“Our two year-old son is a beautiful boy but we have become concerned. He still does not speak, actually, he doesn’t really look at you when you speak or appear to have any interest in what you say. We had his hearing tested by our physician and nothing appeared wrong. Our son does not initiate play with other children nor does he actually appear to have any interest in his peers. While he is a loving little boy, he does not really hug you back. Someone suggested that we have him tested for autism and we’re scared. Is he autistic? What do we do?”

Autism refers to a neuro (brain) developmental disorder that affects an estimated 1/166 to 1/500 children each year in the United States with an annual growth rate in diagnoses of 10 – 17%. Staggering statistics? Surely, but even more importantly notice the incidence of 1/166 to 1/500. Why the significant range?

I recall being horrified (as a youth) when Dalton Trumbo in Johnny Got His Gun indicted the United States government when he revealed that their own offices could not provide an accurate statistic on the number of soldiers who died in Vietnam, often missing the number by thousands. Were the lives lost so insignificant? I now find myself in a somewhat similar position. Why the significant variability or range in estimates of the incidence of autism? Why doesn’t someone know how many children have autism? Are the children with autism lost and insignificant? Hmmmm…

The answer may lie in the fact that autism is not a thing but rather the diagnosis refers to a constellation of symptoms/problems with a developmental onset or emerging during first three years of life. The diagnostic criteria or symptoms/problems required for the diagnosis of autism reads something like a Chinese Restaurant menu including “A total of six (or more) items from (1), (2) and (3) with at least two from (1), and one each from (2) and (3)”… that should clear everything up. Want to know what criteria (1), (2) and (3) are? Google Autism Disorder DSM.

But what are the core or essential characteristics of autism? Hmmm… the answer is that the symptoms vary as a function of age. What is normal in a one-year old may be abnormal in a four year-old.

• Early signs (during the first 6-12 months of life) of an autism spectrum disorder may include poor eye contact during parent-child interactions, an absence of cooing/babbling, an absence of reciprocal smiling and apparent indifference to others that may include tactile sensory features ranging from recoiling from touch to requirements for swaddling/holding close.
  
• During the 12 – 24 month age range, symptoms of a potential autism spectrum disorder include persistence of early signs along with no attempts to speak with associated gestural communications, limited communicative intent, limited play, repetitive body movements (ie., hand flapping, rocking, etc.), fixation on objects (ie., moving fans, prisms, balls, etc.), resistance to change and a tendency for the child to become overwhelmed in high stimulation settings.
  
• Later (age 24 months+) emerging features of a potential autism spectrum disorder include (in addition to persistence of other symptoms noted previously) a lack of initiation to engage in reciprocal play with peers, limited play, emergence of over-select behaviors (ie., lines up objects, requirements for sameness, etc.) and difficulties following the gaze of others. In addition, emergence of exaggerated fear responses ranging from extreme rage to total indifference (ie., to pain) is often observed.

So, does your child have an autism spectrum disorder? I do not know but I tend to have infinite faith in the gut feelings of mothers. If a mother informs me that she has fears that something may be amiss in the development of her child, I generally believe that something may be wrong. The answer? Sorry if I sound repetitive on this… but… you may wish to consider an evaluation to shed some light on the fears. So, if it is an autism spectrum disorder, what causes it? Hmmmm… let me think about that one (see you next week)…

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

HWAT's a Paretn to oD? dyslexia and your Child

“My child cannot read. She’s in second grade and she still reverses letters, omits letters in common words, guesses words when she reads rather than actually reading the words. It’s a constant struggle to get her to read. It takes all evening to get through a book, she gets so frustrated and is constantly in tears and we (her parents) feel horrible. Its not supposed to be like this. We took her to a professional who told us she has dyslexia but, now what?”

Dyslexia simply refers to a disturbance (dys) of reading (lexia). Enlightening, huh? Hope you didn’t pay too much to have it revealed that your daughter has a disturbance in reading (which, by the way, I assume you actually told the professional about two minutes into the interview).

The real challenge is to understand the underlying breakdown in processing that result in dyslexia or a reading disorder.

Reading is like a chain with each link providing its own unique and necessary contribution to reading. While professionals with different educational backgrounds and training may identify some different individual components (or links) that compose reading, most breakdowns of reading indicate links that include:

(a) visual acuity (can the child see)

(b) oculomotor functions (can the child scan a row of letters/words),

(c) visual-perception (can the child recognize and discriminate visual configurations)

(d) auditory acuity (can the child hear)

(e) auditory perception (can the child recognize and discriminate speech sound units)

(f) grapheme (letters) - phoneme (speech sounds) integration (can the child link sounds with letters)

(g) sequential grapheme-phoneme processing of units (can the child read individual words)

(h) sustained attention (can the child keep track of what was read)

(i) storage of data (can the child store a series of words)

(j) linking ideas/themes with words (can the child create mental pictures/images of what the words “say”)

(k) development of a general theme (can the child understand what was intended in the written communication)

(l) development of a response (can the child respond to the written words) and motor programming a response (can the child articulate the words or formulate a motor plan based on what was read)

So… your child has dyslexia? What are you supposed to do? It all depends on the stage at which reading breaks down. A chain is only as strong as the weakest link. Therefore, interventions directed towards “weak links” or components in the reading process are likely to result in the greatest benefits. The first step… complete a comprehensive evaluation of reading components or links. The intervention?… direct or focus interventions on weak links to obtain the greatest benefits or “bang for your buck.”

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

M&M’s and a Spray Bottle Part 2

I wish I had asked for more than a week to address your question from the last installation.

You indicated that your four year-old daughter presents with multiple developmental delays along with eating non-food items, self-stimulation, self-abuse, some biting and rocking. The cluster of behaviors that you are describing tend to be classified as being primitive, meaning that the symptoms emerge during the neonatal/infant period and are generally related to limbic system-driven drives (eating/biting) and instincts (fight or flight). Under “normal” conditions of development, these instinctual behaviors are suppressed starting at about age three years. Onset of inhibition of these primitive drives/instincts corresponds with emerging development or maturation of frontal lobe inhibitory processing.

The same frontal lobe mechanisms that inhibit lower level drives/instincts (biting, pica, exploratory behaviors, “fight or flight”) are responsible for inhibition (over-rides) of sphincter reflexes for successful completion of potty training. Prominence of instincts/drives in governing behavior beyond about 3-4 years of age typically indicates a high potential for frontal lobe dysfunction or maldevelopment (which also undermines cognitive, adaptive and social development giving rise to references to “mental retardation”).

The behavioral program you described as being a “failure” in our last installation was an operant conditioning model. The frontal lobes learn via operant conditioning. Taken together, it should not be terribly surprising that a child who shows delays in frontal lobe development should fail to show benefits to an operant conditioning intervention. Development of a software program (operant conditioning intervention) that relied on hardware (frontal lobe) that the child did not possess was doomed to fail and as a result, you and your frontal lobe have been “punished” by the failure with resulting high levels of frustration.

In contrast, the limbic system is 40,000 years old, has not changed appreciably in 40,000 years and I’m guessing that you will not change it with a few M&M’s. Limbic system responses are elicited by unconditioned (no learning necessary) stimuli that are “hard-wired” into the system. However, the limbic system can be modified via classical or Pavlovian conditioning. Remember Pavlov? His work went something like this… present a dog with food (unconditioned stimulus) and it salivates (unconditioned response). No learning necessary. Use the can opener (neutral stimulus), present the food (unconditioned stimulus) and the dog salivates (unconditioned response). Eventually, open the can (conditioned stimulus) and the dog salivates (conditioned response). Limbic system responses are not modified by consequences, but are elicited or controlled by antecedents (triggers).

Hmmmm … and what has this to do with our child? The first strategy is to record the ABC’s (antecedent – behavior – consequence) of unwanted behaviors with an emphasis on identification of those antecedent stimuli or triggers that consistently elicit maladaptive behaviors. Recall (in previous installations) how I preach evaluation and assessment? This time, you get to do my job. Assessment is not a specific set of tests or tools, but a way of thinking and your assessment and recording are central to any program. Antecedent (A) stimulus recording generally includes the date, time and external environmental stimuli (who, what, when, where, etc.) that were present prior to the onset of maladaptive behaviors. Recording is an important part of the entire intervention process since it both sets a baseline against which to judge the effectiveness of any interventions and provides important information regarding potential antecedents. Once specific antecedents are identified, the next step is to avoid antecedents. I love this one (that I hear once a month) “every time we go to K-mart, my child acts out.” Solution, “do not go to K-mart.” The goal is to have low elicitation of limbic system-driven “fight or flight” responses. If one cannot avoid the antecedent (such as a sibling coming home from school), the next step is to “put the frontal lobe in front of the antecedent.” This rule suggests that once specific antecedents are identified, attempts should be made to introduce structured activities (frontal lobe functions) during high risk time frames. Provide your child with a routine task or set of tasks to complete (ie., set the table) when antecedents (ie., sibling coming home from school) are present.

You are probably wondering, “then what?” Hmmm… give me 2-3 weeks (see my frontal lobes are learning).

M&M’s and a Spray Bottle

“Our four year-old daughter has always been slow… slow to sit up, slow to walk (she never really crawled but sort of GI-Joe’d it across the floor), slow to talk (she has only a couple single words that sort of telegraphically communicate her wants)… and potty training?… it seems like it will never happen with no progress during the past year. She was diagnosed with mental retardation.”

“The most recent problems have been eating non-food items, she eats every piece of fuzz on the carpet, self-stimulation, self-abuse, she hits her head on the floor when frustrated, some biting and rocking. When recently seen by a professional (psychologist, physician, therapist, etc.), it was recommended that we initiate a behavior modification (operant conditioning) program in which we reward her with preferred items (attention, M&M’s, touches, etc.) when she displays positive behaviors, ignore her (extinction) when she is engaged in negative behaviors that are not physically injurious and spray her with a water solution (punish her) when she is engaged in self-injurious or aggressive behaviors. After two months, our daughter has shown a dramatic increase in physical aggression and has learned to adeptly avoid sprays to the face while we have felt like total failures as parents while our child appears to fear our presence. What do we do?”

First things first. The diagnostic system adopted by the American Psychiatric Association and utilized by the American Psychological Association is an “axial” system that is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM for short). Numerous versions and revisions have been completed across time that reflect changes in our understanding of various symptom complexes.

The axial system has five axes that include: Axis I (Clinical disorders that may be the focus of clinical attention or treatment), Axis II (Personality disorders and mental retardation including factors that may mediate symptom expression), Axis III (General medical conditions that are potentially relevant to understanding and treating Axis I and II problems), Axis IV (Psychosocial and environmental problems or stressors that may affect symptom/problem severity and Axis V (Global Assessment of Functioning or the clinician’s judgment of the individual’s overall level of functioning).

My take on the process? Axis IV and V are so poorly correlated among observers to be irrelevant or meaningless (this opinion may not be shared by others). Axis I is analogous to the current weather conditions (it is raining, it is snowing, it is a thunderstorm, etc.). Axis II is analogous to the severity of the weather conditions or associated factors (28 degrees, high winds, etc.) and Axis III is analogous to the underlying cause of the current weather conditions (a cold front from Canada merging with a warm front from the Gulf of Mexico) that cause or contribute to the Axis I (thunderstorm) and Axis II (high winds) diagnoses.

For your daughter the Axis I diagnosis is the presenting symptoms/problems or what you are seeking assistance in addressing. Axis I diagnoses may include Pica (eating non-food items) and a Disruptive Behavior Disorder (self-abuse, aggression). To discover that your child has been diagnosed with Pica or a Disruptive Behavior Disorder is not particularly enlightening (particularly since you told the professional what those symptoms were). The Axis II diagnosis of mental retardation is similarly unenlightening, it simply refers to the degree to which your child’s cognitive, behavioral, adaptive living and social development deviates from the average or middle of the bell curve. You said “slow” or “delayed”… the IQ score simply provides an estimate of how much (IQ = 60 = 40% delay relative to peers, IQ = 55 = 45%, got the idea, 100 – IQ = % delay).

To discover that you finished fifth in a race does not provide insight into how to improve your running speed.

In contrast, the Axis III diagnosis refers to biological and/or neurological factors that underlie or are the cause of the Axis I and II diagnoses. Axis III diagnoses could potentially include maldevelopment of myelinated axonal connections from limbic to frontal regions secondary to premature birth, frontal lobe disconnection secondary to perinatal hydrocephalus, stroke involving the left middle cerebral artery, shear strain injury secondary to high force trauma to the head, etc. The Axis III diagnosis is designed to identify the “hardware” (computer analogy) limitations or factors that contribute to, drive or cause the presenting symptoms (Axis I).

Does your daughter have mental retardation? No… she may show a slow (retardation) rate or incomplete development of skills. What do we do?” Hmmm… give me a week to think on that one.