AHC Neurocognitive Study

1. AHC Neurocognitive Study Joshua Magleby, PhD Integrative Neuropsychology Inc. Consulting Psychology Inc.

2. AHC Neurocognitive Study • Examined the neurocognitive, behavioral and adaptive functioning in AHC • In the one report of detailed neuropsychological evaluation up to that time (2005), pervasive deficits in memory, attention, executive functioning, language, psychomotor skill and psychosocial functioning were found • 41 participants • 20 males, 21 females • Mean age = 11.33 years • Mean age of diagnosis = 3.23 years • 2003-2006

5. AHC Neurocognitive Study • Below age expected scores were the norm for participants with a low FSIQ • Wide range of performances of participants with higher FSIQ scores from markedly impaired to intact or better • Neurocognitive functioning appears to decline as an individual ages • Frequency and severity of AHC attacks seems to play a role in adaptive functioning • Frequency and severity of hemiplegic attacks had variable influences on cognitive and behavioral functioning • Medication status did not appear to influence participants’ scores • However, there was also considerable variability in test scores and parent ratings, indicating that AHC is syndromatic in regards to neurocognitive and adaptive functioning

6. Behavior: Assessment, Modification & Management Joshua Magleby, PhD Integrative Neuropsychology Inc. Consulting Psychology Inc.

7. Agenda • The ABCs of behavior • Influences on behavior • Behavior modification and management • AHC behavior data

8. Shocking News 98% Of Babies Manic-Depressive (MARCH 23, 2009, ISSUE 45•13) NEW YORK—A new study published in The Journal Of Pediatric Medicine found that a shocking 98 percent of all infants suffer from bipolar disorder. "The majority of our subjects, regardless of size, sex, or race, exhibited extreme mood swings, often crying one minute and then giggling playfully the next," the study's author Dr. Steven Gregory told reporters. "Additionally we found that most babies had trouble concentrating during the day, often struggled to sleep at night, and could not be counted on to take care of themselves—all classic symptoms of manic depression." Gregory added that nearly 100 percent of infants appear to suffer from the poor motor skills and impaired speech associated with Parkinson's disease.

9. For example… Behaviors of a typical 4-year-old boy Inattentive, hyperactive, impulsive ADHD Noncompliant, oppositional, argue ODD Behaviors of a typical 12-year-old girl Sad, irritable, moody Mood Disorder Behaviors of a shy child with misarticulations Atypical language, poor social skills PDD

10. Developmentally Typical Many behaviors that a parent or school might find disruptive, obnoxious or strange are developmentally typical That is, these behaviors typically occur in individuals of that age Impulsivity, Tantrums, Moodiness, Fidgeting, etc E.g., tantrums in a 3-year-old child That DOES NOT mean that interventions shouldn’t be tried or won’t be successful Shaping

11. What is Behavior? • It is the response of the system or organism to various stimuli or inputs • B.F. Skinner • How the individual “operates” on their environment • All behavior serves a function • The trick is to figure out what that function is

12. Factors • 3 important factors to consider are… • Antecedent • Behavior • Consequence

13. Behavior Chain • Main behaviors are made up of a chain of “mini” behaviors • These “mini” behaviors build upon one another to cause main behavior • Breaking the chain stops main behavior from occurring • 1------> 2------> 3------> 4

14. External Environment Home Classroom Temperature Sound Visual Internal Individual Genetics Development Temperament Sleep Diet Activity Beliefs Emotional distress Anxiety What Influences Behavior?

16. The Child Brain All behavioral development has to do with the brain Brain development is dependent upon both experience and genetics The brain has a great deal of plasticity and can recover over time Frontal lobes are the last to develop, taking upwards of three decades to complete this process Primary location of behavioral and emotional regulation, impulse control, etc. Often [but not always] more impaired in individuals with neurological disorders

17. Influence of Medications • Medications can improve or worsen behavior problems • E.g., Keppra • Works well with stopping seizures in children • However, also increases emotional/behavioral dysregulation and aggression • Flunarizine • Drowsiness, anxiety, depression

18. Influence of Lack of Sleep “If sleeping and dreaming do not perform vital biological functions, then they must represent nature’s most stupid blunder and most colossal waste of time” • Evolutionary Psychiatry, 1996, 2000 • Alertness and arousal decrease • Concentration decreases • Motivation for activity decreases • Emotional/behavioral regulation decreases • Fidgeting/overactivity increases • Hypnogogic experiences • Sleep deprivation in kids has been linked to what are assumed to be entirely unrelated phenomena, including lower IQ, obesity and ADHD

19. Age and condition Average amount of sleep per day Newborn up to 18 hours 1–12 months 14–18 hours 1–3 years 12–15 hours 3–5 years 11–13 hours 5–12 years 9–11 hours Adolescents 9–10 hours Adults, including elderly 7–8(+) hours Pregnant women 8(+) hours NSF Data

21. Influence of Fear and Anxiety • Fear • An emotional response to a perceived threat • Related to escape and avoidance behaviors • Anxiety • “To vex or fear” • Related to situations perceived as uncontrollable or unavoidable • Both can manifest in ways that do not indicate either

22. Behavior Modification • In order to modify behaviors, ABC must be known [in detail if possible] • Modification also depends on a number of other factors • Age • Disability • Previous experience • Neurocognitive functioning • Presence of co-occurring issues • Reduce target behavior versus increase replacement behavior • What’s more important?

23. Behavior Modification • Working with a professional • Problem identification • Problem analysis • Intervention development • Intervention implementation • Intervention monitoring and “tweaking” • Habituation

24. Modification Techniques • Positive reinforcement • “Giving” something that increases or maintains a behavior • Teaches the replacement behavior • E.g., child is given a tangible for staying on task or for kindness to sibling

25. Modification Techniques • Negative reinforcement • Behavior (response) is followed by the removal of an aversive stimulus, thereby increasing that behavior's frequency • E.g., removing being grounded for using kind words

26. Modification Techniques • Response cost • “Consequence” rather than “punishment” • E.g., “If you don’t put on your shoes you won’t be able to go to the movie” • Taking a marble out of the jar when physical aggression occurs • Stepwise - consequences increase • As “natural” as possible • A word about punishment… • Can be effective…but… • Does not teach the replacement behavior • Tends to be short-lived • Can worsen the behavior

27. AHC Family Data • Behavior questionnaire 15 • Behavior • Aggression 12 • Property destruction 3 • Temper tantrums/”rages” 3 • Mood swings 3 • Indecision 2 • Attention seeking 2 • Overly dependent 2 • Impulsivity, leaving without permission, echolalia, eating problems, shyness, O/C, attention problems, yelling/screaming, toileting problems, transitional problems

28. AFC Family Data • Interventions • Removal from environment 4 • Ignoring 3 • “Lecture” 3 • Sleep 2 • Holding • Time Out • Tangible • Patience

29. Ideas • Know the ABCs of the behavior • E.g., physical aggression • A = frustration • B = aggression • C = holding • Reduce frustration situation, praise/tangible for “keeping their cool”, remove from situation, prompt before situation begins

30. Ideas • E.g., physical aggression • A = being corrected for something they know is wrong • B = aggression • C = taken to room and allowed to calm down • Praise for appropriate behavior, give a prompt/cue that behavior may become inappropriate, maintain calm, maintain distance

31. Ideas • E.g. crankiness • A = waking from a nap • B = crankiness • C = held, comforted • Soothing waking, primary reinforcer immediately upon waking, patience

32. Ideas • E. g., irritability/“personality change” • A = physical discomfort [headache] • B = irritability/personality change • C = medication and rest • Early identification, collect data on headache incidence [e.g., frequency, pattern], maintain calm

33. Important Points • Differentiate developmentally typical vs. atypical • Can my child perform this behavior, based on: • Age • Impairments • Experience • Remember…AHC kids are just that…kids • Remember…ALL kids have bad days • Know the chain of behaviors, so you can stop progression to more extreme behavior • Be consistent with your responses • Be flexible in your interventions • Remember…YOUR behavior influences THEIR behavior • Stay calm • Stay vigilant • Stay consistent

34. Resources • Websites • www.apa.org/releases • www.behavioradvisor.com • www.asha.org • Books • Parenting the Strong-Willed Child by Forehand & Long • Helping the Noncompliant Child by Forehand & McMahon • SOS! Help for Parents: A Practical Guide for Handling Everyday Behavior Problems by Lynn Clark • 50 Great Tips, Tricks & Techniques to Connect With Your Teen by Debra H. Ciavola • maglebyphd@gmail.com • www.ini.org