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PEELING BACK THE LAYERS OF THE “I” FROM A NEUROPSYCHOLOGICAL PERSPECTIVE October 19 th , 2013 3 rd Annual DIR/ Floortime Coalition of California Conference Dr. Jonine Biesman. MAIN POINTS TO TAKE AWAY: #1.

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slide1

PEELING BACK THE LAYERS OF THE “I” FROM A NEUROPSYCHOLOGICAL PERSPECTIVEOctober 19th, 2013 3rd Annual DIR/Floortime Coalition of California ConferenceDr. JonineBiesman

main points to take away 1
MAIN POINTS TO TAKE AWAY: #1

LOCALIZED MODELS OF BRAIN FUNCTION AND CATEGORICAL MODELS OF DIAGNOSIS (DSM and ICD) SERVE NO UTILITY IN OUR UNDERSTANDING AND TREATMENT OF NEURODEVELOPMENTAL DISORDERS.

main points to take away 2
MAIN POINTS TO TAKE AWAY: #2

COMPLEX BRAIN SYSTEMS REQUIRE COMPLEX, MULTIDIMENSIONAL INTERVENTION MODELS!

main points to take away 3
MAIN POINTS TO TAKE AWAY: #3

WE WILL BENEFIT FROM EXPANDING OUR UNDERSTANDING AND ASSESSMENT OF THE “I” IN OUR OWN DIR MODEL.

main points to take away 4
MAIN POINTS TO TAKE AWAY: #4

NONE OF THE ABOVE IS REALLY RELEVANT UNLESS WE TAKE WHAT WE ARE LEARNING ABOUT BRAIN FUNCTION AND THEORY AND TRANSLATE THIS INTO DAY TO DAY PRACTICE TO BEST GUIDE INDIVIDUALS AND FAMILIES.

slide6

ACT ONE:LOCALIZED MODELS OF BRAIN FUNCTION AND CATEGORICAL MODELS OF DIAGNOSIS (DSM and ICD) SERVE NO UTILITY IN OUR UNDERSTANDING AND TREATMENT OF NEURODEVELOPMENTAL DISORDERS.

consider the differences
CONSIDER THE DIFFERENCES…

DSM:

NEUROPSYCHOLOGY:

Seeks to identify the brain regions, systems, and/or networks that generate behavior

Defines diagnosis by a set of behaviors that are assigned to a category

there are huge problems with our diagnostic systems1
THERE ARE HUGE PROBLEMS WITH OUR DIAGNOSTIC SYSTEMS.
  • Behaviorally defined NOT neuroanatomically organized without consideration of an
  • We need to embrace the current neuroscientific understanding of brain-behavior relationships, interaction of large scale brain networks, that drive all cognitive, affective, motivational, executive, and sensorimotor functioning.
yaryura tobias ja et al 2003 journal of clinical psychiatry
Yaryura-Tobias JA et al.. 2003Journal of Clinical Psychiatry
  • Concluded that children presenting for clinical evaluation simultaneously met full diagnostic criteria for between one and five DSM diagnoses
  • IF DIAGNOSTIC CO-MORBIDITY IS THE RULE OF THUMB, SEARCHING FOR A SINGLE DIAGNOSIS AND MINIMIZING CO-MORBID SYMPTOMS LENDS ITSELF TO TOO MUCH SUBJECTIVITY, MIS-DIAGNOSIS, AND INAPPROPRIATE, INCOMPLETE TREATMENT PLANS.
there are huge problems with our diagnostic systems2
THERE ARE HUGE PROBLEMS WITH OUR DIAGNOSTIC SYSTEMS.
  • BRAIN NETWORKS DO NOT WORK IN ISOLATION, SO NO WONDER WE SEE THE CO-MORBIDITY THAT WE DO.
  • NEOCORTICAL, BASAL GANGLIA, AND CEREBELLAR CONNECTIONS INTERACT WITH LARGE-SCALE BRAIN NETWORKS TO GENERATE ALL BEHAVIORS: COGNITIVE, AFFECTIVE, MOTIVATIONAL, EXECUTIVE, AND SENSORIMOTOR.
consider instead
CONSIDER INSTEAD…
  • Clarifying the foundation of observed behaviors (from where do the symptoms arise?)
  • Understanding the brain-behavior relationships that underlie them
  • Gaining an understanding of unique profiles and subtypes in ways that are neuropsychologically based as opposed to behaviorally defined, because my interpretation of a behavioral definition may be different than yours. (problems with inter-rater reliability)
what is rdoc
WHAT IS RDOC?
  • LAUNCHED IN 2009 BY NIMH
  • DIMENSIONAL VERSUS CATEGORICAL APPROACH; VIEWS BEHAVIORS ALONG A CONTINUUM
  • HELPS AVOID UNDERTREATMENT (e.g., just because 5 instead of 6 criteria are met does not rule out real-life, real-time difficulties
examines specific constructs across a multitude of domains
Examines Specific Constructs Across a Multitude of Domains

DOMAINS:

  • Genes
  • Molecules
  • Cells
  • Circuits
  • Physiology
  • Behavior
  • Self-Report, etc.
specific constructs under examination
Specific Constructs Under Examination:
  • Positive and Negative Valence Systems
  • Cognitive Systems
  • Perception
  • Cognitive Control
  • Working Memory
  • Social Communication
  • Perception and Understanding of Self and Others
  • Arousal and Regulatory Systems
http www nimh nih gov research priorities rdoc nimh research domain criteria rdoc shtml toc matrix
http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml#toc_matrixhttp://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml#toc_matrix
slide18

Looks Different from Our “I”:-Regulatory Capacities-Motor Planning-Auditory-Verbal: Receptive & -Expressive Processing-Visual Spatial Processing-Praxis- EF Prefrontal CortexHmmmmm??

lets look again this list does not even include the rdoc sub constructs
Lets look again (This list does not even include the RDOC sub-constructs):
  • Positive and Negative Valence Systems
  • Cognitive Systems
  • Perception
  • Cognitive Control
  • Working Memory
  • Social Communication
  • Perception and Understanding of Self and Others
  • Arousal and Regulatory Systems
we are moving away from a purely cortico centric model of the brain
We Are Moving Away from a Purely Cortico-centric Model of the brain:

SO SORRY CORTEX… IT IS NOT ALL ABOUT YOU. YOU HAVE TO BE GRATEFUL FOR YOUR SUPPORT SYSTEM, BECAUSE YOU RELY ON THEM…HEAVILY!

slide22

“The cerebral cortex cannot drive all behavior independently. Rather, the brain usually drives behavior by functioning as an integrated whole that requires interactions between the cerebral cortex, the basal ganglia, and the cerebellum. “Top-down,” higher level cognitive and behavioral functions only occur with “bottom-up” subcortical support. –Koziol et.al, 2013

slide23

The cortex, basal ganglia, and cerebellum operate in parallel to generate adaptive behaviors.The basal ganglia and cerebellum play important roles in deciding what information is or is not “used” by the cortex

the cerebellum
The Cerebellum
  • The great modulator; smooth operator
  • Not limited to motor control; Part of the cerebro-cerebellar circuitry system that plays an equal role in cognitive, emotional, motivational & behavioral functions that are critical to adaptation.
the cerebellum1
The Cerebellum
  • “What the cerebellum does for movement, it also does for thought; the cerebellum allows us to think just as effortlessly and automatically as we move. Just as we are usually unaware that we are moving, so we are often unaware that we are thinking. This is because the operations of the cerebellum are outside of conscious cognitive control and awareness.”

-Koziol et. al, 2013

the cerebellum2
The Cerebellum
  • THERE IS A UNIFORM OUTPUT OPERATION OF THE CEREBELLUM.
  • WHETHER INFORMATION IS RELATED TO MOVEMENT, THOUGHT, AFFECT, OR MOTIVATION; THE CEREBELLUM REGULATES ITS RATE, RHYTHM, AND FORCE (e.g., writing, meltdowns, thinking logically and fluidly, placing the right amount of emphasis on a thought, flat response to a distressing situation)
the cerebellum3
The Cerebellum

IN DOING SO, THE CEREBELLUM REGULATES THE QUALITY OF BEHAVIOR BY ALLOWING AUTOMATED BEHAVIORS TO BE ADAPTED TO CHANGING SITUATIONS.

the basal ganglia
THE BASAL GANGLIA
  • A group of gray matter nuclei situated at the base of the forebrain deep within the white matter of the brain that act as a cohesive functional unit. Strongly connected with the cerebral cortex, thalamus, and other brain areas.
the basal ganglia1
THE BASAL GANGLIA

They Consist of:

  • Striatum (caudate, putamen, nucleus accumbens)
  • Globus Pallidus *SubstantiaNigra
  • Subthalamic Nucleus

THEY SERVE AS A MASSIVE INHIBITORY SYSTEM. IN ESSENCE, THEY TELL WHAT REGIONS OF THE CORTEX TO BECOME ACTIVE WHEN– A GATING FUNCTION.

the basal ganglia2
THE BASAL GANGLIA

WE HAVE COME TO UNDERSTAND THAT A WIDE RANGE OF BEHAVIORS CAN BE EXPLAINED ON THE BASIS OF BASAL GANGLIA PRINCIPLES OF SELECTION AND INHIBITION.

slide36

Way more than coprocessors of movement….It is theorized that the brain evolved to control action and movement. These same neural circuits are involved in cognition, emotion, & motivation. The mapping of frontal-basal ganglia connections demonstrates the neocortex does not function alone!

slide37

DESPITE THE BEST ATTEMPTS OF CORTEX, A DISTURBANCE WITHIN THE BASAL GANGLIA WILL COMPROMISE TOP-DOWN VOLITIONAL CONTROL. CARRYING OUT INTENTIONS REQUIRES THIS ADDITIONAL BOTTOM-UP SUPPORT.

slide38

THE BASAL GANGLIAThe basal ganglia are associated with a variety of functions, including voluntary motor control, procedural learning relating to routine behaviors or "habits" (e.g., eye movements, cognitive,and emotional functions.Involved in action selection, or the decision of which of several possible behaviors to execute at a given time. Experimental studies show that the basal ganglia exert an inhibitory influence on a number of motor systems, and that a releaseof this inhibition permits a motor system to become active.

slide39

Since at least 95% of what we do during the day as humans requires us to function automatically and without thinking, when the neural circuits that allow for this are disrupted, learning and adaptation become affected. Namely, we operate with two systems -- one that is automatic and one that requires cognitivecontrolfor novel situations. When we are faced with those tasks for which we cannot rely on our automatic responses (because they do not work for a particular situation), we must make adjustments. Then upon making and practicing such adjustments, we then become more skilled in the situation or task that was novel.

7 patterns of cortical connectivity in the human brain yeo et al 2011
7 Patterns of Cortical Connectivity in the Human Brain, Yeo et al., 2011
  • FRONTOPARIETAL NETWORK
  • DORAL ATTENTIONAL NETWORK
  • POSTERIOR PARIETAL CORTEX
  • VENTRAL ATTENTIONAL NETWORK
  • VISUAL NETWORK
  • DEFAULT NETWORK
  • SENSORY MOTOR NETWORK

www.natbrainlab.com

frontoparietal network
FRONTOPARIETAL NETWORK
  • A “COGNITIVE CONTROL,” EXECUTIVE FUNCTION, WORKING MEMORY TYPE OF NETWORK
  • Commonly engaged during effortful cognitive tasks that require rules be kept in mind to guide a particular behavior
  • Goal-directed behavior in novel situations
dorsal attentional network
DORSAL ATTENTIONAL NETWORK
  • PRIMARY BRAIN REGIONS INVOLVED IN SHIFTING THE FOCUS OF ATTENTION AND CONTROLLING SPATIAL ATTENTION
  • CRITICAL TO ADAPTATION IN CONSTANTLY CHANGING ENVIRONMENTS
  • REGISTERS WHERE SOMETHING IS AND HOW TO DO SOMETHING IN RELATION TO IT
posterior parietal cortex
POSTERIOR PARIETAL CORTEX
  • RECIPROCAL CONNECTIONS WITH PREMOTOR AREAS AND THE FRONTAL EYE FIELDS
  • FOCUSES ON SPATIAL INFORMATION
  • VISUAL CONTROL FOR ACTIONS, PERSONAL MOVEMENT SPACE
ventral attentional network
VENTRAL ATTENTIONAL NETWORK
  • “THE SALIENCE NETWORK”
  • REGISTERS WHAT IS BEING SEEN; WHAT AN OBJECT IS USED FOR
  • OBJECT IDENTIFICATION PATHWAY
  • CAN OPERATE IN MENTAL SPACE IN THE FORM OF A MENTAL REPRESENTATION
  • THE REWARD VALUE ATTRIBUTED TO AN OBJECT WILL DIRECT ATTENTION TO A CERTAIN ASPECT OF THE ENVIRONMENT
visual network
VISUAL NETWORK
  • CONSISTS OF OCCIPITAL LOBE, LATERAL TEMPORAL REGION, SUPERIOR PARIETAL LOBULE
  • INTERACTS WITH THE DORSAL AND VENTRAL ATTENTIONAL NETWORKS
  • IN AGGREGATE, PLAYS A CRITICAL ROLE IN SUSTAINING ATTENTION AND IN SUPPRESSING ATTENTION TO IRRELEVANT STIMULI
default network
DEFAULT NETWORK
  • PHYSIOLOGICAL BASELINE OF THE BRAIN AT REST
  • INCLUDES A PERSON’S EXPERIENTIAL HISTORY
  • ACTIVITY IS HIGH (MUCH MEANINGFUL ACTIVITY OCCURRING WHEN THE BRAIN IS AT REST) UNTIL ACTIVE, GOAL-DIRECTED COGNITIVE PROCESSING IS REQUIRED
  • LESS ACTIVE DURING THE PERFORMANCE OF COGNITIVE TASKS, BUT IN THOSE WITH ADHD, THE DEFAULT NETWORK IS RECRUITED AND ACTIVITY IS NOT SUPPRESSED (E.G., LAPSES IN ATTENTION “HMM…WHAT HAVE I PREVISOULY DONE AND WHAT WOULD I LIKE TO BE DOING NOW?”)
sensory motor network
SENSORY MOTOR NETWORK
  • REPRESENTS MULITPLE BRAIN AREAS (E.G., PRIMARY MOTOR CORTEX, PRIMARY AND SECONDARY SENSORY CORTICES, PUTAMEN, THALAMUS, CEREBELLUM, ETC.
  • INVOVED IN MOTOR SKILLS AND MOTOR ACTIVITY. DISRUPTION MAY RESULT IN THE HYPERACTIVITY/MOTOR ANOMALIES SEEN IN ADHD
  • WE SEE DISRUPTION IN THIS SYSTEM IN MANY NEURODEVELOPMENTAL DISORDERS. THERE IS A STRONG RELATIONSHIP BETWEEN MOTOR DEVELOPMENT AND THE DEVELOPMENT OF EXECUTIVE CONTROL.
act two
ACT TWO

COMPLEX BRAIN SYSTEMS REQUIRE COMPLEX, MULTIDIMENSIONAL INTERVENTION MODELS!

slide50

“One synapse may contain on the order of 1,000 molecular scale switches. A single human brain has more switches than all the computers and routes and internet connections on earth.”-Stanford University Professor Steven Smith

slide51

OR… THINK OF IT THIS WAY:Imagine a bustling city the size of New York. Give every person in that city 10,000 pieces of string. Tell each person to attach each piece of string to a different person. Now make the city a thousand times bigger. This is the incredible tangle we call the… BRAIN!

advances in imaging that allow us t o see these exquisite images
Advances In Imaging that Allow Us To See These Exquisite Images…
  • Diffusion tensor imaging (DTI)is a method that provides a description of the diffusion of water through tissue, and can be used to highlight structural changes in tissue tracts. DTIhas tremendous implications to brain research, as it makes it possible to trace how fibers are connected in the brain, yielding a map of how the brain is wired.
advances in imaging that allow us to see these exquisite images
Advances In Imaging that Allow Us To See These Exquisite Images…
  • Diffusion spectrum imagingis a variant of diffusion-weighted imaging that is sensitive to intra-voxel heterogeneities in diffusion directions caused by crossing fiber tracts and thus allows more accurate mapping of axonal trajectories than other diffusion imaging approaches.
slide63

The continuous formation and remodeling of long-range white matter connections occurring very early in life is a necessary prerequisite for the development of normal cognitive functions.Alterations of this process may be responsible for adverse neurodevelopmental consequences

connectome
CONNECTOME

Discovering the…..

CONNECTOME

connectome did you say
“Connectome” did you say?!
  • Connectomics is an application of neural imaging and histological techniques in order to increase the speed, efficiency, and resolution of maps of the multitude of neural connections in a nervous system. The principal focus of such a project is the brain, The map produced by such a project is called a connectome.
mapping the connectome this is your brain
Mapping the Connectome: This is Your Brain
  • In the midst of the Decade of the Brain, science’s lack of even a basic understanding of neuroanatomy was lamented.
  • “Clearly what is needed for modern human brain anatomy is the introduction of some radically new techniques” –Francis Crick & Edward Jones, 1993
mapping the connectome this is your brain1
Mapping the Connectome: This is Your Brain
  • With the advent of new techniques, neural circuitry is being mapped with unprecedented resolution and completeness.
  • The NIH has dedicated nearly $40 million dollars to chart the wiring of the human brain.
  • THE RESULTS MAY REVEAL NOTHING LESS THAN THE NATURE OF HUMAN INDIVIDUALITY.
slide68

Sebastian Seung and his lab at MIT are inventing technologies for identifying and describing the connectome, the totality of connections between the brain's neurons -- think of it as the wiring diagram of the brain. We possess our entire genome at birth, but things like memories are not "stored" in the genome; they are acquired through life and accumulated in the brain. Seung's hypothesis is that "we are our connectome," that the connections among neurons is where memories and experiences get stored.

slide70

At the TEDGlobal Conference 2010. Seung put forth some “ideas worth spreading”:1) “We are our connectome.”2) It took over 12 years to map the connectome of a worm that has 300 neurons

slide71

Seung (cont.)3) The human brain is far more complex with 100 billion neurons and 10x as many more connections.4) The theory was puported that memories, personality, intellect are stored in the connections between neurons

slide72

Seung (cont.) 5) Finding an entire human connectome is one of the greatest technological challenges of all time and will take the work of generations to succeed.

slide73

Seung (cont.)6) To some extent neurological changes are programmed by our genes, but that is not the whole story…There is evidence that our neural activity is encoding our thoughts, feelings, and perceptions of our mental experiences.

slide74

Seung (cont.)THIS MEANS THAT EXPERIENCES CAN CHANGE YOUR CONNECTOME. THAT IS WHY EACH CONNECTOME IS UNIQUE.“The connectome is where nature meets nurture.”

slide76

The term “connectome”

was coined in analogy with the “genome”—the entirety of an organism’s hereditary information

human connectome project pieces together neural data through brain scans june 25 2012
Human Connectome Project pieces together neural data through brain scans, June 25, 2012

“Historically, we focused on mapping brain structure, but we haven’t spent a lot of time looking at how those structures are wired together, what the connections between them are, and how they function.”

-Arthur Toga, Director of the UCLA Laboratory of Neuroimaging

slide81
ACT THREEHOW DO WE EXPAND OUR UNDERSTANDING AND ASSESSMENT OF THE “I” IN OUR OWN DIR MODEL?UNDERSTANDING THE “I” WITH OUR NAKED “EYE”
slide83

Well, Yes. We do have Standardized Measures to Access Across a Range of Brain Functions…BUT…It is the process that tells the story, not the numbers. It is the time spent with a child developing a strong relationship and seeing what we see that matters most… Of course, with the benefit of a strong foundation in brain-behavior relationships.

slide84

1) Because they are multi-factorial, they have limited utility

2) They too often get interpreted at face value

3) Limited ecological validity

There Are Inherent Problems with the use of Standardized Neuro-psychological Tests & Measurement Methods in Isolation:

slide87

In neuropsychology Go/No-go tests are used to measure a participant's capacity for sustained attention and response control. For example, a go/no-go test that requires a participant to perform an action given certain stimuli (e.g., press a button - Go) and inhibit that action under a different set of stimuli (e.g., not press that same button - No-Go).

this is why in the scheme of things one test measurement means nothing we must look for patterns
This is why in the scheme of things one test measurement means nothing. We must look for PATTERNS.
slide89

How Are those Sticky, Daily Life Problems Best Addressed With a More Sophisticated Understanding of Individual Differences?Meltdowns, homework, stress/hardship, screen time, distractibility, disorganization, non-compliance, aggression, sibling conflict, separation anxiety, fear, obsessions, etc.

slide90

Limits will still be established and implemented, but within the framework of understanding, parent education, compassion, flexibility, and skill Modifying the environment around a child with special needs can be one of the most important things we do.

some thoughts for parents
Some Thoughts for Parents:
  • Be Firm But Empathic in Limit Setting
  • Stop for One Moment When Your Child is Arguing with You and Say: “Tell Me Your Idea. I am Listening.”
  • Instead of Thinking You Always Need to Consequence Your Child for an Infraction, Consider Instead an Act of Kindness:
  • Keep Communication Simple and Straightforward
  • Expect to Adjust Your Parenting Strategies Based on Your Child
some thoughts for parents1
Some Thoughts for Parents:
  • Realize That Some Brains Do Not Handle Screen Time in The Same Way That Others Do, and Don’t be Afraid to Do Something About It
  • Establish Family Values Early On and Let That Be a Source of Pride for Your Children
  • Take an Interest in Your Child’s Passions and Nurture Those Passions Above All Else
slide94
Perhaps the most exquisite interventions will be those that parallel brain developmental and neural connectivity.
slide95

ABA seems likened to old models of brain localization. It often teaches to an isolated skill set that is disconnected in the moment from any meaningful context. In this way, learning seems subpar, not as likely to be meaningfully encoded.

slide96

If we have to get to the level of automated functions, what is the best way in which to accomplish this? And how can we prepare children, adolescents, and parents for “cognitive control episodes?”

slide97

Not all practice looks the same. Nor, does it generate the same results. Sure, learning involves a level of reward saliency and reward contingency (If this, then that); but we prefer a model that suggests, “If/when you look at me the result is warmth and connection”, versus “good job looking”

slide98

USE THE “SYMPTOMS” BEFORE YOU TO THINK IN “SYSTEMS”. START TO PUT THE PIECES OF THE PUZZLE TOGETHER THROUGH YOUR KEEN BEHAVIORAL OBSERVATIONS, AND THINK OF NEURAL SYSTEMS, FAMILY SYSTEMS, PEER SYSTEMS, EDUCATIONAL SYSTEMS AND COMMUNITY SYSTEMS IN CONTRUCTING A WHOLISTIC TREATMENT PLAN

always ask these questions
Always Ask These Questions:
  • What am I seeing most prominently? Why? And to what degree? What are the most significant impacts on daily functioning?
  • How can I best prioritize when I think of time and resources? Neither are limitless, so how do I best allocate the time in the day?
  • OFTEN TIMES THIS REQUIRES THINKING OUT OF THE BOX AND GOING AGAINST THE GRAIN
broad strokes thinking
BROAD STROKES THINKING:
  • Strengths first! Build from here.
  • Movement
  • Sleep and Nutrition
  • Affiliation and Connectedness
  • Family and Parenting Support
  • Academic Accommodations
  • Academic Environment
broad strokes thinking1
BROAD STROKES THINKING:
  • Experiential, meaningful learning
  • Supporting Big Picture Thinking
  • Advocacy
  • Resources & Education
  • Prioritizing of intervention modalities
  • “Upping the anty” in some cases
  • Technology and Brain Training
slide103

“It is high time that movement came to be regarded from

a new point of view in educational theory. Especially in

childhood we misunderstand its nature and a number of

mistaken ideas make us think of it as something less noble

than it actually is. As a part of school life, which gives

priority to the intellect, the role of movement has always

been sadly neglected. When accepted there at all, it has

only been under the heading of ‘exercise,’ ‘physical

education,’ or ‘games.’ But this is to overlook its close

connection with the developing mind” (Montessori, 1949).