AHC Neurocognitive Study

Joshua Magleby, PhDIntegrative Neuropsychology Inc.Consulting Psychology Inc.

AHC Neurocognitive StudyExamined 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

(M[SD]) RangeGeneral Intellectual Functioning (viaWASI)

FSIQ 62.52[14.00] 50-94VIQ 69.15[15.88] 55-104PIQ 63.65[15.35] 53-103Matrix Reasoning 27.50[10.40] 20-53

Academic Achievement (via WJ-III)Reading

Rapid Picture Naming 54.88[24] 13-101Letter-Word ID 60.83[27.37] 19-140Passage Comprehension 45.10[26.22] 6-92Word Attack 51.06[28.40] 1-91

MathematicsCalculation 51.40[22.40] 18-97Applied Problems 62.46[29.87] 36-139

LanguagePPVT-III 62.44[19.82] 40-112WASI Vocabulary 29.40[12.45] 20-57WASI Similarities 30.12[10.16] 20-50

AttentionWISC-III: Digit Span-Forward 68[8.51] 60-85

Executive Function/MemoryCVLT-C

Trial 1 79.33[18.24] 55-115Semantic Clustering 96.22[20.01] 63-123Learning Slope 78.67[14.37] 55-100Recall Consistency 71[26.81] 55-100Perseverations 88.9[7.55] 78-100Primacy 119.27[42.02 55-175Recency 108.44[38.91] 55-175Trial 5 63.25[27.67] 25-108Long-Term Recall 60.5[19.17] 55-93Recognition 88.4[12.70] 63-108Discriminability 64.1[31.40] 25-108Total 61[9.15] 40-112

WISC-III: Digit Span-Backward 66.15[13.10] 55-100WISC-III: Digit Span-Total 63.08[12.17] 55-90CMS Faces: Immediate Recall 67.5[17.65] 55-95CMS Faces: Delay Recall 67.23[18.79] 55-105

Visual Perception/Visuomotor IntegrationClock Drawing 47.32[11.12] 40-81VMI 60[17.45] 45-95

BroadIndependence

Motor Skills SocialInteraction/CommunicationSkills

PersonalLivingSkills

CommunityLivingSkills

Total SS 32.44[25.05] 26.05[22.46] 59.77[27.65] 44.96[29.29] 36.32[26.59]Total Range 1-97 1-86 1-113 1-110 1-91Total Age 5.27 3.63 6.88 5.64 5.85

INDEX/Skill Total T(M[SD])

TotalRange

% At-risk orClinicallySignificant

EXTERNALIZING 54.53[12.81] 18-83 25Hyperactivity 63.93[16.88] 30-92 39Aggression 49.43[9.05] 27-69 10Conduct Problems 48.03[12.55] 10-79 10

INTERNALIZING 53.33[12.79] 16-76 25Anxiety 46.55[10.93] 29-73 7Depression 52.37[12.75] 7-72 25Somatization 59.37[13.63] 36-94 37

BSI 57.23[12.71] 12-76 34Atypicality 59.63[12.10] 43-97 25Withdrawal 56.60[16.00] 9-88 34Attention Problems 59.40[13.52] 7-76 41

ADAPTIVE SKILLS 42.93[12.85] 21-85 39Adaptability 43.50[13.01] 22-74 50Social Skills 48.14[14.52] 20-97 20Leadership 37.33[8.15] 21-58 15

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

Behavior: Assessment, Behavior: Assessment, Modification & Modification & ManagementManagement

Joshua Magleby, PhDIntegrative Neuropsychology Inc.Consulting Psychology Inc.

AgendaThe ABCs of behaviorInfluences on behaviorBehavior modification and

managementAHC behavior data

Shocking NewsShocking News 98% Of Babies Manic-Depressive (98% Of Babies Manic-Depressive (MARCH 23, MARCH 23,

2009, ISSUE 45•13) 2009, ISSUE 45•13) ◦ NEW YORK—A new study published in NEW YORK—A new study published in The Journal The Journal

Of Pediatric MedicineOf Pediatric Medicine found that a shocking 98 found that a shocking 98 percent of all infants suffer from bipolar disorder. percent of all infants suffer from bipolar disorder. "The majority of our subjects, regardless of size, "The majority of our subjects, regardless of size, sex, or race, exhibited extreme mood swings, often sex, or race, exhibited extreme mood swings, often crying one minute and then giggling playfully the crying one minute and then giggling playfully the next," the study's author Dr. Steven Gregory told next," the study's author Dr. Steven Gregory told reporters. "Additionally we found that most babies reporters. "Additionally we found that most babies had trouble concentrating during the day, often had trouble concentrating during the day, often struggled to sleep at night, and could not be struggled to sleep at night, and could not be counted on to take care of themselves—all classic counted on to take care of themselves—all classic symptoms of manic depression." Gregory added symptoms of manic depression." Gregory added that nearly 100 percent of infants appear to suffer that nearly 100 percent of infants appear to suffer from the poor motor skills and impaired speech from the poor motor skills and impaired speech associated with Parkinson's disease. associated with Parkinson's disease.

For example…For example…Behaviors of a typical 4-year-old boyBehaviors of a typical 4-year-old boyInattentive, hyperactive, impulsiveInattentive, hyperactive, impulsiveADHDADHDNoncompliant, oppositional, argueNoncompliant, oppositional, argueODDODDBehaviors of a typical 12-year-old girlBehaviors of a typical 12-year-old girlSad, irritable, moodySad, irritable, moodyMood DisorderMood DisorderBehaviors of a shy child with Behaviors of a shy child with

misarticulationsmisarticulationsAtypical language, poor social skillsAtypical language, poor social skillsPDDPDD

Developmentally TypicalDevelopmentally TypicalMany behaviors that a parent or school Many behaviors that a parent or school

might find disruptive, obnoxious or might find disruptive, obnoxious or strange are strange are developmentally typicaldevelopmentally typical

That is, these behaviors typically occur in That is, these behaviors typically occur in individuals of that ageindividuals of that age◦ Impulsivity, Tantrums, Moodiness, Impulsivity, Tantrums, Moodiness,

Fidgeting, etcFidgeting, etc◦E.g., tantrums in a 3-year-old childE.g., tantrums in a 3-year-old child

That DOES NOT mean that interventions That DOES NOT mean that interventions shouldn’t be tried or won’t be successfulshouldn’t be tried or won’t be successful

ShapingShaping

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 functionThe trick is to figure out what

that function is

Factors3 important factors to consider

are…

Antecedent

Behavior

Consequence

Behavior ChainMain behaviors are made up of a chain of

“mini” behaviorsThese “mini” behaviors build upon one

another to cause main behaviorBreaking the chain stops main behavior from

occurring

1------> 2------> 3------> 4

What Influences Behavior?ExternalEnvironment

◦ Home◦ Classroom◦ Temperature◦ Sound◦ Visual

InternalIndividual

◦ Genetics◦ Development◦ Temperament◦ Sleep◦ Diet◦ Activity◦ Beliefs◦ Emotional distress◦ Anxiety

The Child BrainThe Child Brain All behavioral development has to do with the All behavioral development has to do with the

brainbrain Brain development is dependent upon both Brain development is dependent upon both

experience and geneticsexperience and genetics The brain has a great deal of plasticity and can The brain has a great deal of plasticity and can

recover over timerecover over time Frontal lobes are the last to develop, taking Frontal lobes are the last to develop, taking

upwards of three decades to complete this upwards of three decades to complete this processprocess◦ Primary location of behavioral and emotional Primary location of behavioral and emotional

regulation, impulse control, etc.regulation, impulse control, etc.◦ Often [but not always] more impaired in Often [but not always] more impaired in

individuals with neurological disordersindividuals with neurological disorders

Influence of MedicationsMedications can improve or worsen

behavior problemsE.g., Keppra

◦Works well with stopping seizures in children

◦However, also increases emotional/behavioral dysregulation and aggression

Flunarizine◦Drowsiness, anxiety, depression

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 decreaseConcentration decreasesMotivation for activity decreasesEmotional/behavioral regulation decreasesFidgeting/overactivity increasesHypnogogic experiencesSleep deprivation in kids has been linked to what

are assumed to be entirely unrelated phenomena, including lower IQ, obesity and ADHD

8(+) hoursPregnant women

7–8(+) hoursAdults, including elderly

9–10 hoursAdolescents

9–11 hours5–12 years

11–13 hours3–5 years

12–15 hours1–3 years

14–18 hours1–12 months

up to 18 hoursNewborn

Average amount of sleep per dayAge and condition

NSF Data

Influence of Fear and AnxietyFear

◦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 unavoidableBoth can manifest in ways that do not

indicate either

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?

Behavior ModificationWorking with a professionalProblem identificationProblem analysisIntervention developmentIntervention implementationIntervention monitoring and

“tweaking”◦Habituation

Modification TechniquesPositive 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

Modification TechniquesNegative 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

Modification TechniquesResponse 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 occursStepwise - consequences increaseAs “natural” as possibleA word about punishment…Can be effective…but…Does not teach the replacement behaviorTends to be short-livedCan worsen the behavior

AHC Family DataBehavior questionnaire 15Behavior

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

AFC Family DataInterventions

◦Removal from environment 4◦Ignoring 3◦“Lecture” 3◦Sleep 2◦Holding◦Time Out◦Tangible◦Patience

IdeasKnow the ABCs of the behaviorE.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

IdeasE.g., physical aggression

◦A = being corrected for something they know is wrong

◦B = aggression◦C = taken to room and allowed to

calm downPraise for appropriate behavior,

give a prompt/cue that behavior may become inappropriate, maintain calm, maintain distance

IdeasE.g. crankiness

◦A = waking from a nap◦B = crankiness◦C = held, comforted

Soothing waking, primary reinforcer immediately upon waking, patience

IdeasE. 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

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

ResourcesResources◦ WebsitesWebsites

www.apa.org/releaseswww.apa.org/releases www.behavioradvisor.comwww.behavioradvisor.com www.asha.orgwww.asha.org

◦ BooksBooks Parenting the Strong-Willed Child Parenting the Strong-Willed Child by Forehand & Longby Forehand & Long Helping the Noncompliant Child Helping the Noncompliant Child by Forehand & McMahonby Forehand & McMahon SOS! Help for Parents: A Practical Guide for Handling SOS! Help for Parents: A Practical Guide for Handling

Everyday Behavior Problems Everyday Behavior Problems by Lynn Clarkby Lynn Clark 50 Great Tips, Tricks & Techniques to Connect With Your 50 Great Tips, Tricks & Techniques to Connect With Your

Teen Teen by Debra H. Ciavolaby Debra H. Ciavola

◦ maglebyphd@gmail.commaglebyphd@gmail.com◦ www.ini.orgwww.ini.org