this program is presented by university of california television like what you learn visit our website or follow us on Facebook and Twitter to keep up with the latest UC TV programs so thank you for having me it's a pleasure to be here and get a chance to talk a little bit about what I do within the UCLA system as a clinical neuropsychologist and as a as a researcher I have a somewhat ambitious agenda for this morning I wanted to go through your clinical neuropsychology as a practice for the pediatric practitioner and what kinds of things to look for when you would refer what you would get out of that referral but also then change the focus a little bit to my area of work which is pediatric brain injury and how neuro psychology helps us to understand what happens in a brain injury and what kinds of things to look for and follow so neuro psychology is the interface of the brain and behavior so clinically what a neuropsychologist does if there's a behavior of concern it's an attention or a learning problem or an emotional difficulty some manifestation and we want to see what the etiology of that is so that we can get more information to help inform our intervention is when clinical neuropsychologist get pulled in the picture so across the age span there's a wide range of cognitive and behavioral issues that you would seek an evaluation for but within the pediatric field I've listed the bread and butter of what a neuropsychologist would most often be wrapped in to do and know obviously cognitive disorders secondary to a medical condition we're talking about tumors and epilepsies and strokes learning disorders and of general pediatric practice language problems ADHD and the broad range of things that that encompasses spectrum disorders other developmental kinds of things and emotional behavioral issues as well so I'm probably preaching to the choir with this slide in terms of risk factors because you probably know them very well but just as a reminder anger when you're working in the pediatric population these are the kinds of risks risk factors that may clue you in into you know there may be an underlying cognitive or processing issue that this child is having to deal with sometimes it's very obvious other times it's very subtle and you know you would want to possibly dig further into genetics whether it's a very strong family of history of something that you that your patient is presenting with or a genetic condition that you know of environmental kinds of things neglect nutrition issues secondary to medical condition but also a number of insults in terms of prenatal exposures perinatal factors an injury a head injury and some kind of neurologic insult chronic medical conditions sometimes we we forget those we neglect those that those have ramifications medical treatments in terms of radiation therapy chemotherapy or any kind of chemical exposure and there's probably more to the list but those are the ones that came to mind every time I put up risk factors I also want to put a protective factors because the risk factors many times we can't change but the protective factors we possibly can and the two here that always stick out to me are a feeling of connectedness so if a child feels like they're connected to someone if they feel like there's someone that they can rely on that is looking after them that's loving them that's a protective factor in all of those conditions that we talked about early and the right kind of intervention also is a big one so if there is a way to identify what the real issue is and be able to connect the child whether it's a school service or some other kind of therapeutic intervention that we have in mind then we can improve the outcomes many times I get asked the question why do you work with kids it's so hard and they're so it's so sad and I always think no matter where a child starts there's always potential for change and improvement and this as an example of that is even when you have you know a child with a hemispherectomy with the right kind of nurturing and environment and intervention they can still manage to have good quality of life and that's a very rewarding part of doing this kind of work so when would you refer many times in pediatric practices the issues that I listed in the previous slides ADHD may be some emotional anxiety kinds of things can be handled within a general practice but if there's any question about differential diagnoses is it the child is socially anxious is it a spectrum kind of issue or is it anxiety or is it both that would be a good reason the presence and the nature of any kind of comorbidities and I can't stress how important these comorbidities are I almost can't think of a child I've worked with with a learning issue who also doesn't have a little bit of anxiety who's not internalizing or withdrawing or acting out so many times they're called morbidities of a condition that you're able to treat in the clinical environment but also need need some attention as well the third one not all ADHD is ADHD and that's my pet peeve so ADHD by definition is the presence of a number of symptoms right so if a parent and a teacher for someone in school endorse a number of items on a checklist a child is distractible is not finishing tasks is an attentive etc if enough of those items are checked off then you have the diagnosis but why are those symptoms there is it really classic ADHD is it because and I'm going to use an extreme example they're partially deaf or they have a subtle processing issue or learning issue or working memory issue so it's really important to especially if you see it see a child who's not responding in a way that you would expect them to to stimulant medications or a little bit of structured school then you start wondering why is why are those symptoms there and an evaluation would help inform that a thorough evaluation informs your intervention and that really is key is to the more data points you have about what the issues are the better able you you can direct resources and time to to intervene I was going to use one example of the list that I gave you before to kind of show you clinically what learning disabilities may look like and the kinds of things children may present with so what is a learning disability it's the inability to attain academic achievement expected for a child's potential it could be in reading and math or in writing and it can't be secondary to some other thing obviously so let's take the example of a reading disorder dyslexia which is probably the most common type of learning problem many of them many kids with behavioral issues also have a learning disability so the comorbidity there I've listed 10 to 25 I imagine that that's them in reality that's probably a little higher than that they also have quite a bit of psychological and emotional issues that either internalize they withdraw they give up or they externalize and they have behavioral problems so we see kids cheating acting out clowning around and more extreme cases delinquency problems with the law so many of these things go hand in hand on the other hand that on the flip side the good news is that dyslexia for example is very easily identifiable pretty early you know in the kindergarten first grade levels and very accurately and with appropriate intervention it's highly highly treatable and so here's an example the top panel the two the the two examples of the brain so this is an EMA fMRI scan the top two brains the right side being the left hemisphere and get the mouse working and this being the the right hemisphere is of a child picture of a child's brain who has dyslexia so that's an abnormal pattern neuronal circuitry and when a child is is reading and we take an fMRI scan after an intervention the second set of pictures are actually the way a brain should look when they're engaged in the process of reading so we actually with the intervention phonics based intervention can make enough changes to the brain where the circuitry and the connectivity changes and we see that behaviorally in terms of improvements in ability to to read this is daunting information but there's some key statistics here that that are somewhat baffling so 60% of prison inmates are illiterate and 85% of juvenile offenders have reading problems in LA County over 50% of suicides under the age of 15 are also kids who are diagnosed with a learning disorder and that's not to say that a reading disorder causes you to commit suicide but if there's any kind of vulnerability these learning issues really tend to trigger that so that's why I think I've sort of said sent the message home in terms of how important it is to diagnose accurately and early so what are the red flags and I've listed a bunch of red flags and you're probably familiar with them but I also put up there when there's resistance there's a challenge and I always oftentimes tell parents this and that actually comes less from my product clinical practice and more from my own work with my children my kids want to make me happy so if I want them to do something and they don't and there's resistance there's usually a difficulty so when the kids resisting whether they're quitting they're clowning they're not doing their work there's usually some underlying issue that they're struggling with so taking a step back and looking at what that might be is really helpful clinically so what is the assessment process when you have some questions diagnostically or you're wondering about where to go in terms of resources and support the school district is one place it's free but it's got certainly its challenges and limitations part of the issue is that schools have this process where you wait to fail so they need a child to be scoring below their academic level before they actually kick in services and so as we have been talking about up until this point by the time you get a child to fail at that point they're pretty feeling pretty crummy they've lost motivation they think they're dumb and many cases it's hard to bring them out of that an example that comes to mind it's again an extreme example is of a young boy I saw about a year ago is 11 who has been diagnosed ADHD because on forms he met all the criteria right he wasn't learning he wasn't finishing tasks he was inattentive distractible turns out he has an IQ of 70 so they have this boy who's struggling who's really anxious really wants to do well can't learn met diagnostic criteria for ADHD but potentially he really struggles he has great deal of difficulty dealing with abstract concepts so on top of his ADHD diagnosis and medications he was giving given medications for anxiety and so on and so forth so sometimes getting partial data points partial picture hurts a child as well so if there's any concern if the intervention plan and the treatment plan is not working it's really important than to look more broadly and see what else may be going on if you have a student who already is actively engaged in an IEP process at school and receiving services but there is some disagreement between the the district and parents about whether or not services are adequate or if the diagnoses are accurate then there's a process by which parents can get an independent evaluation paid for by the school district to be able to get a much broader perspective in terms of assessing what may be and shoo and obviously parents can always do evaluations privately and and share that with the school so why is it important to accurately diagnose and treat early really embroiled down to and this is what I tell parents the learning issue the cognitive issue almost never concerns me even if I see a child with pretty extreme difficulty with learning in school they can by the time they finish high school they'll find something that they're passionate about that they can do that they can be okay with the process though of going through school and feeling like you're not good enough you're not smart enough losing self-esteem losing motivation those are the things that worry me then you end up with an adult with a lot of issues with needing years and years of therapy to to be able to deal with those kinds of ramifications of learning issues so treat died diagnosing early in treating early often helped alleviate some of these other sort of more challenging outcomes learning learning disabilities so I'm going to switch focus here and talk about the role of neuropsychology and sort of cognition in an area of research that I've been involved in for the last 10 years or so roughly in terms of traumatic brain injuries and then we'll talk a little bit about mild brain injuries and concussions since that seems to be a big hot topic in the media recently so there's quite a bit of literature identifying cognitive issues secondary to brain injury in kids and across the board in terms of the kinds of things neuropsychologists like to measure IQ learning issues attention issues you name it kids with traumatic brain injury have have trouble and here's a meta-analysis that we put together a few years ago now and it's a looks more complicated than it is actually so the set first set of slides are kids who are in the post-acute face so these are kids 0 to 6 months after a moderate to mild moderate or severe injury and the severity ranges are in the boxes with the white being mild and then moderate and severe and as you can see 0 would be these are standardized scores so 0 would be no different than their controlled sort of normal controls and the farther you go from 0 down the the bigger the gap between what would be expected of a child of the age that was measured and their actual performance on the range of cognitive issues what's noticeable is that in the chronic phase so these are now 2 years post-injury we see very similar pattern and in some cases we see a bigger gap actually so what we put together with was this picture and I like these summary sort of bottom line pictures of pages and pages of data that we pulled from a number of studies is that you have time and the bottom axis and general cognition functioning it's also combined together in the in this axis right here so you have your normal development and you have an injury right so the the dark line is if a child did not have an injury that's sort of their their rate of development over time with the mild injuries initially they show some difficulties in terms of their overall cognitive functioning but over time they don't look any different than their healthy control counterparts what was interesting is that initially our moderate and severe groups look more similar but over time the moderate group has a same rate of development but lags Oh continuously tends to lag a little bit in terms of some skills over time what was most striking to see sort of visually was the the more severe group or initially doesn't look that bad but over time the gap between them and their healthy normal counterparts grows and we think that has something to do with if those early disruptions and networks that help support cognitive functions are disrupted essentially then you set up this trajectory of difficulty over time and as the bar increases over time in terms of intelligence and in terms of abstract thinking in terms of executive skills kids with a very severe traumatic brain injury have trouble with the basic skills that would allow them to do those higher-order kinds of functioning so the extent of outcome after an injury is moderated by a number of factors many of which you can probably guess the the longer you wait the better you look there's a recovery with some exceptions as we sign the picture just before this slide age at the time of injury actually with these kinds of diffuse axonal injuries younger is not better younger is actually worse but again you disrupt these networks that are still developing so you have an injury superimposed on development and that has a negative consequence and then their injury severity obviously how long you were in a coma and a number of other things also predict that what's interesting is that there's some non clinical predictors of outcome and again I get excited about these because some of these we can actually do something about so you can't change go back and change a child's initial GCS but if you can empower parents to do more positive parenting be resourceful teach sort of problem-solving skills that are more effective and less emotion based and you know you may not be able to change issues with social disadvantage but if you're able to plug in a child with the right kind of resources in the community or in the school system then you can actually change that trajectory of families and one example that comes to mind is in our severe brain injury project here at UCLA we had one boy a 14 year old we had enrolled who came from a single-parent family mother did not speak English and he was walking and talking and he was maybe about 4 months post his in we had been in a coma for a while so I had a pretty significant injury we have an MRI protocol for for our brain injured kids so he lay down on the scanner we did the scan and when we got up we noticed some fluid that was on the on the scanner bed turns out that he has an open wound that his mother had tried to clean during a bath and had taken some screws off of the plate that was on his head and had put an onion peel as a protective measure and so we put him in a cab and sent him directly back to the ER and then later on asked her why did you not take him in this boy has an open wound and she said I didn't know I could just go to the emergency room I thought that someone had to call me to make my follow-up appointment that's an extreme example but you know if those kinds of situations don't create an environment for a child like that to gain maximum benefit from the resources that are available to them versus some other families where they will knock down every door they will call different medical centers they will do whatever they can to find whatever little program whatever clinical trial that may be out there to be able to to help their child so empowering parents and letting them know that they have rights and they can seek services and seek help makes a big difference in terms of outcome so what do we think underlie these the cognitive difficulties that we see children aren't just little adults as I said and a brain injury is superimposed on development and that has consequences so here's a picture of just to kind of show you this is a normal healthy brain I think an adolescent brain and the corpus callosum and the fibers that come out from that region of the brain here's a brain injured child so the the disruption in terms of connectivity and the networks seem to under why the morbidity we see in terms of and nura behavior here's another slide this one's a little more hopeful this is the same child an adolescent a 17 year old initially this is probably two three months after an injury so we see limited connections in regions of the brain where we would expect more this is about 12 months after so there's reconnection there's a re-establishment of these connections and in our study we're finding that the change what we're calling recovery over time actually seems to predict neurobehavioral recovery as well so that's that's what we've been interested in so I like pictures this is the way I wrap my mind around numbers so most brain injuries I mean if this was the totality of brain injuries most brain injuries are mild what caught my attention was within that mild group there's about 15% that have chronic issues that can't be explained by the severity of their injuries so just keep that little purple circle in mind and we'll loop back to that so what is a concussion now it doesn't need to be a physical hit but it's a it's a biological process that affects the brain induced by a physical force it could be a whiplash kind of movement anything that changes neurochemically the function of the brain and symptoms start very quickly but the the disruption is transient typically unless there's a complication and most people get better so in an adult and about a week or so symptoms seem to resolve in children it's up to two weeks it's a little longer so that's something to be mindful of so if there's a single non-complicated concussion there's typically not much that can be done other than reassurance which seems to help families quite a bit there's a system metabolic cascade the kinds of changes we seem to think underlie the neurobehavioral and the neurological symptoms that we see following an injury I like this picture because it's pretty but it shows you in terms of sanal and cellular communication there's a number of places in that synaptic process and in the axon sort of structure itself where neuro metabolically there could be changes that again underlie the the symptoms that we see so you know can migraine be explained by this possibly slower processing speed reaction time vulnerabilities two-second injuries and whatnot so this is the cellular level here's a striking picture published about fifteen years ago that's still striking to me it's a PET scan single individuals so it's not a combination of various scan so here's a normal individual and sort of the the energy patterns that would be expected in a normal brain in the second slide in the middle slide we have a severe head injury so this patient I forget the details but I believe was comatose and secondary to to to a brain injury the first one which is the striking one is a mild head injury this is a college student who walked to get a scan taken after a concussion so if you look at in terms of energy crisis following a concussion even though you have a walking and talking patient metabolically the brain of a concussed individual looks very similar to the brain of a severely injured patient who is comatose so what are the symptoms that would follow that metabolic cascade and the changes it could be a number of things and not all of them have to be present headache dizziness a lot of these things are probably looking familiar to you confusion and attention disorientation loss of coordination emotional kinds of issues being very weepy and teary-eyed memory loss and a period of unconsciousness although that's certainly not part of the deaf who gets concussions a large sports sports related concussions a large proportion obviously you can see in the red are football players and then the second largest group are soccer girls soccer and boys lacrosse what's interesting is if you look in this table in terms of the spread between boys and girls so we have high school players and college players for the various sports if you look at the sports where both genders participate girls actually have a higher rate of concussion than boys pretty consistently across across the board so you know girls aren't necessarily protected by that so if you look within the same sport they actually have a greater risk of a concussion so what do we know so far is that the course of a concussion or mild TBI now in this talk I've used those interchangeably are self-limiting and they're pretty predictable and with a little bit of reassurance and cognitive restructuring they go away these permanent cognitive or psychological or neurological consequences are relatively uncommon we talked about the the span of time and whatever effect we see is usually sub-threshold and transitory and many times there's associations with sort of social and personal factors and there's a high rate of premorbid issues but back to that little purple circle again in our clinic setting obviously we don't see the concussion cases that resolve naturally we see the this persistent group who seem to present with a pretty straightforward concussion but for some reason is having chronic issues and ongoing issues and are there to get some some help so to help sort of set up what were those that fifteen percent may come from there's a study we recently published on I think it's one of the largest cohorts of my a traumatic brain injury and it's also uniquenesses in children it's also unique in that not only does it have a healthy control group a non injury group within the same emergency rooms we also recruited an other injury group so the other injury group was kids who present it to the same emergency rooms for injuries other than to the head so these were twisted ankles broken bones lacerations whatever they may be and then obviously the TBI group was our was our head injury group if we look at a number of again things neuropsychologist like to measure memory attention issues executive kinds of things we see that statistically we would look at this and say oh yes there are group differences in terms of all of these areas when we look at mild traumatic brain injury versus our control groups but when we look closely we see those differences are present between the TBI group and our healthy control group but we also see those differences between our other injury group and our healthy control group so who your control group is makes a big difference because if we didn't have that other injury group we would look at this and say oh yeah mild TBI causes these chronic issues with with cognition so where we went with that was there are some non injury or general injury factors that put kids at risk for having chronic neurocognitive impairments and can we identify what those risks are how are those two injury groups different than a healthy control group why are they having a large proportion of them a larger proportion of them having issues down the road so you know 32% of both the TBI and the other injury group at one year post their concussion was having chronic cognitive issues as opposed to the healthy control group so we went fishing around to see what factors can we pull from our database to be able to explain that so our outcome is this 12-month cognition cognitively impaired yes no the dash lines are variables that we looked at or chunks of variables that we looked at but did not statistically predict the outcome so clinical variables in terms of how significant the actual injury was was not predictive and any kind of post injury we you know behavioral problems added little what was significant was the best predictor of 12-month outcome was one month outcome and the best predictor of one month outcome was academic achievement before the injury so the kids who had trouble before are the kids who are having trouble after so these may be kids who have ADHD and they're somewhat impulsive and they're running through the street get hit by a car whatever the scenario may be but also contributing to that or parent education again those family factors and premorbid academic and behavioral problems as well so understanding premorbid history is a big part of understanding why a child is having post concussion issues and many times that's that's where we go so what contributes to development and maintenance of post concussive symptoms and here's a list there's probably more to the list but obviously the more severe the injury the higher the risk headache the somatic kinds of symptoms including a history of prior headaches fogginess and dizziness of the longer list of concussive symptoms that I've presented to you before younger age history of a prior concussion and the number of non injury factors as well many of them we talked about in terms of premorbid functioning in terms of psychological factors and then symptom exaggeration is a small part of that as well so these are the risk factors so when we see a patient in clinic and they present with one or more of these things these are the ones that we like to follow to to be able to help so that brings us to our newly formed UCLA brain sport program the clinic itself has actually been functioning for the last two years we're very proud it it's multidisciplinary I think it's one of a kind in the way we run the program we have the team includes neurology neuro psychology and sports medicine and nursing so it's a one-stop-shop for patients with a concussion many of them who have complicated situations so these are we typically don't see the kid who had a concussion two days ago and is showing the normal pattern of recovery unless they need some formal you know return to activity note or something like that from us we have a wide range of referrals we see kids from childhood anywhere in childhood up through you know sort of the mid 40s and 50s and reason we have that age group as we've been seeing quite a few retired professional athletes as well so they're included in this cohort and we do a comprehensive evaluation the list of things they're presented to you and about a23 our appointment they're able to see everybody we come up with a plan that's comprehensive and depending on what the issues are whether they're more academic and learning versus more symptomatic in terms of their neurological functioning we give them the sort of the intervention plan if we need to have them come back we do and and we work with other referral sources that we send them out to or if we need to send something to the school or refer them to a more comprehensive evaluation then then we can do that as I said we've opened the clinic in June 2012 recently got a nice gift from mr. Stephen Tisch with the UCLA brain sport program which is our new new of new name for the program it has a clinical component a research component an outreach and educational component so we're very excited about the possibilities of this program moving moving forward from a neuropsychological perspective though when we see patients that are seen in the clinic many times they present with concussive symptoms and this is just my sort of clinical sense so far is I have a child who's presenting with I can't concentrate I can't read anymore I'm foggy I wonder you know is it really post concussive or is it a number of other things and these circles probably should be overlapped a lot more but I couldn't get them to fit with all the with the text but many times there's a either a history of depression or a novel depression if you have an athlete who really wants to play and this thing happened to them and they've been sitting out or they're sitting home they're depressed so if they're depressed they can't concentrate they have poor memory and they have a number of other issues if they have headaches obviously if you don't if you feel crummy if you don't feel good then you're going to get depressed you're going to be foggy not be able to concentrate concentrate and so on and so forth so when we see kids in clinic we try to address as many of these issues as we can and if we can't do that within our structure and the limited time we have with them we'll refer them for more diagnostic workup and the other nice thing we do with the kids that we see is we actually a hand them many of you are familiar with neuropsychological evaluation sometimes it takes weeks or months for parents to get a written report where they can actually take it somewhere and do something with it the nice thing here is they walk away with this form where we have sort of a general description of what the issues may be but then send them back to school with a number of possible recommendations in terms of extended time or shortened day or rest breaks and whatever the situation may warrant so that they can go back to their schools and get some support so they can at least reintegrate to some degree so I'm going to do a shameless plug for a number of our projects and programs we have an ongoing study the wrappi study which is observational and we recruit moderate to severe traumatic brain injury we have a network of hospitals within the Raider LA County system of kids 8 to 18 and we do two sets of very thorough evaluation so kids come to us about two to four months post injury and at one year post injury and we have a battery of neuropsychological tests we do an evaluation give them a report if they need one to send them back to school and many times getting this kind of evaluation privately would cost parents thousands and thousands so they get a free evaluation and a free report and some resources in terms of return to school or work or whatever the situation may be we also have a two to three-hour imaging battery fairly novel we do fMRI both active and resting state we have DTI we do a spectroscopy protocol as well to look at chemical changes so we're in the tail end of this project in the process of putting together some papers so stay tuned for some nice material to read but we're still actively recruiting so if you can think of patients that are about two to four months post injury in that age group who would benefit from participating in the study then this would be one the second is a clinical trial with a similar demographic of patients again moderate to severe injury similar age group but we recruit them about a year later and we enroll them in a clinical trial that uses a drug and a cognitive training program to help improve working memory and attention ability abilities and kids with a traumatic brain injury so again if you come across a patient who's about a year out who would want to participate in a trial like this to help improve attentional issues and working memory issues that's another possibility and the referral information is there the second plug is the UCLA neuro psychology clinic just across the street and Cemil that has a full-service children ages four all the way through adulthood we would do all sorts of evaluations to rule out any number of the issues that I've talked about in this in this talk and so the the referral information the phone number to call would be is at the bottom of the slide and finally our mild TBI sports concussion clinic there's some pictures of doctor Giza who's heading up the the group and dr. Chae who's in the audience somewhere who is part of the neurology team we have an office in Santa Monica Twelfth and Wilshire that's ongoing we meet to Tuesday mornings which is fairly convenient if many of the concussions happen over the weekend we have Monday to do scheduling kinds of things and can bring kids in very quickly again which is one of the strengths of our program with concussion you know if you wait two three weeks then your intervention many times is not going to be as helpful as getting them in quick current and addressing the issues we are soon going to be opening a second clinic here on campus hopefully in 2015 sometime so stay tuned for that and there's a referral information and contacts are also on that slide and if you need any more information about head injury concussions checklist screening forms more information pamphlets the cdc has a wonderful head web site heads up that will that is geared towards the clinician and is a very nice set of resources for you to use and your practices is you work with families so may be dealing with some of these issues so I'll stop there and I'm happy to take any questions you