Lecture 6: Clinical Child Neuropsychology

Brain and behaviour are strongly correlated. Dysfunctions, structural and functional abnormalities have various causes and can result in problems in thinking, doing and feeling. Damage to a developing brain will have different consequences than damage to an adult brain.

Neuropsychological assessment is done by history taking (interviewing parents and teachers), doing observations (How is the child behaving in class? Is the child easily distracted? How does the child behave in interactions with the teacher and with other children?), tests and questionnaires. Neuropsychological assessments in children are often long-term follow-up assessment. This is done because some weaknesses will be resolved within months or years or new deficits may develop due to the developing brain.

There are different forms of treatment in clinical child neuropsychology. Psychoeducation is about educating the child, parents, teachers and others around about specific difficulties and how they display in daily life. Other forms of treatment are advising the child, parents and the school about how to deal with these difficulties, giving cognitive training, psychosocial counselling, enhancing coping strategies, (cognitive) behavioural therapy and supporting/counselling the family and the school.

Normal brain development

Proliferation is the process of cell growth. It starts in the first month of pregnancy and it is a very rapid process, since up to 250.000 neurons are developed every minute. Migration is the process in which neurons are transported to their location via glia cells. This process ends at birth. Differentiation is the process of developing into specific neurons. This process ends just after birth. Synaptogenesis is the process of developing synapses after birth. Apoptosis is cell death. This is done because some neurons won’t be used or are not necessary (anymore). Myelination continues after birth. All parts of the brain will go through these stages, but not at the same time. The brain develops from the back to the front (bottom-up development). First, the spinal cord and brain stem will develop. Those are necessary for vital and basic functions. After that the limbic system and the cortex will develop. At birth, all the basis structures will be completed.

After birth, genes and the environment influence further functional maturation. Synaptic pruning, the process of eliminating extra synapses, will start after birth. During the critical/sensitive periods the brain will grow intensively and the environment will have a maximum influence on the brain development. Functional development will take longer than 20 years.

The development of cognitive functions is more or less parallel to the development of the brain. Cognitive development can be compared to software, meanwhile the brain can be compared to hardware. Only if brain area X is developed properly, the cognitive function of that specific area will be able to develop. If the occipital lobe has developed properly, visual perception can develop. If the temporal lobe has developed properly, language comprehension can develop, and if the frontal lobe has developed properly, functions in planning and understanding can develop.

Disruption in prenatal brain development

Disruption can occur in prenatal brain development. This can be due to genetic abnormalities or harmful environmental factors. Examples of harmful environmental factors are nutrition (malnutrition, specific diets), stress, illnesses (infections, viruses) or toxic substances (alcohol, drugs, medication). Examples of genetic abnormalities are spina bifida (“open rug” in Dutch) (occurs when the neural tube doesn’t close), microcephaly (too few cells are produced), megalocephaly (too many cells are produced), or chromosomal abnormalities (which can cause syndromes like Down’s Syndrome). Genetic abnormalities can affect various stages in brain development.

If the basic structure of the brain has impaired it will have consequences for further development in the brain and in functioning later on in life. The development of the be compared to building a house. Basis architecture is needed for further building.

Disruption in postnatal brain development

Disruption in postnatal brain development can be caused by factors like genetics, environmental factors and neurological conditions. Disorders like Autism, ADHD and learning disorders are often genetically based. Examples of environmental factors which can affect postnatal brain development are deprivation and abuse. Neurological conditions are often seen later on in life. Examples of these are traumatic brain injury, epilepsy, inflammation, brain tumours and strokes.

Foetal Alcohol Spectrum Disorders

Not all children prenatally exposed to alcohol meet the criteria of FASD, but do suffer from the consequences. Children with FASD have been exposed to alcohol during pregnancy. The extent of the consequences depend on the amount of drank alcohol, and on when during the pregnancy the alcohol has been consumed. Alcohol during pregnancy can cause disrupted brain development, from neurulation to differentiation and from brainstem to the cortex. Areas in the brain which often have small brain volumes are the parietal lobe, basal ganglia, cerebellum and corpus callosum. Facial features are a thin upper lip, big forehead and a flat nasal bridge. Children with FASD have problems in fine and gross motor skills, have a lower level of intelligence, have trouble focusing and have deficits in executive functioning. They often have poor school performances, socio-emotional problems and they show ADHD symptoms and sometimes criminal behaviour.

A video is shown in which children are seen suffering from FASD. Their symptoms are weaknesses in language and sensory integrations, problems tuning out sounds in the background, difficulty in motor skills, hand tremors, emotional problems and learning disabilities.

Autism Spectrum Disorders

Children with autism often show deficits in social communication and interaction and restricted repetitive behaviour/interests/activities (stereotyped/repetitive movements, use of objects, speech, insistence on sameness, routines and rituals and they easily overstimulated).

Different processes in the brain are often disrupted in people with Autism Spectrum Disorders. There is an overactive cell production, underactive cell death and disorganised cell migration. Mainly the frontal and temporal lobes have dysfunctional neural pathways and there is an atypical development of white matter in the brain. In childhood, the amygdala contains more grey and white matter, and less in adulthood.

Cognitive dysfunctions children with Autism Spectrum Disorders are lower intelligence levels (about 60% has intellectual disability), attention problems (many children comorbid ADHD), language disorders (deficits in comprehension and expression), perception (focus on detail and less perception of the whole) and problems with executive functioning, including cognitive inflexibility/rigidity, preservation (stuck in specific routines or rituals, sustained preoccupations) and concept formation, abstract reasoning, planning, inhibition and self-monitoring.

Different forms of treatment are psychoeducation, training/counselling, fixed structure in daily life, communication therapy, social skills training, extra support at school, CBT and pivotal response treatment.

Learning problems and learning disorders

The most common learning disorder is dyslexia. Dyslexia is a disorder in reading and people with dyslexia often, but not necessarily, have problems with spelling as well. It is important to note that not all problems have to be a disorder. Reading performances in those with dyslexia are much lower than expected for their age, measured intelligence and education. They have difficulties in phonological reading (matching sounds to letters, decoding every single letter into a specific sound) and graphemic reading (learning visual word forms). Reading problems occur at word and textual level. Letters, syllables and words are often omitted, added, turned around, swapped or distorted. Their reading style is often different, for example in spelling, guessing and breaking words into syllables. Their reading and writing is often slow and/or with many words. Their reading comprehension is intact. People with dyslexia often know the rules, but do not understand how to use them. They often spell words how they should be pronounced.

Brain abnormalities in those with dyslexia and other learning problems/disorders are structural (atypical neural migration) and functional.

Treatment can be done by learning them to link sounds and letters, make them aware of sounds, learn them how to do basic decoding and learn them spelling strategies. It is important to pay attention to their motivation and self-confidence, since they often feel stupid because other kids manage to read and write better and have no problems. Great progress is possible, but dyslexia will continue to exist.

Inflammation: encephalitis

Inflammation is a reaction to infections/viruses which can cause the pressure in the brain to build up and influence healthy brain tissue or brain cells. Encephalitis can be caused by a virus (herpes, rubella, measles, chicken pox), fungi or bacteria. Symptoms are fever, headaches, early altered mental state (confusion, memory loss), behavioural problems, weaknesses in body parts and seizures. Early diagnosis and treatment by a physician is important. Growing into deficit means that as one grows older, more deficits may develop. Some cases are severe with permanent impairments (e.g. sensory, motor and cognitive impairments, permanent brain damage or death), especially herpes simplex virus has severe consequences for cognition, and it also the most common cause.

Inflammation: meningitis

Meningitis is an infection to the brain membranes (meninges) and is caused by bacteria (meningococcus, streptococcus), viruses, parasites, fungi or ticks. Complications are hydrocephalus, abscesses, cranial nerve lesions, thrombosis, infarcts, ventriculopathy or brain damage. Symptoms of meningitis are fever, headache, altered mental statuses, rash, neck stiffness, photophobia, seizures and nausea. Within meningitis as well, as one grows older, more deficits may develop. Fever is more likely in meningitis and personality/behavioural changes are less likely in meningitis. Early diagnosis and treatment (antibiotics) by a physician are very important.

Neuropsychological consequences of encephalitis and meningitis are global cognitive disorders, like lower intelligence and deficits in language, attention and memory, and learning difficulties, for example in math and reading.

Brain tumour

Brain tumours take up space in the brain, causing increased pressure, hydrocephalus and vascular abnormalities. The first symptoms of a brain tumour are headache, drowsiness and suffering from an epileptic fit. Depending on the location of the brain tumour, motor or sensory problems may occur. Early neuropsychological symptoms are loss initiation, fatigue, behavioural changes and lowering academic performances.

Most children suffering from a brain tumour are cured, depending on the type and location of the tumour and the age of the child. Cognitive deficits depend on treatment, tumour size, tumour location, disease and additional complications.

Radiation is the most important cause of cognitive deterioration, especially in young children. Surgery removes the tumour, but may also damage remaining tissue. Chemotherapy harms rapidly dividing cells and passes the blood-brain barrier, but has mostly limited long-term effects. Besides, this form of therapy may also kill healthy cells.

Neuropsychological consequences of brain tumours are lowered intelligence (especially after radiation), mental sluggishness, deficits in working memory, attention and learning, executive function problems, socio-emotional problems and academic problems.

Conclusion

• Brain development is a long-term process with different overlapping stages
• Cognitive development is generally a parallel process
• Development is influenced by genes and environment
• Structural and functional brain abnormalities have various causes
• Recovery depends on severity, nature, extent, location and age
• Crowding: general decrease in functions may occur because some areas must take over functions of other areas
• It is not necessarily true that younger children have greater chances of recovering from brain damage
• Diagnosis and treatment not only involve the child or patient itself, but the family and school as well

*** Exam questions ***

Behaviour problems in children with FASD often resemble those children with …

ADHD

In young children with autism, brain volumes are …, and connections are …

Larger, inefficiently reorganised

In children with reading disorders, what is often intact?

Reading comprehension

What negatively affects neuropsychological outcomes with paediatric brain tumours most?

Radiation therapy

What is a downside of plasticity after brain injury?

Crowding