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MAIN POINTS TO TAKE AWAY: #1

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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MAIN POINTS TO TAKE AWAY: #1

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

  2. 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.

  3. MAIN POINTS TO TAKE AWAY: #2 COMPLEX BRAIN SYSTEMS REQUIRE COMPLEX, MULTIDIMENSIONAL INTERVENTION MODELS!

  4. MAIN POINTS TO TAKE AWAY: #3 WE WILL BENEFIT FROM EXPANDING OUR UNDERSTANDING AND ASSESSMENT OF THE “I” IN OUR OWN DIR MODEL.

  5. 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.

  6. 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.

  7. THERE ARE HUGE PROBLEMS WITH OUR DIAGNOSTIC SYSTEMS.

  8. 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

  9. 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.

  10. 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.

  11. 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.

  12. 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)

  13. NIMH: RESEARCH DOMAIN CRITERIA (RDOC) ON A BETTER PATH

  14. 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

  15. Examines Specific Constructs Across a Multitude of Domains DOMAINS: • Genes • Molecules • Cells • Circuits • Physiology • Behavior • Self-Report, etc.

  16. 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

  17. 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

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

  19. 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

  20. 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!

  21. CUTTINGEDGETHINKING PAVING THE WAY…

  22. “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

  23. 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

  24. 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.

  25. 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

  26. 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)

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

  28. 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.

  29. 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.

  30. 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.

  31. A Feedback Loop…

  32. 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!

  33. 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.

  34. 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.

  35. 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.

  36. 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

  37. 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

  38. 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

  39. POSTERIOR PARIETAL CORTEX • RECIPROCAL CONNECTIONS WITH PREMOTOR AREAS AND THE FRONTAL EYE FIELDS • FOCUSES ON SPATIAL INFORMATION • VISUAL CONTROL FOR ACTIONS, PERSONAL MOVEMENT SPACE

  40. 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

  41. 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

  42. 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?”)

  43. 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.

  44. ACT TWO COMPLEX BRAIN SYSTEMS REQUIRE COMPLEX, MULTIDIMENSIONAL INTERVENTION MODELS!

  45. THE BRAIN’S COMPLEXITY IS BEYOND ANYTHING IMAGINED…

  46. “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

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