Frequently Asked Questions
Is there a screening tool to help determine if a Neurobehavioral or Neuropsychiatric approach should be considered?
A Neuropsychiatric approach should be considered when a child or adolescent has had a series of treatment failures. It can also be considered as a child’s first placement if there are indicators of a possible brain disorder. The following checklist may be help in screening for a brain disorder.
BRAIN DISORDER INDICATORS:
- Repetitive rage behavior (Pathological Aggression) with no provocation or gain
- Impulsivity with impulsive aggression
- Chronic irritability
- Poor planning skills (runaway with no plan, no money, nowhere to go)
- Short attention span & poor memory
- Laboratory evidence (abnormal CT scan, MRI, EEG)
- History of neurological disease (seizure disorder, encephalitis)
- Abnormal Neuropsychological test results
- Head injury or multiple concussions
- Exposure by fetus to toxic substances (medications/substance abuse in pregnancy)
- Lack of prenatal care, difficult pregnancy or childbirth with late development
- No birth or early developmental history available due to adoption
What Is A Neurobehavioral Disorder?
“Neurobehavioral” refers to the type of behavioral problems that are associated with brain disorders. It is a term frequently used to describe the serious behavioral problems often seen after traumatic brain injury. For example, explosive rage behavior, impulse control problems, mood swings, and poor judgment are neurobehavioral problems. We also use the term “Neuropsychiatric” to refer to the same behaviors. Both of these terms apply to developmental brain problems that are the result of fetal exposure to drugs or alcohol (e.g., fetal alcohol syndrome, crack babies, etc.), or other early brain impairments such as anoxia at birth or shaken child syndrome. When these brain impaired children become adolescents, they sometimes display the same neurobehavioral problems seen in traumatic brain injury cases, including violent temper and very poor impulse control. Unfortunately, traditional psychiatric treatment has been ineffective with these neurobehavioral disorders. The brain problem is a barrier to successful counseling, and typical psychiatric medicines are of limited benefit.
How Is “Neurobehavioral” Treatment Different?
First of all, it is based on a thorough assessment of the brain function as well as psychosocial issues. Many of these children have language or memory disorders that prevent verbal psychotherapy from being effective. Some of these children have partial complex seizure disorders and other treatable brain conditions. By treating those correctable brain disorders and then using modified methods of therapy (e.g., non-verbal therapy to bypass language and memory problems), it is possible to more effectively manage the violent behavior and allow for a re-socialization process to take place. If the individual’s actions present a danger to himself/herself and others, or if symptoms are severe, treatment in a Neurobehavioral inpatient unit is recommended. Once stable and manageable, the juvenile is ready for discharge to a structured aftercare plan.
How Long Does Neurobehavioral Treatment Take?
To stabilize violent behavior, complete a comprehensive assessment process, and develop an aftercare plan, children and adolescents requiring a longer course of treatment may be referred for Neurobehavioral Systems residential treatment. The length of stay can range from 6 weeks to several months. Completion of this extended treatment process allows the problem to be fixed permanently and to prevent repeat acute hospital admissions. Although aftercare is still required after discharge, this aftercare can be organized on an outpatient basis.
Can Outpatient Assessments Be Accomplished?
In cases where the patient is impulsively aggressive but not highly dangerous, outpatient assessments are available at Neurobehavioral Systems. Outpatient assessments are possible for children from age 5 and up, and also for adults. At this time, inpatient services are only available for juveniles aged 5-17. Outpatient assessments are also available for attention, learning, language, and neurobehavioral disorders. Electrophysiological (EEG and evoked potentials) studies assist in determining appropriate medication to treat the specific or the area of brain affected. This increases the probability of successful treatment on an Outpatient basis.
What is an EEG?
The term “EEG” stands for Electroencephalogram. The EEG is a medical test that measures the electrical activity of the brain and, among other things, is used for the diagnosis of epilepsy. Electrodes are placed on the scalp to pick up the electrical activity that is occurring in the brain. It is a non-invasive test that is used when a doctor suspects that an episodic behavior is being caused by an electrical disorder in the brain. Episodic staring spells, shaking of the body, fainting spells or convulsive seizures are common behaviors that may be symptoms of electrical problems in the brain. However, there are other episodic behaviors that may lead a doctor to order an EEG for a patient. These may include some psychiatric symptoms such as poor emotional control or sudden onset of a loss of impulse control. For example, rapid mood swings or repetitive episodes of explosive aggression (against self, others or property) can sometimes be associated with brain electrical disorders. The doctor may order an EEG test.
We recommend a qEEG (Complex EEG) because it includes Evoked Potentials. The Evoked Potentials provide the critical information our Pediatric Neurologist uses to determine the source of brain electrical abnormalities.
What is an Evoked Potential? What does it add to a Neuropsychiatric workup?
Two common types of evoked potentials are Auditory Evoked Responses (AER) and Visual Evoked Responses (VER). Evoked response measurement is similar to an EEG, using the same electrodes on the scalp, the same EEG machine, and a similar measurement of the electrical activity of the brain. However, whereas the EEG measures the ongoing electrical activity of the brain, the Evoked Response (as the name implies) measures the electrical response evoked (stimulated) in the brain by either auditory (AER) or visual (VER) stimulation. For example, for the AER, the patient is presented a “click” from an headphone (many times) and the EEG machine measures the brain’s electrical reaction evoked by that sound. For the VER, a flash of light is used instead of a sound. The advantage of this “evoked” response, for psychiatric conditions, is that it allows the doctor to see if there is any electrical abnormality deep inside the brain. Deep electrical disorders are important because the brain’s systems for controlling both emotions and impulses are located deep in the brain (in the Limbic region). Electrical disorders in this deep region can result in poor emotional control and/or poor impulse control. Abnormal findings indicate that medications to treat the source of the problem behavior can be prescribed.
What is the Limbic System?
In our brains there are several primitive structures that give us important abilities that are needed for the survival of the species. The “limbic system” is that group of brain structures devoted to the ability to fight or run away in an emergency. The limbic system also helps us to remember events that caused strong emotions.
Where is the Limbic System?
Deep within the center of our advanced “thinking brain” (cerebral hemispheres), there is a primitive “emotion brain” (limbic system). The limbic system consists of several structures, including the amygdala (sometimes called the rage center), and the hippocampus (an important part of our memory system).
How does the Limbic System Work?
If someone were to be attacked, the limbic system would first produce fear and then perhaps rage. The fear would energize the body to help you to run away, if possible. If not, your limbic system might trigger a rage, which would prepare the body to fight in a ferocious manner, to protect yourself or your loved ones. Picture a mother bear protecting her cubs from a predator, and you will get the idea.
Why is the Limbic System Important for Neuropsychiatric Disorders?
Since this is our “emotion brain”, it is vulnerable to disorders in brain chemistry and in brain electrical activity. Some disorders run in families and are genetic in origin, while others are acquired by developmental brain damage (e.g.; drugs or alcohol used during pregnancy, or a difficult birth). A disorder in the “emotion brain” can produce emotions that are out-of-control. Extreme acts of violence, suicidal behavior, agitation, and mood swings can be due to disorders of this brain system.
What is Complex Partial Seizure Disorder of limbic origin?
In our patients, we use the example of rage episodes being comparable to an “emotional seizure” as a way of explaining that is it caused by an area of electrical instability in the brain. It is not a true seizure, but seizure-like in that the patient cannot control the episode.
Partial seizures: Seizures are classified into Generalized seizures and Partial seizures. Generalized seizures are epileptic attacks that spread (“generalize”) throughout the brain. In contrast, partial seizures are focal in origin, since the epileptic attack begins in a specific area of brain.
Complex seizures: If there is no alteration of consciousness, the seizure is called a simple partial seizure. If there is a defect in consciousness, during the epileptic attack, then it is called a complex partial seizure. Such defects in consciousness do not usually include drop attacks, but can be disorientation, staring, or other cognitive alterations (sometimes followed by impairment of recall of the event).
Limbic seizures: Some specialists further divide seizures into subtypes according to the location, or origin, of the focal epileptic attack. For example, “temporal lobe” seizures would originate in the temporal lobe. The term “…of limbic origin” indicates that the attack is believed to originate in the limbic region, deep within the temporal lobe (an area critical to emotional control). Such attacks may be manifested by severe emotional dyscontrol and may include perceptual distortions, sensory abnormalities, illusions, automatisms, fugue states, or other signs of temporal lobe disorder.
How is Complex Partial Seizure Disorder of limbic origin related to rage behavior in juveniles?
When a juvenile shows repeated outbursts of out-of-control rage behavior it is reasonable to assume that the individual is suffering from some pathological condition. There are many psychiatric conditions that can produce violent rage behaviors. Recently, there has been evidence that many cases of “pathological rage” represent neuropsychiatric disorders.
Such neuropsychiatric disorders often involve a developmental brain disorder that interacts with a juvenile’s psychiatric or psychosocial problems. If this brain disorder involves limbic seizures it may respond to treatment with anti-convulsant medications, which can stabilize the limbic emotional system and prevent rage attacks.
How can one tell if the problem involves limbic seizures?
The EEG is an important laboratory test for the diagnosis of seizures, but recent research suggests that long-latency evoked responses can be more effective in pinpointing limbic electrical abnormalities.
In neuropsychiatric centers that specialize in rage behavior, the combination of EEG and long-latency evoked responses helps to diagnose limbic seizures, but this is not yet a standard procedure outside of such specialty centers. Comprehensive psychiatric evaluation is also required.