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For citation. I. Neuropsychological aid in case of mild neuropsychic pathology and borderline states
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For citation
The publication has been prepared within a framework of a state assignment of the RAE ISCFU
Providing mental and psychological health of a young generation is a crucial issue almost for every country including Russia. A recent decade has witnessed the growing spread of various neuropsychic disorders and growing psychological disadvantage of children and adolescents. The prevalence of pregnancy and birth pathology, somatic illnesses and other pathological states in childhood leading to the impairments of mental development has been growing. Different authors report that the prevalence of perinatal disorder of the neural system in children varies from 45 to 80% [1; 2; 12]. Meanwhile, perinatal pathology of the CNC even in case of a favorable income has remote effects and a negative influence on child’s mental development and social adaptation [9; 14]. The prevalence of basic forms of children’s mental illnesses grows by 10—15% each ten year; in 70% cases, neuro-mental illnesses cause child incapacity [11]. There is a growth of suicides among children and adolescents, the number of which has recently increased by 35—37% in Russia. In 2013, the Russian Federation occupied the first place in Europe by the number of suicides among children and adolescents [4]; there is one suicide death for almost 200 suicidal attempts [5]. Specialists assume that over 80% of children need some psychological, psychotherapeutic, or psychiatric aid now [13]. The increasing prevalence of both severe and borderline forms of mental pathology in a child population is a kind of challenge for modern psychiatry, clinical and special psychology, defectology, and pedagogics, a challenge that, in our opinion, has not received an adequate answer yet. We assume that there is a need for a complex approach to this issue. Only interdisciplinary interaction of specialists in this area can improve health and harmonize the development of a growing generation. Neuropsychology of child age is one of the disciplines to elaborate scientific and applied aspects of health saving technologies for children and adolescents.
Child neuropsychology as a scientific trend has been developing for several decades and its methods have long been successfully applied for the correction of various pathological and borderline states in children; however, many specialists are not well aware of the tasks, methods and specifics of this trend. Child neuropsychology " studies and analyzes the interaction between the formation of mental functions and cognitive sphere of a child and the maturation of neural sphere; besides, it investigates the specifics of mental functions disorders in case of organic injuries and impaired brain work in childhood [6, p. 7].
We identify two aspects of a neuropsychological approach to providing mental health of children and adolescents:
| I. | Neuropsychological aid in case of mild psychoneurological (neuropsychic) pathology, borderline states, and deviating development to children from a " risk group": neuropsychological diagnostics and correction, secondary prophylaxis. |
| II. | Neuropsychological aid to children with severe pathological states and a complicated structure of the defect: neuropsychological correction, neuropsychological support of ontogenesis, secondary and tertiary prophylaxis. |
I. Neuropsychological aid in case of mild neuropsychic pathology and borderline states
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Borderline disorders usually involve minimal brain dysfunctions (MBD), attention deficit hyperactivity disorder (ADHD), cerebrasthenic syndrome, neurocirculatory dystonia, light degree hypertension-hydrocephalic syndrome, mild speech impairments etc. Children without neurological diagnoses (parents often do not try to obtain the consultation of a neurologist) who have difficulties in learning and social adaptation also constitute quite a large group. From the standpoint of neuropsychology, the successful learning and socialization of a child are largely conditioned by morphological and functional maturity of cerebral structures as well as correspondence between the tasks represented during learning and morphological-functional maturity of brain. One of the most frequent reasons of child’s failure in learning and social adaptation is partial retardation in the formation of higher mental functions, which can be associated with functional insufficiency of certain brain structures. In this case, neuropsychological correction aims at overcoming functional insufficiency of different brain areas, each of which provides a certain psychological factor, i. e. an " element" of one or several mental functions. The improvement of neural system activity and harmonization of brain work enables to achieve various tasks — to reduce neurodynamic impairments, to improve attention and memory, emotional sphere (including the development of so-called social emotions), to stimulate the development of thinking, speech and motor functions, and to improve child’s behavior in general. The process of neuropsychological correction should be preceded by neuropsychological diagnostics, which enables to reveal preserved and impaired factors, which define the main focus of correctional work.
To specify neuropsychological factors of the impairment of behavior and social adaptation in childhood, we have conducted a study, which involves 170 children: 80 children aged 5—7 and 70 children aged 8—10. All these children had difficulties in mastering educational program and demonstrated certain forms of sustainable maladaptive behavior. Some parents addressed to a neurologist with a child (diagnoses are listed above), but most children were not followed up by a neurologist. We have conducted the study using the following methods: A. R. Luria’s technique modified for children, questioning of parents and pedagogues, and analysis of the EEG data. The results of the study have allowed us to identify and describe three basic neuropsychological syndromes, each of which is based on the impairment of a certain neuropsychological factor (see fig. 1).
Fig. 1. The relationship between the number of subjects and different
neuropsychological syndromes
1. The syndrome of functional insufficiency of subcortical (subcortical-stem) brain structures is the most frequent syndrome (76 persons, about 45% of children). This group of children is the most numerous, i. e. functional insufficiency of subcortical (subcortical-stem) structures is usually caused by perinatal pathology of the nervous system (NSPP). In turn, the prevalence of the NSPP is quite high now. These children are mostly characterized by the impairments of a neurodynamic factor, which is manifested in such phenomena as low capability, increased fatigability, inertness, insufficiently balanced processes of agitation and inhibition, long " warm up" period, oscillations of efficiency, and distortion of the tempo of activity. Children have difficulties in both playing with peers and acquiring learning material due to neurodynamic dysfunctions. This has a negative impact not only on the process of cognitive development, but also on the forming children’s self-esteem as well as on the level of their acceptance by peers.
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Besides, children from this group have specific features of mental functions development. They report difficulties in concentrating and shifting attention, some reduction of audio-speech (and sometimes visual) memory. Children acquire very little information from the first time due to inertness and difficulties of orientation. They usually have an extremely low volume of direct primary reproduction (2—3 elements out of 10); however, the volume of the second reproduction is two or three times larger than that of the first reproduction. Besides, we register an increased influence of interfering (distracting) impacts, the retrograde interference being the most frequent. These children have motor insufficiency due to general regulatory and neurodynamic disorders. The majority of them report the impairments of muscular tone, tempo and rhythm of movements, less accurate movements, quite strong synkinesias, hypo- or hyperactivity, and general disorganization of movements. These children are also characterized by the insufficient development of spatial and kinetic praxis (including reciprocal coordinations), which is reflected not only in special assays, but also in everyday life: these children have difficulties in drawing, constructing, and dressing (for example, in tying shoelaces). General motor awkwardness of these children and excessive or deficit motor activity lead to difficulties in the development of everyday skills, writing and actions with objects. Insufficiency of visual-spatial representations and visual-motor coordinations can lead to the development of constructive dyspraxia and substantial retardation in the development of graphic-motor activity (drawing, writing etc. ) in these children. The analysis of children’s speech development reveals certain regularities. Thus, the development of such speech factors as phonemic hearing, a nominative factor, understanding and usage of complex logic-grammatical constructions (comparative units, preposition forms etc. ) is the most impaired. The reduction of audio-speech memory, speech functions, inertness and other neurodynamic disorders create prerequisites for deterioration of the indices of thinking development. Besides, children with this syndrome have specific features of emotional sphere: difficulties of adaptation, a tendency to stereotyped responding in case of necessity for getting used to new conditions, emotional lability or " stiffness", easily occurring addictions and neurotic habits. In educational establishments (a childcare center, a school), children of this group often become closed, manifest negativism and aggression towards others, they are too disinhibited, hyperactive or, on the contrary, slow and sluggish during the classes. Various compulsive actionstypical for these children often attract the attention of people around; these compulsive actions can be of various intensity, frequency and social disapproval (tics, nail biting, winding hair around the finger, nose picking. child masturbation etc. ). One of distinctive features of emotional sphere and behavior of these children is dependence from a general functional state: fatigue, unfavorable meteorological conditions etc. lead to the increase of negative emotional-behavioral manifestations. Generally, children with functional insufficiency of subcortical brain structures are characterized by some immaturity of emotional sphere, when emotions have a slightly decreased function of behavior and interpersonal relations regulation. Adaptive functions of emotions and affective control are more focused on vital needs and a need for maintaining quite stereotyped interrelations with environment.
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In many children with the insufficiency of subcortical-stem brain structures, a special complex of symptoms gradually develops. It can be called a " subcortical-frontal" neuropsychological syndrome: against the background of changed activation from subcortical-stem structures, the functional state and development of the frontal cortex of the brain impairs, which, in turn, begins to perform the organizing function towards subcortical structures insufficiently; in this case, the basic type of impairments is a decreased voluntary control against the background of neurodynamic dysfunctions. As these children grow up, the deficit of voluntary regulation of activity gradually becomes the leading. They partially constitute the second group of children with deviating development described below.
2. The basic impairment observed in the following neuropsychological syndrome (60 subjects, about 35%) is the insufficiency of voluntary regulation of mental activity, which is provided by the work of pre-frontal brain areas. This syndrome is associated with retarding development of pre-frontal brain areas and the impairment of the establishment of associations between frontal lobes and subcortical-stem brain structures. During neuropsychological study, these children often do not follow the instruction, do not accept the set conditions of work, act impulsively, and " slide" into the game. Insufficiency of voluntary control, i. e. " managing functions" affects the quality of performing complex gnostic assays, which leads to the decrease of indices of attention and memory as well as speech development. In studying audio-speech memory, the peculiarities of the reproduction process come to the foreground — the repetition of the same words, associative " intrusions", difficulties of delayed recollecting. In studying motor sphere, the performance of assays associated with learning motor programs is poor, there are frequent perseverations. In speech sphere, there are clear difficulties of independent building of a detailed statement; thus, the narration basing on the picture very often becomes a laconic citation of the characters’ actions (" A boy is running. A man is standing. This man is watching…" ). In the analysis of the specific features of emotional-volitional sphere of children from this group, the difficulties of control over emotions, emotional lability, insufficient maturity of higher levels of affective sphere, i. e. insufficiently developed " social emotions" (sense of duty, responsibility, guilt for offences etc. ) come to the foreground. Children with this syndrome very often have field behavior and distractibility; they need constant external control to maintain long-term productive work. Voluntary regulation is violated in each element: goal setting, programming (planning the stages of activity) and control suffer. Children with this syndrome know the rules but do not observe them, and this is manifested in all the spheres of activity: in younger children — in the game and the formation of everyday skills, then — in pre-school training, later — in performing tasks in Mathematics, Russian (dysorthography is often formed) and in behavior in general. These children do not observe the rules in the games, they are likely to quarrel and engage in a fight easily. They combine the aggression towards peers with negativism towards adult members of the family, caregivers, and teachers. The affective explosions with aggression and protest responses, especially when an adult tries to regulate the activity of a child and make him perform some rules are quite frequent. Besides, these children have an impaired " sense of distance" and a reduced ability to form deep emotional ties, the communication is more superficial. They usually demonstrate a combination of increased emotional sensibility, susceptibility, and vulnerability towards themselves with quite a low sensibility towards others, insufficient ability for empathy, and emotional sympathy.
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We should note that insufficiency of voluntary control in children often does not cause anxiety in parents and pedagogues, who explain it by the child’s age. However, this impairment becomes apparent in school: children violate the rules of conduct, do not keep distance in communicating with a teacher, do not always write down their home assignment, and are attentive only when they are interested in something. This often leads to poorer school performance, conflicts with teachers and peers, social maladaptation. A child, though preserved (and sometimes gifted) intellectually, who manifests his abilities in more " free" conditions of a childcare center, becomes incapable in the conditions of school education. Thus, the insufficiency of executive functions leads to negative effects for child’s further development and future.
3. The third neuropsychological syndrome typical for 20% of subjects is associated withfunctional insufficiency of the left hemisphere and misbalance in the functional development of the left hemisphere against the background of retarding formation of interhemispheric interaction. In children with this syndrome, peculiarities of behavior reflected in both the situation of the study and parent’s complaints come to the foreground. Sometimes, strong obstinacy, hot temper, proneness to hysteria, and some bizarrerie begin to manifest themselves as early as in childhood. Bizarrerie in behavior can acquire all possible forms depending on child’s emotional-personal peculiarities: tiptoeing, using words in a foreign language, various manipulations with the content of the pot, increased attention to things that are usually unpleasant to people, strange requests, demonstrative-theatrical or provocative behavior etc. Children may begin to ask questions about death, illness, murder etc. very early and thus baffle their parents and caregivers. Many parents report weak efficiency of reinforcements and punishments as well as unstable motivation of a child. These children have specific interests: very often, they prefer collecting Lego-type constructors, watching cartoons with active characters, listening to music and do not like reading books, working with a text, having classes at the table etc. The emotional sphere of most these children is paroxysmal (attack-like) — now a child is having a great fun and almost euphoric, then suddenly he starts crying or being afraid of something. The emotional background is often decreased, a child is capricious, he is likely to evaluate others negatively, and he has many fears (bizarre fears are frequent). Possibly, these children resort to rituals and stereotypies due to increased anxiety. There are cases when a child is in a good mood while there are no requests to him; however, when even small requirements appear (for example, regimen), a child became obstinate, he starts shouting, crying, quarrelling; besides, aggression (a child threatens, beats other people, throws various objects etc. ) or self-aggression can occur. These children may give an abrupt vigorous response, " hysterics", often with a note of demonstration (they fall down the floor, hit their heads, heads, and feet etc. ) at any reason (the reason is usually one — they do not get what they want). It is this category of children that often causes the sense of " pedagogical helplessness" and trouble in parents who start seeking aid from various specialists (neurologists, psychiatrists, psychologists, neuropsychologists etc. ). However, while some parents are expectedly anxious about it, others began to appease a child. They think that a child is small and later everything will be solved by itself, a child will " overgrow" it. As a result, the situation worsens; negative characterological traits are formed and fixed in a child.
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Increased egocentrism, orientation merely on his fantasies, wishes, needs (often – up-to-the minute) and neglecting society (emotional responses of others, rules of conduct etc. ) affect child’s social adaptation. Children with this syndrome often prefer loneliness or communication with older children and adults (since they " adjust" to a child) instead of their peers. In games, they impose their " scenario". In competitions, they try to become first at any price. If they fail to win, they demonstrate increased emotional responses. These children often form inadequate affections to a mother, a caregiver, a pedagogue etc. On the one hand, this is symbiotic attachment; on the other hand, most negative manifestations and aggressive actions are usually poured out to the object of affection. These children often avoid tactile contact or do not observe tactile-corporeal distance — they try to touch, caress, hug, kiss etc. anyone, even unknown people. At early or preschool age, children with this syndrome often report stereotypies, selectivity in food, difficulties in acquiring trimness skills. In some cases, peculiarities of behavior in these children at early age can be so vividly expressed and lead to such difficulties of interaction that doctors suspect an autistic spectrum disorder in a child, which is not confirmed later. At school age, children of these group preserve basic peculiarities of behavior; they often lie and threaten in communicating with other people (for example, they say, " I will kill you" ), call names, and snitch with pleasure (they often fantasize); there is often enhanced proneness to demonstrative behavior, aggression, theft, runaways; the development of voluntary control is retarded. In education, these children often report difficulties in mastering the program in Russian and reading, dysgraphia and dyslexia are often formed; school copybooks and a diary are specific: they are torn and crumpled, there are a lot of drawings on the margins and pages. The tendency (with varying intensity) to left-sided ignoring is quite often revealed. The behavior of such children is still focused on satisfying spontaneous, sometimes bizarre wishes and needs. Arguably, these children even at the age of 9—10 live and act " here and now" without focusing either on possible circumstances of their deeds or on the opinion of others or emotional response of close people.
In the situation of the study, children with this syndrome manifest difficulties in establishing a contact and observing distance. It is usually impossible to conduct a full-fledged neuropsychological study at early and preschool age available for other children of the same age due to behavioral peculiarities of a child. They turn their back and press themselves to their parents, they may call names, cry, and they refuse to perform a task or do it in their own way. During the study, children of this group report the prevalence of the signs of the right hemisphere domination: these are children with manifest or covert left-handedness and/or sinistrality according to auditory and visual analyzers. Besides, children are not brilliant in performing assays aimed at the analysis of the right hemisphere functions — tactile gnosis, body scheme, simultaneous synthesis etc. However, these children are much worse in perform the tests for studying the functions of the left hemisphere. Most children also demonstrate very low results in the assays on interhemispheric interaction. Children of this category have some peculiarities of speech development. They often report the retardation of speech development, stumbles, stutter, and sustainable replacement of sounds, at early age — the use of so-called " gibberish" (a set of sounds). The formation of phonemic hearing is usually retarding, echolalias are preserved longer. Even if speech development corresponds to the age, the speech of these children is specific. There can be a phenomenon of scanning speech, paraphasias, neologisms, replacement of words by foreign words. While a child is read aloud, he may be enchanted by the intonation and pay little attention to the sense of the text. The meaning of a word is very often distorted, a child is rather focused on the emotional-imagery gestalt hidden in this word than on the sense. This phenomenon often frightens parents. Thus, they may hear from a small child " I will die", " I do not love you, you are bad", " I will kill you" (me, others and other options), and often obscene expressions. Apart from speech peculiarities, the retarded formation of graphic-motor skills (drawing, copying, and writing) often attracts attention. Interestingly, children of this group have psychosomatic disorders. Children with this syndrome need long-term neuropsychological sensory-motor correction combined with a competent work of a speech therapist-defectologist. This work is necessary for both overcoming impairments in a child and preventing pathological formation of a personality as well as psychopathy-like and deviant behavior. The key factors of successful correctional work are regular training and timely beginning (as a rule, the younger is a child, the more efficient is the aid).
We should mention that there are no impairments that are pathognomonic for this particular syndrome either in performing the assays of neuropsychological study or in the peculiarities of emotional sphere development, behavior etc. (see fig. 2). Thus, insufficiency of voluntary control is observed in varying degree in all the syndromes, while aggressive manifestations (though slightly varying in nature) are reported in children with the second (" frontal" ) and the third syndromes.
Fig. 2. The prevalence of some peculiarities of emotional sphere in children
with various neuropsychological syndromes
Nevertheless, we cannot assume that the syndromes are identified conditionally. Each of them is based on a basic impairment, which constitutes a " core" of the syndrome, manifests itself the most clearly, is a symptom-forming factor and prevents normal ontogenesis and socialization of a child in the greatest degree. Here, we have the same principle as in a pathopsychological study. As noted by B. W. Zeigarnik, " the same pathopsychological symptom can be conditioned by different mechanisms; it may indicate different states… The nature of impairments is not pathognomonic, i. e. specific for a certain illness; it is just typical for them and can be evaluated in conjunction with the data of an integral pathopsychological study" [3, p. 24].
The peculiarities of child’s behavior, which are directly associated with the impairment of functional development of brain structures, can worsen and become fixed by a wrong style of family upbringing [10]. We assume that in case of the formation of sustainable negative patterns of behavior in a child, there is a combination of external (social, including family) and internal (biological) factors. The maturing of different brain structures is known to be a necessary prerequisite for the development of mental functions. Parents and other members of the family, in turn, address different forms of social impacts to a child, define a way of mental functions formation, and cause a stimulating influence on the maturing of the corresponding structures of his brain; this influence can be either positive or negative. Thus, certain peculiarities of the style of family upbringing can contribute to the insufficient formation of the functions of some brain areas (for example, appeasing hyperprotection and laissez-faire style of upbringing often lead to functional insufficiency of frontal lobes). However, the " choice" of aupbringing style by parents is not occasional; it depends not only on the personalities of parents themselves, but also on the peculiarities of a child, to which a family often has to adjust. We need a complex approach, which involves both methods of neuropsychological correction of a child and working with family, to overcome the impairments of behavior and difficulties of social adaptation in children.
The group of children with borderline states is both an easy and a difficult category in the context of a neuropsychological work. On the one hand, competently organized neuropsychological correction can be quite efficient in overcoming child’s impairments and preventing further development of pathological states. On the other hand, mild pathology may be unnoticed and underestimated by parents and some specialists. Parents may refuse from curative-correctional events due to various reasons (psychological defense mechanisms, lack of consent between family members, expectance for the aid of sport and other clubs and that a child will " overgrow" the problem etc. ). In this case, a gap between social (for example, school) requirements and child’s abilities is gradually growing. A child should resort to various defense responses, his social adaptation may be impaired and the development of personality may be distorted. Such a child enters adolescence with insufficiently developed " managing" functions/ a deficit of voluntary control, often with asthenoneurotic traits, infantilism, and proneness to depressive states. As a result, the probability of deviant behavior (including suicidal), the occurrence of various addictions and neurotic responses, the formation of various accentuations of character are formed. This can be prevented by timely neuropsychological correction.
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