II. Neuropsychological aid to children with severe pathological states

It refers to the illnesses leading to severe deviations of mental development and serious dysfunctions in the CNC work; a child often has several different impairments (a complicated structure of the defect). In our practice, the most frequent combinations are atypical autism (usually with catatonic agitation), mental retardation; impairment of the work of locomotor system (and others), epilepsy, mental retardation; autism, epilepsy, mental retardation; impairment of the work of locomotor system, microcephaly, mental retardation; sensory insufficiency (decrease of vision and hearing), autistic traits, developmental delay or mental retardation. In many cases (though not always) parents register their child as a disabled person. Nowadays, Russia sees the unprecedented growth of the number of disabled children (see table 1). The first three positions in the structure of child disability are occupied by such classes of illnesses as mental and behavioral disorders, congenital anomalies (developmental defects, deformations and chromosomic impairments) and the illnesses of nervous system [8].

Table 1

The number of disabled children younger than 18 (up to 2000 — younger than 16)
who receive social pensions on January 1 of the year [7]

Ethological factors of the severe impairments of ontogenesis vary. Usually, there is a combination of endogenous factors, hereditary pathology and perinatal disorders of neural system, less frequently — only a severe perinatal (intrauterine and/or birth) disorder of the CNC, various cranio-cerebral traumas etc.

The main tasks of a neuropsychological work with a child who has severe forms of the defect are to improve the functional state of the nervous system in a whole, to stimulate the development of cognitive, speech and motor functions, and to create prerequisites and possibilities (" ground" ) for learning and social adaptation. In this case, sensory-motor methods of correction including the author’s method [6] are optimal as a basis of work with sensory activation often being a basic component (in some cases, motor activation is impossible or possible only in a passive variant due to the impairment of the work of the locomotor system). In case of epileptic manifestations, the goal of neuropsychological aid is not only to optimize mental ontogenesis, but also to accelerate the coming of clinical-electroencephalographic remission. Sensory-motor correction enables to increase maturity at the level of the CNS functioning, to differentiate the work of the brain, to improve ties between neurons, and to optimize a balance between agitation and inhibition processes. As a result, clinical manifestations of epilepsy are substantially reduced and the data of children’s EEG are qualitatively improved, which allows a doctor in charge to take a decision about the correction of medical therapy (about the decrease or lack of necessity to increase the dose of anti-epileptic drugs, transition to monotherapy, the beginning of drug discontinuation etc. ).

One of the main factors of efficient aid to children with a complicated structure of the defect is competence and high qualification of a specialist working with a child. Meanwhile, we constantly face the challenge of total ignorance of the specialists in this area. Psychologists, speech therapists, pedagogues and other specialist often do not have even elementary ides of child’s illness or defect and offer (for a charge) their methods elaborated for healthy children with normal developmental thus taking advantage of parents’ hope. For example (cases from our practice), they offer a method of teaching reading to a child with the Angelman syndrome and deep mental retardation (idiocy); sand therapy — as a curative method to a child with combined atypical autism, epilepsy, and middle degree mental retardation (imbecility). Our long-term experience of correctional work with children who have considerable deviations in development shows that these children need a special approach. Correctional-developmental work with such a child differs not only from the work with normally developing children but also from the work with children with less severe deviations of the ontogenesis. Specialists who wish to help (and not to hurt) children with severe forms of pathology and a complicated structure of the defect need a special training. This training represents a multidisciplinary complex of knowledge including the structure of neural system, regularities of its work in norm and pathology, the structure of defect in different variants of dysontogenesis, ethio- and pathogenesis of various illnesses, neurophysiological and neuropsychological regularities of ontogenesis, the effect of psychopharmacological products etc. Incompetence of specialists, their excessive assurance in their abilities in working with children who have severe developmental impairments often leads to irreversible negative effects.

Another factor, which is of crucial importance for giving successful aid to children with severe developmental impairments, is an adequate position of parents. The choice of both a way of interacting with a sick child and ways of correctional work depends on the peculiarities of parents, their worldview, upbringing mindsets, and level of intellectual and personal development. Undoubtedly, the most unfavorable situation is when parents refuse from a child or from any correctional events. However, this variant largely occurs in so-called socially deprived families. Sometimes, the following variant is very frequent: to try " everything and at once" with a child. Parents are often not ready for regular long-term (often — multiyear) correctional-developmental training due to their personal peculiarities, they are constantly looking for a " magical tool". In such families, children are overloaded by various procedures, visiting various establishments in different cities and countries, consultations of specialists who appoint more and more drugs, diets, and biologically active supplements. They are often subject to apparently doubtful " curative" and developmental methods, homeopathic drugs and esoteric techniques found by their parents on various forums and websites. In some cases, parents, especially mothers, instinctively focus on child’s emotional background and are likely to refuse from everything that causes negative emotions in him including training and treatment. The situation when a child is supervised by a competent specialist (or a group of specialists) who conducts continuous correctional-developmental work with gradual inclusion of additional techniques and timely attraction of short-term methods is optimal. Neuropsychological correction can serve as a basis for such work. No short-term, or " rotation" method including those in rehabilitation centers and in-patients facilities will give a sustainable positive result, if it is not combined with a constant regular work with a specialist who " supports" child’s ontogenesis.

Preliminary diagnostics is obligatory during correction; however, it is often impossible to conduct a " classic" neuropsychological study of a child with severe impairments. In such cases, a diagnostic stage consists of supervising over child’s behavior and his actions in everyday life, collecting medical background, the results of medical studies, and interviewing parents about the specifics of their child’s state. Correctional work with a child who has severe deviations in development should be strictly individual; a program should be elaborated with account for the data of the examinations of the nervous system state — electroencephalogram, MRT etc. Besides, it should contain the information on child’s somatic health (for example, a cardiovascular and locomotor system). As mentioned above, children with combined severe pathology need quite long, multiyear neuropsychological correction. In many cases, we can discuss not just correction but the support of child’s mental ontogenesis. We should note that regular training are one of the main factors of efficiency. It is important to note that correctional process often causes some discomfort in a child, especially at the initial stage. Necessity of doing something often leads to quite sharp protest responses in children; therefore, training are often conducted against the background of a negative emotional state. However, as children acquire correctional program and get used to work hard, the emotional background gradually normalizes. The efficiency of correction should be evaluated not only by parents, but also by specialists (specialists conducting a correctional process and a supervisor who is possibly a physician), and by means of objective methods (EEG-control and other medical examinations). The neuropsychological correction by a competent specialist has a double effect of drills themselves and specially organized interaction with a child for whom this correction creates unique conditions. A complex approach is the most effective when a sensory-motor correction is combined with other methods of a psychological-pedagogical work. Neuropsychological correction reduces neurodynamic impairments, improves attention and memory, and increases the understanding of speech, ability to follow the instruction and child’s ability for learning. Against this background, the efficiency of the work of other specialists — a pedagogue-psychologist, a speech therapist, an АВА-therapist etc. substantially increases. Thus, the " choice" that parents often have, like " a speech therapist OR a neuropsychologist" is inappropriate, BOTH a speech therapist and a neuropsychologist as well as other specialists, if necessary, should work with a child.

In conclusion, we note an important, in our view, issue that is not discussed in literature, though it usually emerges in neuropsychologists who think about working with children suffering from severe impairments. The costs of moral and physical forces in working with such children are very high, while the results are incomparably less than if they these forces were applied to the work with more preserved child. Often, the work is executed without any hope to approach normal ontogenesis and, sometimes, it is very difficult to inform the members of child’s family about it. Besides, sometimes it is difficult to build a contact and preserve friendly relations with the parents of these children, who, as noted before, can resort to all possible " healers" in looking for a miracle, ascribe all the success to them, set unreal goals or evaluate inadequately the dynamics of child’s state. In this respect, many specialists refuse to work with such children. However, we see that even small positive dynamics in a child’s state causes quite essential increase of the life quality of a child and the entire family.

Thus, neuropsychological aid to children with mild neural-mental disorders aims at overcoming current impairments, achieving mental and psychological well-being, normalizing ontogenesis, preventing the formation of more serious deviations in development and behavior, and reducing the risk of social maladaptation. Neuropsychological correction of children with a complex structure of the defect and severe impairments of ontogenesis enables to improve child’s development, to raise his ability for learning, to prevent some secondary pathological states from occurring, to raise the level of social adaptation and to improve the life quality of a child and a family in general.