On this episode of CITV, Dr. Matthew Worth takes us through a clinical case of an 11-year-old female with a history of sensory aversion, behavioral concerns, and anxiety.
If you’d like to learn more about strategies for working with neurodevelopmental disorders, check out Dr. Worth’s upcoming Neurodevelopmental Disorders program beginning this June in Cape Canaveral, FL. Courses are available on-site, live stream and on-demand.
– Hello, my name is Dr. Freddy Garcia. Today we’re here with Dr. Matt Worth. Dr. Worth, how you doing?
– Doing fantastic. How about you?
– Doing awesome. Hey, we’re getting on video again because everybody loved the first video case review you did. You are spearheading the Neurodevelopmental Disorders Program starting this June for the Care KC Works. Excited to have you lead that program. And we decided to give people a sneak peak of how you work with your patients and these are the things that you’re gonna be teaching the scholars to help other similar types of patients. And that first case review was received so well we decided to have you back on and we’re doing another one. So let’s get right into it. You ready to do this?
– Let’s do it.
– Alright. Hold on. Let’s kick this thing up here. And I think, yeah, I think we have that up there. All right, what do we have today, Dr. Worth?
– Okay, we’re gonna talk about a patient, a girl named Elliott who came in. And it was suspected that she had autism, but we ended up finding out it was more of a Sensory Modulation Disorder complicated by anxiety. So I wanted to go through that and talk about some of the things that we found during the examination, some of the things we treated, how we treated em, and then go over that with the learners.
– Let’s do it.
– All right. So, let’s start with the case here. Elliott’s an 11 year old girl with a eight year history of sensory aversion, some behavioral concerns and some anxiety. Some of the sensory things we saw as far as defensiveness, was movement specifically angular acceleration. So, she did not like to go on merry-go-rounds and do things that caused spinning at all. Tactilely, she doesn’t like tags, fabrics especially spandex, nylon, microfiber and she doesn’t like to wear underwear for some reason even if it’s cotton. And then certain foods that she has a defensiveness cause of texture would be the broccoli, cauliflower, crunchy foods and beef for whatever reason. She also demonstrates some significant anxiety in large group settings, going into public bathrooms or closed-in spaces alone. And she also has difficulty sleeping at night in her own room. Now, her parents kind of made this worse for her because they’ve allowed her to sleep in their room on the floor and now she doesn’t want to get out of the room, but we’ll talk about that in a little bit. Deviations from normal routines are very difficult for her, both at home and at school and she kind of needs to be aware of what events are gonna be taking place in the future to feel comfortable. And she has some associated behavioral issues and hyperekplexia, which is really that she has an over exaggeration of sensory information that comes in. So if something is loud for you, it’s extremely loud for her. And if it’s a light touch to you, it would be a real deep pressure to her. And we’ll talk about the mechanisms of that. She also suffers some nocturnal enuresis and with frequency of maybe four to six nights a week. But she doesn’t have any accidents during the day, and there’s no bowel incontinence. Some of her developmental history includes that she was born at 38.5 weeks. She was 7.8 pound baby with an APGAR of seven. She was a vaginal delivery with no complications. She was bottle fed because she couldn’t get the idea of how to grand the latch on for breastfeeding and really overall motor skills, fine motor were the ones that were delayed compared to her peers. Now, I’m gonna go over some of the thing with you here that are just positives when we do the examination because it’s an extensive exam that we’ll talk about in the neurodevelopmental course. But for this case and purpose we’re go and hit the positives. Parents report that she was always easily startled, so that moral reflex was there and it continues to be there. And she did not like to be rocked to sleep or swaddled. She didn’t like the deep pressure or the movement. At two years of age, they noticed that she didn’t like to be hugged. She never liked swings or merry-go-rounds. She’s hypersensitive to touch, noise, pressure, textures of foods and clothing and she hates the Fourth of July. Fireworks are the worst thing for her because she can’t go ahead and see, once they’ve been launched, where they’re going. So, that unknown is really difficult for her. If we look at the social history here, she’s an only child and she resides with both parents at the same house. They’re still married and she’s a school-aged girl. She has a few close friends. She doesn’t currently participate in any organized sports or really physical activity. Doesn’t spend a whole lot of time on computers or tablets, but she does take two art classes two days per week. And patient’s a permanent resident. She hasn’t traveled abroad. No known exposure to alcohol, tobacco, mind-altering medications at this time and the parents report deny use of caffeine as well. So, let’s take a look at her academic history. She’s in a public school in the fifth grade. She’s a full time student. She gets great grades and she’s in regular classes. She doesn’t receive any special services with the exception of a 504 plan. Last time we talked about that, but a 504 is something that she can qualify for if she doesn’t have necessarily a learning disability but she has another health impairment. Another health impairment would be like ADHD. So the intelligence is there but the ability to focus isn’t. For her, the loud environment is something that’s a problem for her so her 504 states that she’s able to go ahead and go into a quiet setting when she starts to get anxious or she has testing. Again, strengths for school, she is great grade-wise across all domains. She doesn’t have any weaknesses at all academically but her behavior is that she doesn’t like high stimulating environments. Okay, she want things to be quiet. She wants low stimulation. She doesn’t do well in airports. She doesn’t do well at malls. All those things that, like a club, she could never go to because it’s just too much stimulation. She doesn’t even go to the movie theater right now. Let’s look at the mom’s history, because we always have to look at maternal history to figure out a little bit more about why the child may be the way the child is. So, if we look at her, the mom was 34 years old when she got pregnant. She was unaware that she was pregnant because she’s a lifetime of irregular menstruation cycles. So, she didn’t know she was pregnant for the first four and a half months. At the time of conception, she was height weight proportional. She had ten year history of hypothyroidism mourningly. She had some seasonal allergies, which she takes Benadryl periodically for and she also has seasonal depression disorder. Now, not knowing she was pregnant actually allowed her to go ahead and consume a fair amount of alcohol for that first trimester. When she found out she was pregnant, she discontinued the alcohol, but again she didn’t know she was pregnant for the first four and a half months. Some of the history on the mom’s side here is that her father, or Elliott’s grandfather, had some cardiovascular disease, hypertension, obesity and depression. Grandma or the mom’s mom, she had thyroid’s disease, alcoholism, hypertension, and if we look at this in the timing relationship to the pregnancy, she died two months prior to the conception from a hemorrhagic stroke. So, prior to her getting pregnant, her mom ended up dying. So, this caused a fair amount of stress for her. Our sibling history, her brother committed suicide and in timing relationships to the pregnancy, it was two weeks before the pregnancy. So, two months before the pregnancy, she lost her mom. Two weeks before the pregnancy, she lost her brother. So, it’s a pretty high stress situation for her, losing family like this and then she felt guilty about the alcohol intake at the time as well. So, let’s take a look at Elliott here. On the examination posturally, she had some internally rotated posture. We always look at posture because it’s a good indicator of the four tracts that are responsible for maintaining posture, which include our medial and lateral vestibulospinal tracts and our medial and lateral reticulospinal tracts. She has some scapular winging more prominent on the right. She has a little bit of a head tilt with some contralateral rotation. When we looked at her eyes, pupils, they were symmetric. But in ambient light they were at seven millimeters and in the dark they were at eight. So, you can see that the pupils were rather large at all times. And when we look at that, we often times think we have decreased parasympathetic activity or overactivity of the sympathetic system. Either way, we know that there’s probably a lot of mesocephalic windup going on as a result of it. Pupillary light reactions, they’re rapid to summate, rapid to fatigue. But there was a plastic pupil noted on the right which means that it contracted and it held for a longer period of time with some efficiency. These things are usually indicative of some basal ganglionic disorder and we’ll talk about that and how that plays a role into this as well. She had a marked tectal response upon photic stimulation in all fields. And if you remember, if you put light in a patient’s eye and they withdraw from it, that’s a tectal response to the photic stimulation and we also know that she startles very easily, okay. So, again, we have that mesencephalon driving really high at this point. Cardinal signs of gaze are grossly intact with compensatory head movements in all planes. So, as we do the cardinal signs of gaze, she’s unable to follow with her eyes and we start to see some compensatory head movement to keep up. Now, due to the history of mom drinking for the first trimester or so, we wanna look at her face to make sure that she doesn’t have any evidence of fetal alcohol syndrome. There are certain characteristics of a fetal alcohol baby. Some of them are gonna be like an increased philtrum or the space between the nose and the upper lip. We also see sometimes a long thin lipped mouth but Elliott doesn’t have any of that stuff. So, we don’t see any physical findings that would support the idea that she was a fetal alcohol baby. Motor-wise, all her spindle responses are three plus throughout. We went ahead and checked her mental reflex was there as well. If you guys remember back when you were taking some of your early neurologicals, if we have increased reflexes everywhere in the body, we always want to check the mental reflex. That’s absent in most people. If it’s present, then, the heightened reflexes at a three plus may be normal. If it’s not present, we have to suspect possible cervical myelopathy until proven otherwise. As far as tone, she was monotonic. As far as retained permanent reflexes, the only one that we could elicit was the moral reflex, which again is that startle reflex. If we looked at the sensorium here, the sensation to pin and temperature were intact. She didn’t like it but she was able to make it through. However, she couldn’t tolerate vibration at all. And when we went ahead and did tuning fork testing for auditory, she went through from that and basically was starting to have a panic attack so we had to stop. Alright, so when we looked at coordination, gait and station, she demonstrates some intermittent oscillations in all planes when standing with her eyes open and feet together. When we closed her eyes, she ended up falling. So, she’s unable to go ahead and stabilize or stand up still, without falling with her eyes closed. Finger-to-nose, finger-to-finger challenges, she had some dysmetria bilaterally. The heel-knee-shin test, she could do it without dysmetria, if she’s lying down. But if she’s standing up, it’s very difficult. She seems to fall over. She had a lot of truncal titubation where you could see that her body was constantly moving and tempting to correct so that she didn’t fall. Standing in tandem, she fell towards the left and she had a left parietal drift. Some of the overshoot tests were all positive bilaterally so when we went ahead and we hit her arms down, they would rebound greater and then we saw that also in the legs as well. And she was a little bit dyspraxic and had some dysdiadokokinesia on the left side there. When we went and scraped the bottom of her foot, for flex reflex afferent response, I mean it was so heightened, it had triple synergy bilaterally and withdrew. She even complained of a painful response with it. Core strength is very poor on this patient here. Tried to do a VNG with her, however, the goggle tightness was too much for her so we were unable to do that. But we used some other things to go ahead and look at some of the extraocular movements. Optokinetic, there were poor pursuits bilaterally. Cognitively, we wanted to make sure that we didn’t have an issue there, so we ran a Woodcock Johnson Achievement and Cognitive test. She tested across her achievement in the high average to superior range and on the Woodcock Johnson, her IQ is at a 129. 90 to about 110 is average, so she’s a smart kid. We went ahead and had her mom do a Hamilton Anxiety Rating Scale, because she’s 11 and can’t really determine what brings on the anxiety as well as mom can. And mom rated her at a 27, which is moderate to severe anxiety which plays a huge role here. If we look at sensory processing disorders here, you can see that we have three different categories and six subcategories. So, in the Sensory Modulation Disorder, we have a sensory over-responsivity, we have a sensory underresponsivity and then we have the kid that sensory craving and that’s a kid who’s probably rocking and doing some other things, trying to seek more sensory stimulation. They may chew on their clothes and stuff like that as well. Our Sensory-based Motor Disorders include dyspraxia and some postural disorders and then our Sensory Discriminative Disorders, here, included pretty much all of our six sensory systems: visual, auditory, tactile, taste smell, positional movement and interception or proprioceptive. Now, when we went ahead and looked at her, this was the first test that we did with her for the eye movements. If you’re familiar with RightEye, it’s a system here that doesn’t really require any wearables on the patient. They can just look at the screen and it’s measuring or tracking the eye movements. So, her overall score… When we look at my eyes, it says 43, this is kind of an arbitrary number that’s been calculated on based on some of the things that she’s done that tell us how well she functions. If we look here, we can see that her pursuits and I’m looking here. I want to say that’s 46%. I’m thinking that says 46% there. Hold on one second here. There we go, 46%. If we look at her saccades, I believe that says 31% and then her fixations were in the fiftieth percentile. So, if you look at the results here we can see that she does really poorly on maintaining the ability to follow a circle. Now, when she has problem maintaining something like a pursuits, where we see our horizontal pursuits here right underneath our circle, right underneath it we see our horizontal pursuits, here, we can see that she has difficulty staying on the line. And the red lines that you see in there are what they call saccadic intrusions. So, she’s following it across and all of a sudden she loses track of it and then she generates a saccade to keep up with it. So, the pursuit systems are not necessarily where we like them to be. If we look below that, we can see here her vertical and you can see that she doesn’t come all the way to the top. However, she overshoots the bottom. And you can see that we have some deviation here of her being able to stay on the line, affecting her percentages on that. If we look at pursuits, we have to be able to fixate on the target. And if we look all the way over here, on to eye stability and her ability to fixate, we can see that she has terrible fixation, okay. And right underneath that in the yellow where it says fixation, we can see the graph on where it fixates here. So, she’s hypotrophic on her left eye and she’s hypertrophic on her right eye. And then if we go ahead and look down here we can see her saccades in the middle. Her saccades, again, are very poor. Saccades are generated from the frontal eye field and basically she’s trying to hit the targets going back and forth. You can see she’s a little bit better vertically than she is horizontally. So, we can see that she has some processing issues and extraocular movement. So, let’s look at some of her balance things. If we look at her balance here, this is a standard CTSIB test or clinical test of the sensory integration on balance. And you can see here, we have a stability index and a sway index. Stability is in relationship to her center of pressure. The further away from zero she is, the more she loads her hills on this particular test. And her sway index is how much she moves with it. So, if we look at her eyes open on a firm surface here, we can see that she really loads posteriorly here because again she’s further away from zero. But if we look at her sway index here .5 is the upper limits of normal. So, she has nothing to fixate on during this period of time. So she’s starting to move due to gaze instability. She’s unable to go ahead and keep her eye fixated on a white wall where she doesn’t have a target and all of a sudden she starts to move more. When we close her eyes, you can see, she actually does a little bit better as far as loading the more of her forefoot here. And we can see also that her movement is less if we look at the numbers overall. Visual conflict, we put goggles on her that conflicts the information visually and vestibular-wise. Again when we do that, again we see that she’s moving more towards her forefoot on center of platform here and she has a much better score when we go ahead and take the messages from the extraocular system and we go ahead and we take it away from the vestibular system. So, they work better independently than they do together, which tells us a little bit more information about how we’re going to treat this. If we look at her eyes open on a foam surface, again, foam forces you to load the forefoot, but she’s really still on her hindfoot here. And we can see, again, eyes open this should be the easiest of the three on foam. She’s at 4.36, which puts her way out the normative range here. When we closed her eyes, she ended up falling and the visual conflict on the foam, she ended up falling as well. Let’s go back and take a look at some of the other things. Alright, so let’s talk a little bit about some of the things that we saw here with the intervention here. So, in the office we provided some neural feedback with her, because we really need her to go ahead and be able to decrease some of here anxiety and work a little bit more of that frontal lobe of her brain. Also, we did some vestibular therapy starting off with some gait stabilization exercises which she took home with her. We worked on some angular acceleration. And when we did gait stabilization we not only did that sitting, we did it standing, we did it while walking. She was asked to go ahead and hold a card out with the letter and she was actually turning her head while walking in various planes. And then when we went ahead and did the angular acceleration, she had to go ahead and look at letter cards to make sure that they were still clear and that we didn’t see an issue. We did some dynamic visual stability where she was requested to turn her head and read as well and if it was clear then she was able to do it at that level. And then we did some things to recalibrate her optokinetic responses. We also went ahead and did some tragus stimulation with her. If you’re not familiar with that, it’s a little alligator clip that goes onto the tragus of the left ear and then we also go ahead and put a electropad, about an F4 on the left wrist about two breadths above the crease of the wrist there to stimulate tragal and the vagal system to go ahead and decrease some of that amygdalar or that limbic escape there that was happening with the anxiety. She was requested to go ahead and wear yellow glasses or yellow lenses to slow down some of the photic stimulation that was coming in and then we progressed later on to green and to blue and then we ended up getting back to white light again. And as permitted that she do some cognitive behavioral therapy on being able to be okay with idea of being in a room full of people because those are things that I think are necessary for her to be able to be exposed to and learn how to deal with because it’s something that’s unavoidable in life. The home therapies that we did with her included dietary modification and some supplements to decrease some gut inflammation. We went ahead and did the binaural beats with her to go ahead and decrease some of the aberrant brain activity that we saw on the neural feedback. And then we worked on something called sensory brushing and joint compression techniques. Now, I taught these to mom and what we do is we take this little plastic brush that has some medium bristles on it and what we started doing was brushing the hands and then we would go ahead and brush different areas of her body to go overcome some of the sensory aversion to tactileness. We also went ahead and did some things with her toothbrush to brush her tongue so that she was able a little bit more to tolerate some of the foods. She still doesn’t like broccoli or cauliflower but she is able to go ahead and eat potato chips now which is just fantastic and she’s eating chicken and some beef, if it’s prepared a certain way. And then, I also was asked to attend the 504 meeting at school. So, as a patient advocate I ended up showing up and discussing what I saw upon parent’s request in schools, talk to the OT there and then we went ahead and made recommendations so that she could go ahead and get some vestibular stimulation at school so that she can make it through school a little bit better throughout the day with less anxiety. We admitted her 504 plan as well. So, let’s take a look again at some of the post results that we saw with the extraocular movements. Alright, so if we look here we can see that her number for her IQ for the brain went up. We’re at 88 here. You can see that her pursuits are relatively high there. I believe that says 89% in the tile. Her saccades are much better than they were where actually I think that says 82nd percentile. And her fixations are well in the green range. I can’t, unfortunately, read that because the slide’s a little small but you can see a difference between her ability to pursue and keep her gaze stable while doing it on her circles. Underneath it, you can see it again on her smooth pursuits on horizontal plane and vertical plane. If we look at her fixation, you can see that she doesn’t have that hypertropia, that she had earlier, or the hypotropia that she demonstrated either. And then if we look at her saccades, these are the worst of all of ’em however, they’re in an acceptable range. There’s just room for improvement. So, we ended up doing, again, some gait stabilization activities. We did some eye exercises in the office and at home. Let’s take a look at her balance. If we look at her balance here we can see that she still loads her hindfoot quite a bit. However, she’s in a normative range for her sway index. If we close her eyes now and we’re utilizing the proprioceptive system and the vestibular system a little bit more, we can see that she’s in the normative range of .56 and she’s loading her hind foot a little bit less. The visual conflict again takes the visual information and the vestibular information and it keeps them from communicating. And she’s a rockstar, she’s at a .63. When we put her on the foam surface, if you remember this number here was way out of range at a 4.36 and now we’re right at the upper limits of what normal is at .76. And if she closes her eyes, if we remember the next two, she fell so we didn’t really have data to compare it to. But when she closes her eyes, she’s at a 1.68 for a sway index and a 2.2 for her stability index. And finally if we look at her visual conflict on the foam, again, this number should be as close to zero as possible, at 1.8 she’s even better and then we look her she’s in normative range for that as well. So, let’s talk a little bit about some of the discussion in regards to what happens with the mesencephalon. Let’s talk about dopamine and some stress. So, if we look here we can see that prenatal stress elicits or increases dopamine transport almost 50% in binding the striatum, 17% the putamen and 13% the head of caudate compared to those who didn’t have it. Now, I want you guys to understand that when we look at the head of the caudate, head of the caudate also is responsible if we have issues in that area. Our caudate is responsible for the areas that cause things like Tourette Syndrome, bipolar syndrome, schizotypical schizophrenic-type disorders, motor stereotypies, attention issues and things of that nature. So basically she’s having increased binding there which is actually causing things to be overstimulated. And when you have striatal binding it correlates negatively to habituation to repeated tactile stimulation and positively with tactile responsivity. So, she’s getting an exaggerated response because we have basically upregulation of some of the dopamine. If we look at the maternal exposure to mild daily stress during pregnancy, it increases the binding capacity. And as a result of that, it’s gonna go ahead and cause behavioral characteristics and tactile hyper-responsivity and problems with behavior in kids. While you would think the alcohol would have played a bigger role in this, stress is actually being shown to have a greater effect on prenatal maternal stress than alcoholism, if it’s moderate. If it’s severe then we have the whole fetal alcohol baby thing. However, when we start looking at it here, mom’s stress plays a huge role with this. Okay but if we look here Schneider, Moore and Atkins found that prenatal stress reduces sensory processing optimality here. It increases again tactile over responsivity and reduces vestibular function compared to those with no prenatal stress. If you look at Madison, Cocker and Gwen, they found out that prenatal alcohol is more widely known as developmentally toxic and correlation evidence shows association with neural behavioral problems, including reduced inhibitory control which we know is frontal lobe, impulsivity attention deficits and problems with regulations of arousal. If we look here at some of the dopamine, dopamine system’s been linked to early life vulnerability and it’s gonna play a huge role in regulating mood, affect motivation, reward response and motor behaviors. If you remember those circuits there it’s gonna go ahead and basically receive in the basal ganglionic areas, input from the entire cortex here and it’s gonna go ahead and project to our prefrontal, premotor and supplementary motor areas. And these circuits are gonna regulate roles in predicting future events. I told you earlier that she doesn’t like to do things that she doesn’t know what’s gonna happen. She needs to know what’s going on throughout the day before it happens so she can prepare herself for it. Shifting attention sense is another thing. So, basically that’s what these circuits control. Movement and spatial and working memory here. And if we also look here, we know that some of the things that affect prenatal stress, they can actually change brain programming in fetuses and have permanent changes in neuroendocrine regulation and behavior. So, again prenatal stress has a huge effect on early programming of brain functions. So, that’s something to consider when you’re taking a history on treating a kid who has ADD or any types of issues here. Then we wanna also go ahead and get good history about what the maternal life was prenatally cause mom may have been doing some things that she didn’t really think were an issue. I mean we found out all sorts of things in the last probably five years in regards to things like Benadryl use, antidepressant use while pregnant and how it affects the fetus. So, that’s the end of this case here and I hope you guys learned a little bit. I’m excited to go ahead and talk to you guys about the new Neurodevelopmental Disorder Program coming up in June and I’d like to go over some more of this stuff here so you guys have a little bit better understanding how this affects kids and the development of children and adults.
– Dr. Worth, that was incredible. So, this last slide I want to go to it. I really like the section where you’re going over and connecting all the brain circuitry to the various conditions that can be seen in some of these neurodevelopmental disorders. Are you gonna be going over more things like this in the program?
– I have a good amount of experience in physical neurologic examinations, it’s what I do, but this is a niche, right? To connect that circuitry to those conditions that’s very eye opening for me to hear. You’re gonna do more of this?
– Absolutely, and unlike some of the previous or other programs that were out there, everything that we’re gonna be discussing will be referenced. It’s very evidence based. We’re moving away from some of the things that used to be thought of as being really key components because we’re finding out more and more information that seems to show us that this is gonna be the way that… I mean, you can’t argue the point here. There’s references and it’s not chiropractic literature. This comes straight out of brain literature, psychiatry literature and child developmental literature. So, this really allows you to open up doorways here with other providers, whether you’re working with OT’s, PT’s, speech language pathologists, pediatricians or pediatric neurologists because they can’t argue the point here. They see this literature if they’re reading it. And if they don’t, you’ll have references for it.
– And part of it is writing the reports and educating them, then you build a stronger network. And they respect that which is great.
– I can’t wait to learn more about that circuitry. Dr. Worth, I’m sure everyone’s gonna love this case review again. If we can find another gap in your schedule, we’ll do another one. Again, the Neurodevelopmental Disorders Program kicks off June 28th through the 30th 2019. It’s a six module program and Dr. Worth just thank you so much again. I really enjoy and I learn from you every single time you share these lessons so thank you and we’ll catch you next time.
– Thanks for having me.