Dr. Matthew Worth takes scholars through a clinical case of a 9-year-old male with ADHD. For more information on our upcoming Neurodevelopmental Disorder program, click here.
– On today’s episode of CITV, Dr. Matt Worth will be taking us through a clinical video case review of a nine year old boy with ADHD, stay tuned.
– Hello my name is Dr. Freddys Garcia and we are joined by Dr. Matt Worth. Dr. Worth, how are you doing today?
– Fantastic, thanks for asking.
– Hey so today we’re gonna do a video case review. Because you are spearheading our Neurodevelopmental Disorders program starting in this June of 2019. Which is a very complex topic and one of the questions that we get all the time is hey, what does this look like in the real world? How do I help these patients? Some people have a desire to help people with neurodevelopmental disorders but don’t really know what that looks like in the real world so the Carrick Institute went out there, found some of the best which is you and this is why we kinda brought you on board. So kudos to you reaching this level of success. But before we even go into this video case review, can you explain to us what is a neurodevelopmental disorder, what are we really dealing with here?
– Well, neurodevelopmental disorders can happen prenatally, they can happen in gestation, they can happen after the fact epigenetically so basically it’s alterations of the neurotypical patient and basically we have alterations in various things, could be behavior, could be attention, could be motor-control or sensory modulation, those types of things.
– Right, so I hear, so I’ve heard of sensory processing disorders, what are the other names that you see out there, per neurodevelopmental disorders, just so people can become more familiar with it. What are the names you see out there, the labels that are given?
– I mean we see a lot of things like disintegration disorder or coordination disintegration disorder, and we see a lot of the AST disorders and the spectrum disorders. ADHD, we see executive function disorder which is actually more recently in the last two years been added to the DSM V. And sensory modulation disorders as well.
– Got it, yeah, so great I just wanna get everybody comfortable with those labels that are out there because they’re seeing on these patients, their patient’s cases, not really sure how to approach ’em. So let’s go into it here. I know you have a case study for us. Let’s see if that pops up. Is that on your screen, Dr. Worth?
– It is, looking good.
– Okay, excellent, well hey, let’s have at it. What do we have here?
– Okay so today we’re gonna take you through a case of an ADHD child. Mom and Dad are both well educated. Dad’s a medical doctor, Mom is actually a chemical engineer. And they have a son named Chris that’s about nine years old that came in because he’s having behavioral issues, attention issues, acting out in class. And just the same rigamarole that you see with a lot of these kids today. And I’m gonna show you a little bit about what’s going wrong with the kid. Some of the things that we did, some of the things that the parents did wrong. And talk a little bit about parental rehabilitation as well.
– Interesting, yeah, alright. So let’s get into it here.
– Alright, so if we go ahead and look here. This is Chris is a nine year old male. And he has a four year parent reported history of inattention, impulsivity, disorganization, memory difficulties, emotional outbursts as well as food and tactile aversions. He doesn’t like certain fabrics, he won’t eat certain foods. He’s very, very picky. Mom and Dad pretty much give him what he wants to eat because they would rather him eat something than nothing. Parents state that Chris has always been an awkward child regarding social interactions or reciprocity. He always seems to want to be in charge. Against his peers, his motor activity, he’s really a clumsy kid. And he’s easily frustrated when things don’t go his way. And bursts out with periods of aggression. And he continues to suck his thumb at night and in class and chews on his clothes regularly. Over the last 16 months, he’s progressively become more withdrawn and has poor sleeping habits that are getting worse and worse.
– So you know what? I’m looking at those symptoms, to me it seems like any clinician could hear a section of those symptoms and kind of go, maybe I can do something for them, maybe I can’t. But it really is like a wide arrange of symptoms that some of these patients are experiencing.
– Absolutely and the program for the neurodevelopmental program that we’re gonna be reviewing things, you’re gonna help us try to pinpoint areas of the brain to target for our rehab. So that we can go ahead and get the best result possible.
– Right yeah, interesting, alright, very cool.
– Alright, so let’s go head and take a look here at some more patient history. Parents report that at seven years of age, Chris was diagnosed with ADHD by his pediatrician. Most pediatricians that diagnose it will give the mom and dad a survey to fill out and a teacher survey and if they match up in certain parameters then the kid must have ADHD. You’re seeing less and less pediatricians prescribe some of the medications that are out there. However, we still have a handful out there that are really doing this and and they don’t really have as good of an understanding of not only the medications but some of the issues that are going on with the kid. They don’t really get a whole picture of it like we’re gonna talk about today. So Chris has gone through a variety of medications, he’s been on Adderall and Concerta and Focalin. Those three are stimulants and Focalin if you guys remember is just an isomer of that old one Ridalin. Straterra is a selective norepinephrine reuptake inhibitor, and then we have Intuniv and Guanfacine. And both of those are pretty much the same drug. Intuniv is the extended release, the Guanfacine also undergoing 10X is basically the non-extended release version of those. And we’re gonna talk a little bit about those drugs in our program too so that you have an understanding on what mechanism they work on and maybe why that drug isn’t gonna be helping him or developing other symptoms that he didn’t have before. The only thing–
– I would imagine that if you know about the medications and where they, how they kind of work, you get an idea as to why some would for a patient or why wouldn’t. You can kind of use that information clinically in the future when you wanna help them at a better level, right? Just by looking at their past medication use, right? Which wouldn’t help the most, which one didn’t?
– Absolutely and he didn’t do well with stimulants whatsoever. The Straterra seemed to go ahead and make him even more aggressive and the Intuniv and the Guanfacine, those are non-stimulants but they didn’t seem to really do a whole lot for him, they made him dizzy and had some other side-effects that had to do with eating and things which he’s already really a poor eater.
– Got it, wow, okay.
– Okay so currently he’s not really taking any meds right now but he does take Clonodine at night which is a sleep agent. And he’s young to be on it but I guess the parents felt that it was probably a good move as long as he’s getting some sleep. Now Mom, being an educated chemical engineer, she thought it would be a good idea to go ahead and pull out wheat, gluten, soy from his diet. And she heard that if you give him omega-3 fatty acids and she just throws chia seeds in some sort of shake she makes, that he seems to go ahead, or she feels that this will make him better. Now we all know that supplements out there are helpful, and we know about the gut-brain access. Dr. Clark has done a fantastic job talking about that in regards to Autism among other things. But we really need to test for some of these things, I’m not a real big fan of pulling things away from kids or adults for that matter, that don’t have problems with those things because you can make life pretty miserable if you take out everything that you enjoy as long as there’s no reactivity to it. Alright, so let’s take a look here. So Mom’s history, at 37 years old which was the time of conception. It was an uncomplicated pregnancy, however, she had moderate stress due to repeated viral infections, allergies, asthma, and some minor depression. At that time she was given Metformin, that’s usually given for people who had problems conceiving. Because that thickens up a lot of that, or it regulates some of the blood sugar levels. And the insulin responses. She was given Progesterone to help increase that endometrial lining so that the egg would implant. And then the Benadryl she was giving for the allergies and asthma symptoms and the Zoloft at 30 milligrams a day were to help depression. Now we’ll also go over some meds that have effects on the fetus. So if we start looking at Benadryl, we know that Benadryl while pregnant, increases the incidents of all sorts of neurodevelopmental disorders as well as some of the antidepressants out there, specifically selective serotonin reuptake inhibitors. And we’ll talk about that stuff again in the NAD program. She gained 77 pounds of weight during her pregnancy. And then developed gestational diabetes and at 36.5 weeks she had an emergency C-section due to placenta insufficiency. Which is just a vascular situation. Alright so let’s look at Chris now. Chris he was delivered at roughly 37 weeks and Mom had the placenta insufficiency. He was 6.2 pounds, he had low blood sugar despite Mom having gestational diabetes. His APGAR was seven. Now seven, eight, nine seemed to be pretty normal so he’s at the low-end of normal on here. If we go ahead and look at some of his adaptive skills as he developed, basically they were met within a timely fashion as were communication. His tongue protrusion was an issue, because he has a small maxillary arch which has since then been stretched out. Today even, he has motor skill delays compared to his peers. Plenty of social skills were met within a timely fashion, however he’s become more reclusive I told you, probably in the last 16 months. And his pre-academic cognitive were met within a timely fashion as well. Parents described his temperament between the ages of two and five as social, happy, crying, irritable. Hypersensitive, curious and playful. And for those of you docs out there who really pay attention to dominance, he had a left-hand dominant hand, a right dominant foot. A right dominant eye, right dominant hearing on the right. If you guys talk about cross-dominance and how that plays a role into this, I think it was the Door Institute that really started hitting on some of that stuff. Mother also reports difficulty falling asleep, staying asleep, and he’s a very picky eater about food, and suffers a poor appetite. While we go through here, I wanna talk to you a little bit about some of the things that have to do with the hemispheristic model. Because we’re kind of moving away from that. Now while language resides largely in the left side of the brain, we do use the right side to go ahead and help process language. And as we go through here I’m gonna show you that. Alright so the social history, Chris is one of two kids in the same household, parents are still married. He does not have any close friends but when he isn’t in around other kids he gravitates toward younger kids where he can be in charge and be in control. Right now he doesn’t participate in any physical activity whatsoever. He used to do Tae Kwon Do for a while, when he didn’t pass his first belt, all of a sudden he threw a temper tantrum and said he was never going back. Mom said that was perfectly fine. Currently he gets approximately four hours of screen time during the week, and eight to ten hours on the weekend. This is not good. We talked about screen-time in regards to development and developmental delays. There was a new article that just came out, that is posted on the Clinical Neuroscience Forum, if you guys want to take a look at that and seeing some of the delays that happen. Patient permanent resident, he didn’t go abroad for anything so we’re not looking at any types of infections or anything, he could’ve brought back. There’s no knowledge of exposure to alcohol, tobacco, or mind altering medications. And Mom has gone ahead and pulled out caffeine. He’s always been in a public school. He’s enrolled in the fourth grade as a full time student. He does not receive any special services like OTPT Special Ed. And he does not qualify and was not tested for an IEP or a 504 Plan. For those of you who don’t know what that is, an IEP is an individual educational program or plan that’s set to help the childs exceed in school for those kids who maybe don’t meet the criteria of full-time normal class. They get a little bit more one on one help. The criteria for that is they need a 22 point spread between the reading and the language scores. If they don’t qualify for that, there’s another thing called a 504 plan which for Chris he would probably meet the criteria on. And it would be other health impairment plan, in which case he would go ahead and get extended time, some one on one. He would get some help with some of the things with small groups as opposed to a large classroom to decrease distractions. Some of his–
– Hey Dr. Worth, question for you.
– I get to see a lot of the questions that come in about the NDD program. And a lot of the clinicians have had questions about what happens in the education side of things. Are you gonna be teaching the doctors more specifically about IAP, what it means, and kind of like how to help the parents and the child just kind of discuss this stuff ‘cus I think that the parents sometimes don’t know when they’re gonna entering this role and the clinicians don’t know as well so there’s kinda this disconnect of not everybody knowing this information when it comes to the education side. Are you gonna bring that into the program at all?
– Absolutely because you need to know and work as an advocate for this patient because again the parents don’t know and often times when they do address it with a school counselor, the counselor doesn’t wanna talk about it. They don’t wanna tell you what your kid may be entitled to because it’s more work for them. So they wanna do as little as possible because they just need to get your kid to pass and if he doesn’t pass, guess what? The parents can say we’re not holding him back and the school’s okay with that. Which is sad because they will struggle their entire education as a result of that.
– Great, well that’s great news to hear that you’re including that, thank you very much, thank you.
– Absolutely. Alright, so some of Chris’s strengths include intelligence, conceptual understanding and math. His weaknesses are following directions, reading fluency and comprehension, word attack skills. Fine motor as in writing. And organization and memory. Now most kids his age don’t have memory issues, they have problems attending to things which means that it never really makes it into short-term memory or even long-term memory in that hippocampal area. And we’ll discuss that a little bit later. Some of the behavioral concerns at school include that he’s fidgety, he has problems staying in the seats, he talks, he fails to consider the safeties of others. He’s distractible, he’s defiant, he doesn’t listen, rushes through assignments which caused many times for him to get poor grades or have to repeat the assignment over and over again. Alright so on examination, and my examination is far more detailed than this but I just wanted to go ahead and put some of the positives on here because we would be here all day long going through this six-page exam. So let’s just talk about some of the things that we saw that were positive findings. So postural evaluation, he has internally rotated posture, corresponding scapular winging more prominent on the right. Scapular winging, if you guys remember are pontomedullary areas fired down on the ipsilateral side to control or inhibit flexors on the upper and lower extremities. So scapular winging, that would be more of a right brain problem if we were gonna go ahead and signify a side. He also has a right head tilt, and a contralateral rotation. Again that could be ipsilateral cerebellum, contralateral cerebellum, it could be cortex, we’ll work through here. Ocular-wise, he has some asymmetric pupils. So we have smaller pupils in light at five and six on the right. And in the dark, we have that same discrepancy of about one millimeter. Seven on the left, eight on the right. Pupillary responses are reactive to light, and the right pupil is rapid to sunlight and fatigue. And that left pupil is very plastic, which means that it contracts and holds and holds and holds. It doesn’t get inhibited and fatigue out like the other side. He also had a marked tectal response. So when we put photic stimulation, that lower left, well upper and lower, worse on the lower left temporal field there of vision, he ended up having a withdrawal response due to the light. And it wasn’t because it was too bright, ‘cus it didn’t bother him on the other side. He has a convergence insufficiency on the left and when we went ahead and took him through the cardinal signs of gaze, he went ahead and moved his head almost in every plane to compensate. When I held his head so that his head wouldn’t move he had a hard time keeping up with the pursuits and as a result had saccadic intrusions throughout all planes. V:A ratios were two to one on the left, and three to two on the right. So now we’re gonna look at some muscle tone, okay? Sorry, the motor responses. So his muscle spindle responses are a one plus with reinforcement. So if you think it that your brain regulates tone along with things like your reticular spinal tract and your diblastula spinal tract, if you start thinking about those and he’s hypotonic, he’s actually getting less stimulation coming from the muscle spindles to a cerebellum up into the parietal areas of his brain, which ultimately influence the frontal lobes of his brain as well. He also was mildly hypotonic throughout. Now I’m gonna talk to you a little about these retained primitive reflexes now but this case here I didn’t do anything to go ahead and fix those. I wanted to go ahead and work with some brain things but you’re gonna see that they are resolved despite that. So his tonic labyrinthine reflex, that was present. And asymmetrical tonic neck reflex, that was present. The symmetric tonic neck reflex and a landau response that was all positive. He also sensory-wise, everything looked pretty good there, okay? He didn’t have a problem with any of that.
– Dr. Worth.
– I wanna chime in really quick. So I’m really happy you brought up the primitive reflexes ‘cus again I get to talk to a lot of clinicians and the most common thing that they’ll say is, hey the only thing I really needed to know to look at on some of these patients is primitive reflexes. They’re very popular, a lot of people know what to do with them. And I’ve always noticed that Dr. Carrick when I review his grand rounds, when working with these types of children, he never did a lot of remediation of those reflexes. And I think, and what I wanna ask you is, the model that I always kind of noticed that Dr. Carrick had is he goes hey listen, I’m gonna fix what I see in this person’s neurology, their brain as opposed to doing a remediation of these reflexes that are still present that shouldn’t be and he finds that those things fix themselves when you fix the brain to begin with. Where do you stand on that kind of continuum?
– You know–
– Sometimes you go to the.
– I agree with him, there were some cases that I ended up having to do some remediation with ’em because they didn’t clear up completely. But the majority of the time, if I fix the brain, the reflexes went ahead and followed.
– Right and so the reason I ask that question is ‘cus I kind of want to remind clinicians that. Primitive reflexes, they can be important for some of these patients but realistically, there’s a larger clinical picture that we need to be trained on to be able to observe and do things with. And then you’ll find out these little details kind of take care of themselves when you really help the patient, so, I’m glad that you’re kinda bringing this up. And I’m sure you’re gonna be covering primitive reflexes but I think understanding that a deeper level, how to assess and treat the patient are probably gonna yield us a better result.
– Absolutely, absolutely.
– Awesome, perfect, thank you very much.
– Uh-huh. Alright, so let’s go through here. On examination so this one here is interactive metronome, which is really just a Motor-Sensory Biofeedback Assessment that utilizes both visual and auditory stimuli. Those of you who don’t know it, we’ll be talking about it during the neurodevelopmental modules. But if we look at the chart here, the raw data says that the normative data for a boy his age should be between 70 and 90. And I want you guys to think of this like golf, the lower the better. So he came in at 261.8, which tells me that he’s really not keeping time with this whatsoever. The auditory things are confusing him, the visual things aren’t helping him. If we look at the adjusted data, I always look at that as being more involved with dominance. So the adjusted data should be a smaller number than the raw data. Well we see it’s actually worse. So dominance isn’t leading to a benefit for this kid. If we look at the hyperactivity and impulsivity coefficient, let’s look at the normative data first. And I want you guys to just move that decimal over so it would be at 12.6%, okay? So let’s just say 13% would be normative for impulsivity. For this kid, if we move the decimal, it’s more like 78%. This kid is impulsive almost on three quarters, maybe a little bit more of everything that he did. So he was there before the stimulus. If we look at the sensory processing coefficient, and let’s just go ahead and say that we’re gonna move that decimal again. Seven percent’s a normative error rate, okay? And the sensory processing has to do not only with kinesthetic but it has to do with the auditory and visual processing. But if we look here, he’s 35% almost 36% in error. If we look at the voluntary response calculation, this puts him all activities on the left side of the body and on the right side of the body. And what it does is it says that a normative difference between side to side is 10% allowing for dominance. He actually has a 41% difference with the left side being worse. And if we look here at the percentage within the target ranges, 25 to 30% is the score that somebody his age should be able to get. He was accurate 9.1, or I’m sorry 1.9% of the time. Now the distractibility coefficient or test basically puts in five more auditory signs and visual things that he has to focus on. The things he’s heard and seen 520 times up to this point. And you could see here if we said that 11% was the normative error rate, 71% he was distracted by those other things. And attention over time is the same test as the initial one. If you look here that number is even larger, so the longer he did things, the worse he did as far as focusing and paying attention. So this kind of gives us a little different way to look at what these numbers mean here. And I’ll go through that with you guys too when we go over neurodevelopmental modules. If we look here, this is some newer technology, some of you guys I’m sure have it, some of you don’t. This is called right eye and what it does is it measures out eye movements, fixation, saccades and pursuits, and reaction times and things. So let’s just look here. If we look at his EyeQ score, he’s at 17. Now this brain health EyeQ chart here or result here shows that he has issues with parietal lobe, excuse me, and cerebellar issues. Now if we look here, we can see that, can you guys see this? Freddys, connect view on the cursor.
– Actually if you hit the little draw button at the top you could turn the whiteboard on and draw and stuff. So give that a go.
– There we go.
– [Freddys] Alright go for it, I think you have a little pencil now.
– Okay so if we look over here where I just underlined, this is basically our pursuits. Now you can see here in the pursuits, he did not do well whatsoever. I’m looking and he’s in the seventh percentile. Now in development, if we remember, the pursuit system doesn’t really start to develop ’till around 12 to 15 weeks. Prior to that, we basically develop a psychotic system where you go ahead and you put a little stimulus over here and your child may look over here and do the same thing over here. But pursuits don’t even happen until roughly like I said between 14 and 15 weeks or so. So you can see that he does really poor percentage wise with the pursuits. Now pursuits if we remember, those really start out largely coming from the parietal area on the ipsilateral side. If we look at the saccades, alright? And if you guys remember how the saccades work, my right brain and my left brain are always opposing one another from my frontal eye fields. And it’s the release of the birth cells and the omnopause cells get inhibited and it pushes my eye to a target. Now this takes a lot of brain power and frontal lobe power because our brain’s not following something but it has to calculate exactly where to stop to hit that target and be where it’s supposed to be. So we’ll go through eye movements and how that plays a role in these things as well. And you could see here at this last one right over here, he’s in the 77th percentile for fixations. So if he can’t keep his eyes on something, we’re gonna start to see that he has problems doing things like reading. That was one of the issues that he had. And comprehension, if you’re not paying attention you can’t remember what you read, okay? So let’s look at some of these here. This task here, the patient was asked to go ahead and follow a dot and make circles. You can see he’s unable to keep his eye fixated on that dot. He’s just everywhere. The same thing here. Oh, I’ll tell you what, let’s go here first. So here’s our pursuits in the horizontal plane. Here’s our pursuits right down here in our vertical plane. You can see he’s not anywhere near these lines here or in the horizontal plane. If I go ahead and we do our saccades, he’s much better with the saccades in the vertical plane then he is the horizontal plane. ‘Cus the horizontal plane’s just a mess. If we look down here we can see this is reaction time. So he had to go ahead and respond to certain things and this tells us a percentage on how quick he is to process that information and react appropriately. And this little test here also goes ahead and looks at eye stability over here, which tells us percentages. I can’t really see ’em on my screen very well. But the percentages on how accurate he is on maintaining fixation onto a target. This will play a big role for you guys who work with patients who have balance disorders and your patient does the worst with their eyes open on a firmer foam surface than they do with their eyes closed because of gaze stabilization. And the brain module here, will also suggest the possibilities of having weak eye muscles and it also allows you to go ahead and have… Hold on one second. It’ll allow us to go ahead and come up with exercises based on Lee Enzee’s research in regards to this. So this kind of gives you a little bit of an idea on some of the tools out there that we’re gonna be reviewing. We’ll talk about what dyslexia looks like, what autism looks like, what ADD looks like. So that you have an idea on what some of these things should look like with those patients. For those of you who… Let me see if I can erase some of this stuff, there we go. So for you patients out there, or you docs out there who have the saccadometer, this kind of gives you a little bit of an idea here. So this spot of continuum is time, this is position, the target is roughly around at 20 degrees, which is way up here. So you could see he very rarely hit the target. He had 100 of these so you could see that he didn’t really have too many, the red are going to the left, the green are going to the right. He didn’t really have a whole lot of red ones to begin with. This green right here is latencies, you can see that he’s kind of all over the board here. And as we look at velocities over here which is time against degrees per second, you know what, he has a couple fast ones here but he’s not super consistent as far as to speed and he’s definitely not very consistent with hitting the target if we look here. This is basically the position profile, I like to explain this to look a little bit more like the St. Louis Arch. And we’re not there. This is another IQ test and basically this allows us to go ahead and follow his eyes while we read. So we said that he had reading issues with fluency and comprehension so if we look here we can see that the red ones are basically his saccades. The green ones are his pursuits. The blue ones are his refixation saccades if I remember correctly, I can’t really see real well because it’s pretty small. But if you look at the chart below here, his corrective comprehension was zero percent. He should be roughly at 70%. It’ll give you a blink rate, it’ll go ahead and talk to you a little bit about the reading rate of words per minute. So he’s actually going through a lot of words per minute here, but he’s not remembering anything that he read in regards to that. We outta talk about fixation durations as well, so we can see that whoop. Let me hit this again. His fixation duration down here is 185. The norm is 330. So this kind of is putting our picture together a little bit more as we go along here. Now this test here is basically a Woodcock-Johnson test. And this is a standardized test that the schools will often do. And the schools typically will do these things for free, all you have to do is contact the counselor. Now they may use a Wyatt. And there’s some other groups out there who have taken this information and said, I’m gonna take this Wyatt test, the standardized test, I’m gonna rip it apart and say these are right-brained questions and these are left-brained questions. Well this fails to be a standardized test once you do that, okay? But we wanna look at standardization because that’s what the hallmark is in regards to education. And the educational system. So if we look here, we can see that he has reading fluency issues… So this is gonna be the reading domain here, okay? If we look here, we can see that his reading fluency is very low. Alright and he’s reading at a first grade level, alright? We can see that his fluency is even very low and he’s reading at a first grade level. And his passage comprehension is low as well and you can see here that basically he’s reading at roughly a second grade level. Now math was a good thing for him. He did well in math and if you look at his math scores here, he’s high average, average, high average. So overall math looks pretty good. Now kids who have problems with reading often have times problem with writing and not only the motor component of it, but getting the thoughts onto the page, okay? In a sensicle fashion. Alright so they may write facts that just jump from here to here to here because they don’t organize. And we know Chris has an organization issue regarding this. So if we look here in this area right here, his spelling, he’s at low average. Well if you don’t really read a lot, spelling eludes you as well, okay? His writing fluency is low, and his writing samples are very low. So his overall writing is super, super low. If we look at his written expression, he’s borderline meaning that he’s falling out of the range to where it’s beyond very low and that it’s a real problem. If we look at here, his story recall, one of ’em is gonna be immediate recall, the other one’s delayed recall. We could see that he doesn’t remember this stuff because he didn’t pay attention to it. And these kind of give you an idea here about his overall scores. If you took this to any school counselor and said that we had this done along with this neuro examination, they’re gonna go ahead and put a lot more weight on what you wrote down on your neuro examination because they see that you’re doing what the standards of care are for measuring these learning deficiencies. And we’ll talk a little bit about that. If we look here, this is basically a food sensitivity test. Now I also did an IGE and an IGA test to look for food allergies, I didn’t find any allergies whatsoever, those were all pretty normal. But we did find food sensitivities with him. Now if we look here and I’m not gonna go through all these, I just wanna point out a couple things. Mom pulled out wheat and gluten, okay? Wheat and gluten he wasn’t even sensitive to. Now most people feel better when they pull that stuff out, however she pulled out something that wasn’t necessary, okay? And I’m not certain that it’s not the chemicals on the wheat that causes most of our issues. But regardless if we look here, she went ahead and pulled out wheat and gluten, that’s not an issue. She ended up giving him, whoop, chia seeds right here, for omega-3 fatty acids, which seemed to be really reactive to him, okay? And then basically, what else did she end up pulling or giving him? Freddys you remember?
– Yeah I know. You get something for the fish oil. Oh not a micronutrient. It escapes my memory.
– Escapes my memory.
– Is it fish oils?
– Escapes my memory.
– I can’t remember. Right after we’re done recording it’s gonna pop into our heads.
– Absolutely, sorry guys. But if you guys look here, she’s pulling out stuff she doesn’t need to. She’s feeding him stuff that obviously is an issue for him, okay? So it’s like that parent that says look, my kid eats fruit, my kid eats all these things. And it may be causing a problem for him, but they don’t know because they think it’s on the good food list. So some foods are pro-inflammatory and that inflammation can definitely change ways and behavior. That’s straight out of psychiatry literature. That’s not chiropractic literature, that’s not functional neurology literature. That psychiatry literature was the group that went ahead and came up with the whole gut-brain access and how gut health can affect behavior. Now it doesn’t make you not pay attention, but it does go ahead and play a huge role in behavior in regards to aggression, frustration, anxiety and things of that nature. So if we look here, you can see ADHD if we look at the literature, it really talks a lot about that basal ganglionic area. So if I were to go ahead and hit a couple things live in this area here, we have our motor circuit. And you guys know that the basal ganglia largely inhibits things, that’s what the goal is so that we have the appropriate amount of stimulus for whatever task is at hand, okay? Failure to do this, though, will go ahead and give us absences in motor control if the motor circuit’s involved. If the associative circuit, that dorsolateral prefrontal cortex, and you guys will learn a ton about that if you’re going to the ISCN. Because I know Dr. Stangle is gonna be talking about the dorsolateral prefrontal cortex. But this has to do with attention, okay and focus. And then our limbic areas that have to do with the emotional aspects, the behavior, the anxieties, the frustrations and aggression that go along with it. So again, if you think of it this way here, if my frontal lobe is working really, really well, my basal ganglia will go ahead and cause my limbic areas to dampen down so that my emotional areas of my brain, those primitive, those primitive paleo-cortical areas of my brain aren’t influencing my decision-making. So high frontal lobe, usually very low amygdala, or more inhibition of the amygdala output, okay? If our frontal lobe’s not working well, we lose that inhibition of that area, and then we start to go ahead and get what they call miso-limbic escape and then we start to have a lot of these behavioral issues that play a role. Alright so if we look here, this is just a schematic here of different areas of the brain that are involved with ADHD and some of the things that are, bring up distraction and mind-wandering and sustained focus or the inability to sustain focus. So you can see here that it actually involves both sides of the brain. Both the right side and the left side. Now attention, while it is up in that frontal lobe on that really second gyri there, that wouldn’t explain everything that we would see with ADHD and attention problems because attention issues very rarely live alone or reside on an island alone. They have other things that go along with it. For example, the caudate nucleus, which is part of your neo-striatum, okay? But your caudate nucleus also plays a role in attention, it plays a role in kids who have Tourette’s. It plays a role in kids who are adults who have bipolar, schizophrenic, schizo typical disorder. Now we have all these things that are up there in that area here, but it doesn’t mean we have ’em all. Think of it kind of like a neighborhood. We can go ahead and play with these two houses here. But these people were crazier than we were and our parents didn’t let us play with ’em, okay? So we may have some aspects of all of ’em. OCD lives up in there as well. And how many kids do you know that have ADHD that have obsessive-compulsive tendencies? Even if it’s about their toys, it’s usually never about anything cool like cleaning or anything like that. But it’s often times about things in regards to their possessions, their toys, their brothers or sisters playing with them and stuff. So let’s move on here. So let’s talk a little bit about some of the interventions that we did. I’m a big fan of giving parents and kids things to do at home. So what we did here at the home therapy is we talked about the dietary modifications, we talked about a little bit of supplementation, just to decrease some of that gut inflammation that we expected to see with all the things that she was feeding him that we knew that were pro-inflammatory. And reassess the diet. We gave her some supplements again to decrease the inflammation in there and help reestablish those normal gap junctions that are down there in the small intestines. We gave ’em some eye exercises to do. And we used the right eye and for other things that we did, we used focus builder which was real plain and simple. The Binaural waves or beats, basically those things are used to go ahead and decrease anxiety. So the patient uses an Ipad program that we give them, and they just put headphones on and they listen to that for about 30 minutes. Research is showing that that helps decrease depression as well as anxiety significantly. So we had him do those things at home. In the office we did some cognitive training. A lot of you guys have the NSI or I know Dr. Garcia went ahead and reviewed that just a few weeks ago, maybe a month ago. We use that in our office. We use the interactive metronome. We also went ahead and did Tragal stimulation. So it’s much like a tens unit that attaches onto the tragus here and that’s been shown to go ahead again, decrease anxiety as well as decrease some depressive aspects because he was becoming a little bit more reclusive. And then we also did some reading training with our reading specialist that we work with here. We also went ahead at school, we went ahead and wrote a letter with the parents to go ahead and request testing to be done so that he would eligible for an IEP or a 504. Again he didn’t meet the criteria for an IEP because he’s a smart kid however he did meet the criteria for a 504 which allowed him, what they call other health impairment diagnosis which is the ADHD. And then he ends up getting some extended time, some one on one help. I will tell you this that if a child needs this, they need to get it early on. Because what I see are high school students who come in and ask for an assessment and see if they can get and diagnose this so they can get extended times on ACTs and SATs. This has to be following the child throughout their history, from seventh grade on. Or earlier, if it’s not there they’re not gonna get extended times for SATs. I have seen parents go to the wall for it and they will not allow it. So let’s talk about the other really big precipitating factor for Chris here. And I think that his parents contribute to a lot of these things here. So we went over some parenting skills training in regards to positive and negative reinforcement. Mom went ahead and when Chris did something wrong, she would take something away. Well she’s taken so much away that Chris pretty much is indifferent. He’s like, fine take it I don’t care. And it’s really hard to go ahead and work with a kid or discipline a child when you can’t take anything else away from him because he doesn’t care. Alright, so, kids with ADHD and his profile seemed to do much better with positive reinforcement. So when they do something right, you reward them whether you use a star chart or you go ahead and say, you know what? If you do these things right throughout the week, on the weekend, we’ll go to Sky Zone and go jumping on the trampoline park or something. But if you reward them for behavior and make it attainable, they will actually change overnight in regards to their behavior. We also talked about behavioral training with the parents. Mom and Dad said it was perfectly fine for him to quit things as he went through, whether it be the Tae Kwon Do and they never made him do anything. So there’s no accountability for Chris, so we ended up talking to parents a little bit about how they need to go ahead and address that. If he starts something he needs to finish something. He doesn’t just drop things ‘cus that’s not okay. We’ve talked about screen-time. Screen-time should be limited roughly during the week, I mean if they’re in school, I look at maybe an hour, an hour and a half of screen-time. That includes TV, computers, phones, Ipads. And during the weekend, I would be a little bit more laxed. And with Chris, he ends up getting two and a half hours on the weekend. But basically, with some of the new technology out there, you can actually set the time where it shuts the thing off so it’s a brick. Or you go ahead and you have a timer, set it so that he knows it’s over. Again I suggested setting Chris up for success in regards to the school programs as well as some of the home things that we talked about. And I did mention that we didn’t really address the primitive reflexes. But at the completion when we did the re-exam, the primitive reflexes had all remediated without me really addressing them specifically. And I think that you’re gonna see that happen if you’re addressing these things in the proper fashion. I think a lot of those reflexes don’t clear up when you go ahead and you treat somebody but you’re missing a piece of the puzzle. And then the reflexes still stay there or remain. So.
– Hey Dr. Worth, I wanted to just back up to the intervention page. Because this to me seems very comprehensive. I mean I really see how you’re approaching this patient, this young patient from many different angles to really give him the best care possible. But I just wanna remind the clinicians that are watching this that this treatment plan for the patient that we’re calling Chris for this one, is really tailored to him specifically. So I don’t want people to look at this and say, well I’m gonna go get an IM and I’ll give it to everybody. Or Tragus Stimulation, that seems good I’ll give it to everybody. Just remember that, this was, how you designed this treatment plan was specifically made for this particular patient based off their history, their desires, their physical and neurological examination. This is certainly not a one-size-fits-all because every patient, it’s gonna be very unique, very different in regards to their neurology and what they’re capable of handling.
– Absolutely. So and I want you to go ahead when you look at the interventions that I did, it seems like a lot of stuff. Almost like a shotgun approach, but everything was chosen very specifically to him. When we went ahead and did an interactive metronome, there were certain ways that we did this that he responded really well to. If I followed the standard protocol on the interactive metronome, he didn’t do as well. So we ended up changing some of the rules, and I’ll explain those in the ND modules for you guys. So that you have some options on when children present with this, this may be a better choice. But again, it really relies on your examination findings.
– Awesome, fantastic, thank you.
– Alright, so, if we go ahead and look at the follow-up examination, I want you guys to look here. We had a seven for his EyeQ number. If you look up, whoop. If you look up here, he’s at an 89, okay. If you look at these circles right here. Look at those circles, they actually look like circles. And if we look at right down here, his pursuits in both the vertical and the horizontal planes, they look fantastic. If we look over here at some of the saccades, he’s in the 80, I can’t read that. Freddys, can you read that?
– [Freddys] It looks like 80, I think. Looks like 80 percentile.
– So he’s in the 80th percentile, but he could do better. So basically he continued with doing some of the saccade work at home, even though they look really good when we look here and here, okay? This fixation here, they came up from 17 all the way up to a 67, okay? Which is like rockin’. Now he still has issues with it, but it looks a lot better. And remember that, remember that weak eye muscle they suggested we had down here? It wasn’t really a weak eye muscle, basically it was just a modulation thing. And then you could see here his reaction times have improved. They’re still yellow, so it’s not exactly where I want it. But I mean this was roughly around a nine week course of treatment and a lot of it was done at home. Okay he was in the office two days a week for nine weeks and then the rest was done at home. So when we look at scores like this, I mean this is just amazingly good as far as improvement in such a short period of time, given the fact that he’s had this going on since he’s been four according to Mom. Here’s the comparison between the two. So if you look up here, his score up here was 17. On the left, 89, on the right. When you see, I mean just look at the circles, the pursuits, the saccades. I mean everything looks just amazingly better. And then if we look over here, this was his saccanometer. You can see, we set the targets roughly around 20. I mean he’s hittin’ the target regularly. Look how many his, an equal amount roughly of the left and the right ones that are considered valid data. This little dip you see right here and right here on the bottom two, his head moved a little bit. But you can see it looks much more like an arch right up in here like it should. And this one here’s a little bit more uniform. The left side still, not exactly where I want it but amazingly better. And if we look at finally his IM scores here, so what I did here, if you look under the normative data he should be on the raw data between 70 and 90. He was at 261.8 and now he’s at a 94.1. Which is an amazing change. Now there’s still room for improvement on this. But he wouldn’t be into an active program where he’d be here two days a week for nine weeks or ten weeks or whatever. He may go ahead and do things at home, and then we’ll measure him probably in about six weeks, just make sure he’s maintained everything. His adjusted data came from a 289 down to a 96. His hyperactivity or impulsivity coefficient, if we just said it was a percentage of 78%, he was impulsive. It’s down to 21 and 13 is acceptable for his age. Sensory processing, seven percent’s a normative error rate, it was 35, it’s down to ten. If we look at the voluntary response calculation, we had a 41% discrepancy from side to side. It’s a 16% and ten percent’s acceptable. If we look at the percentage within the target range, he was accurate 1.9% of the time. Now it’s 37.8. So he exceeds his peer group on accuracy. The distraction, if we said 11% of the time was a normative distracted rate, he was distracted 71% of the time, but now he’s down to 20%. And his sustained attention was at 361, the upper limit’s 90. And he’s at 109 right now. So I mean significant improvements with Chris. Now if we look at his reading skills here, as far as the right eye reading test, we go ahead and we see that it still looks like a mess up here up on top here. And this, whoop. Up in this area here, but if you go ahead and look at it, it looks a lot better than the last one. And we can see that right now, after a nine week program for a kid who wasn’t getting anything right with comprehension. He’s in the 60th percentile. And 70% is his grade level. So he’s right above there and if he got probably two more questions right he would’ve been at 70%. If we go ahead and we look at some of the different information down here with, let’s see the reading rate words per minute. 80 words per minute, he’s at 111 now. Fixations per minute, 300, and the grade level is 224. So he’s now fixating a lot more than he was before and his fixations again, the average fixations was 215. 330’s the normal rate and it talks about regressions and things. So the reading has come up significantly. Now I don’t rerun the standardized test, the Woodcock-Johnson. Okay, and the reason I don’t do that is because we need actually 12 to 16 weeks to rerun that. And when you use that test, and the reason I use that one and not the Wyatt is because there’s a form A and a form B, okay? The Wyatt test is a form A and that’s it. So if they’re taking that test again, they’ve seen that test. Where the Woodcock-Johnson test has a form A and form B which tests the same type of test with different material, so it’s not something that they’re familiar with, okay? If you did a Wyatt within a 12 week period of time, a pre and a post, it would be considered invalid because the kid’s already taken the test. If you do the Woodcock-Johnson it’s still considered valid because it’s two different forms of the same test. Now, if they had a Wyatt, they usually have to wait nine to 12 months before they can be re-tested for it to be considered valid. And we’ll talk about what testing I would recommend and what I use in my office, so that you have a little bit better idea on why I use what I used instead of trying to go ahead and do a Wyatt test or another test and repeat that test and not have really valid data because we didn’t wait the normal duration for it. Alright, so this is just gonna touch a little bit on some of the things that we’re gonna do, in the Neurodevelopmental module. It starts in June, I hope to see you guys there.
– Dr. Worth, that was an awesome, awesome share. I really appreciate you giving us a glimpse into your clinical thought process. We’re kinda hearing some of the tools you use, both in the assessment side of things and the treatment side of things. One of the last questions I wanted to ask you is, I see an element of technology being used in this course. And some of this technology may be new to some people. So I’ve heard neurosensory motor integrator. I’ve heard you mention the interactive metronome which I also like very much. Are you gonna be teaching people when to use what technology and then how to leverage it for both assessment and treatment? Are we gonna kinda cover those aspects?
– Absolutely. I not only wanna cover technology, but I wanna cover low technology as well because some docs out there aren’t gonna have every piece of equipment that maybe I do. But you wanna do what we’re doing so we’re gonna tell you how to do those with low technology and still get decent results.
– And my last question, sorry, I know I could talk your ear off. One question I hear all the time is people sometimes have a difficult time with their physical-neurological examination on some of these young patients. Are you gonna be teaching us from your experience how to work with some of these younger patients that are kinda more difficult to perform exams on? Because we still need to get some information so we know where to take them. But there’s gotta be a way to make that part easier, are you gonna have any guidance for us at the NDD program later this year?
– Absolutely, so we’re gonna go ahead and go through examinations of infants. We’ll go through toddlers and adolescents ‘cus all those exams look a little different because developmental milestones have changed for those. And we’ll talk about some tricks to go ahead and make them a little bit more cooperative as well.
– Fantastic. Well listen, I know I’m very excited about this year. I know a lot of the scholars that are calling to Carrick Institute are also very excited. It’s a Neurodevelopmental Disorders program starting in June of 2019. Again Dr. Worth I know you’re a very busy person, thank you for your time, taking the time out of your schedule to share with us your clinical thought process. I would like to do it again because I know there’s many different types of patients, so if you have the time, let’s find an hour in your calendar and do it again. Because I know that scholars really appreciate it. Can we do it again?
– Absolutely, I look forward to it.
– Alright Dr. Worth, you’re the best. Until next time everybody have a great day and we’ll catch you then.
– Thanks guys.