WESTBOROUGH, MA August 6, 2017 Self-monitoring refers to the capacity to observe one’s own behavior in real time. It is easy to see when someone lacks this important neurocognitive feature. Walk into any middle school and there will be hundreds of boys who act and behave without forethought. Self-monitoring is a higher-order function that sets us apart from other species – even primates and is thought to mature in the second or third decade of life. It is possible to lose the ability to watch and adjust behavior such as with traumatic brain injury involving frontal lobe structures and in disorders of cognition such as dementia. How is it possible to lose appreciation for the organization of the task (see drawing on left) and fail to notice one’s errors?
The bicycle task requires a rudimentary capacity to envision the bike and draw it from the image one has in his head. It requires conceptualization, motor control and visual motor integration for success. The task is age old – like the clocks frequently featured in these pages. Self-monitoring is a prerequisite for social pragmatics – a fancy term for acting your age. In some cases the failure in self-monitoring results in errors in behavior that can become socially debilitating – especially when the patient demonstrates an indifference to his limitations and does not respond to redirection and feedback. The task of constructing a bicycle is a screening for higher order deficits. Like the clock drawing it requires planning, organization, even mechanical awareness. Muriel Lezak says that regardless of lesion the task requires judgment, organization, conceptual integration, and accurate self-appraisal. Those with defective self-monitoring often miss important features and omit crucial parts of the bicycle’s mechanism like pedals, chain or both (Lezak, 1995)
“The capacity to self-monitor and modify one’s behavior is required in an open society or the lack of order would result in people being oblivious to each other and indifferent toward their personal effect on social and interpersonal relationships” Michael Sefton 2017
In the first bike drawing the patient constructed the bicycle as asked but became confused very quickly. the two objects extending out from the left and right are wheels that were drawn after I had asked “how does it work?” Interestingly one of the scoring criteria are the correct placement of spokes on the wheels. There are no spokes on the wheels of the second and third drawings. In some cases the concept of perseveration is revealing of decreased self-monitoring. In a published blog the concept is described. It is the process of repeating the same response over and over without awareness.
Lezak, M. Neuropsychological Assessment – Third Edition. Oxford Press, 1995.
Sefton, M. (2016) Perseveration, severation, eration, ation, blog post, taken August 8, 2017.
Westborough, MA May 25, 2017 Cognitive changes are common in patients with dementia. They become increasingly problematic with the disease progression. Some people suffering with dementia have difficulty with even the most basic activity of daily living like dressing themself. Things taken for granted like following directions become a chore as the progression of dementia effects individuals who suffer with the disease. This places a great burden on caregivers who must take over those important functions of daily life.
The clock drawing has been a feature on my blog for several years. It is fun to see people work through the task. Most people complete the task effortlessly. Some are a bit defensive because it seems like such a benign request – “draw a clock…” and I often get “I am not an artist…” in anticipation of failure. I have published over a dozen posts about the clock drawing as a measure of cognitive functioning. Patient with dementia often experience a slow cognitive decline whereby even tasks like constructing a clock become a challenge.
The clocks drawn in this post reflect the effort of a person of 89-years of age who tried very hard to get it right. She had enough preservation of her self- monitoring
3 Clocks drawn in succession by 89-year old female with hypoxia and underlying dementia of Alzheimer’s type – note size in centimeters
that she could tell something was wrong. As you can see the left most circle was the first attempt. It was too small according to the patient and she wanted to try again. The middle clock was her next attempt and shows her disorganization and minimal change in the size of the drawing – approximately 3 centimeters in size. In the center of the drawing there are 2 hands that roughly represent the time 11:10. She told me she needed more space to place the hands so that they could be clearly read and offered to try a third time. On the right is her final attempt. There are two hands (to the right of the number 9 and a second pointing to the number 2). As you can see the circle is only 2 cm in size and was a modest improvement over the first two attempts.
She had fun drawing the clock and did not feel as though she had failed the task. I was encouraging and praised her for staying with the task. At some point she had lost her capacity to plan and execute her visual motor function of crafting the circle. Each attempt was made with the goal of drawing a larger circle. This fine woman was still capable of doing many of her activities of daily living and enjoying her friends and family. She was not at all upset that I had been asked to help with her care.
Dementia requires family support and can be costly to those in need of care. The risk of caregiver fatigue exists in all families. As much as possible, I enourage people to allow the patient to work toward completing their own self-care unless there are risks such as falling due to poor balance. This requires herculean patience and sensitivity because there is often a degree of “awareness” of the cognitive changes experienced by the patient himself. Preserved dignity and sense of independence go a long way toward quality of life in the latter stages of dementia. Most spouses will do whatever it takes to support a loved one with whom they have shared 50 or more years of marriage and experience the decline in functioning as both a personal failure and a heart breaking loss.
WESTBOROUGH, MA September 28, 2016 There will be a free seminar offered at Whittier Rehabilitation Hospital in Westborough on Wednesday September 28, 2016 on Sports-related Concussion along with updated information about post concussion syndrome and its treatment. The program is presented by Michael Sefton, Ph.D., director of neuropsychology and psychological services at Whittier Rehabilitation Hospital and certified brain injury specialist. The program begins at 5:30 with a dinner being served. Call WRH at 508-870-2222 to reserve your spot.
“Mike, the way to get followers is to be clearly understood”
Brian Gagan, Leadership Strategies of Phoenix Arizona
March 24, 2016 As a matter of practice I try and stay in touch with good friends as often as I can. I have some very good friends in this life. Some I have known for over 25 years. We travel together and try to meet two or three times a year. I am difficult to pin down on dates and arrival times, etc. I know this about myself. But occasionally I am vague and my friends become frustrated with me. Especially as our travel dates grow close. Once I had to cancel a planned visit 2 days before hand because of something I had forgotten about that I could not miss. My friend Brian and I have enjoyed a good friendship in spite of being quite different. Our skill sets often complement one another. But in some ways I’d like to be more like him.
Brian is a leader. Intelligent, concise, unwavering. I admire him very much. We worked together as police officers and later by contributing to the domestic violence literature by investigating a horrific case of domestic violence in northern Maine. His decisions are usually sound, forthcoming and without regret. In preparation for our upcoming trip Brian had asked that I confirm plans with him no later than Saturday. I forgot to do this. As a result Brian made alternative plans to meet with other friends who could be more concise and unwavering than I am able to be. The remarks above were made to me during my telephone apology for being late and missing the deadline. “The way to get followers is to be clearly understood.” He is correct as usual. I missed that message in the lead up to the Saturday deadline which I now regret. Clearly Brian had grown tired of my yammering. I wanted to meet him for a few days of R & R but was prototypically vague. By the time my plan crystallized Brian had moved on to other friends and activities – in the lead. My bad. I will miss seeing him next month in Maine along with other friends. But I will be ready for our next visit and I will endeavor to be clearly understood in my communication with him. Perhaps he will follow me next time.
The way to get followers is to be clearly understood. I get it. Thank-you for that lesson in leadership. You are a good friend.
WESTBOROUGH, MA March 10, 2016 There is a growing consensus that sooner rather than later may be a better return to play protocol among high level athletes. The notion that they undergo complete and total rest after being injured may be an unreasonable expectation. I have previously espoused “total rest” for some athletes I see in practice but I am now realizing an important shift in the current standard of care.
Given the proclivity toward years of daily training among elite athletes – and not so elite athletes I might add, allowing a modest amount of noncompetitive, non-contact exertion may facilitate the recovery process. The athletes should remain well below his or her cardiac maximum – some say 50-65 % of maximum
for 10-12 minutes while taking the initial steps toward recovery. Changes in balance is a common consequence that may result from subtle changes in the vestibular system in the middle ear and/or decreased neurocognitive efficiency. This too can be worked slowly in a controlled rehabilitation setting.
Concussion is a serious injury or force applied to the skull transferred to the brain. It is now well known that injuries to the brain have lasting impact – especially among younger athletes. The second or third concussion may be vastly different from recovery to the number one injury in terms of recovery time. This should be monitored by a concussion specialist. Returning to work and school will also require support. Return to play protocols are also key for athletes who are injured in season.
WESTBOROUGH,MA January 7, 2016 Is the game time behavior of parents becoming a menace at some youth sports? According to the Wichita (Kansas) Eagle, “the goal of youth participation in sports is to promote lifelong physical activity and healthy competition, officials said, but too often adults approach their kids’ games with their own goals, such as fame, money, Olympic medals and college scholarships.” This story was published in September 2014 after the wife of a football coach fired her pistol into the air to ward off angry parents who had attacked her husband over the amount of time their children were played in a previous game. According to the Wichita Eagle the coaches wife was not the only gun carrying youth football fan that day. This case was referred to local police to sort out.
Fan violence is a commonplace occurrence at many athletic events at venues around the world. In arenas everywhere alcohol-fueled rivalries turn into violent mob scenes sometimes resulting in lawlessness and death. The outrageous behavior of European football and rugby fans is notorious. In February 2007, the Italian professional football league was shut down for 2 weeks because of brutal hooliganism that took place in Catania in Italy leaving a police officer dead. In 2006, 2000 German police officers were needed to quell a disturbance after England’s soccer team was victorious in the World Cup of football. “The passion of sport sometimes kindles mob-like behavior” according to Allyce Najimy at the center for the study of sports in society at Northeastern University in Boston. This passion may be seen on a daily basis here in the U.S. on the field of dreams at youth sports venues everywhere. It is here that the parents of youth sports derive their greatest joy and heartfelt exaltation while watching their children play sports. Passion is exuding from fans at little league baseball games to Pop Warner and American League youth football to U.S. sanctioned youth ice hockey and all those traveling teams.
In recent years, the behavior of parents has taken on a higher level of scrutiny at childhood sports across the country. Parents are becoming just as fanatical toward players, coaches, and game officials sometimes resulting in physical assault – even homicide. As an ice hockey coach for nearly 10 years I was never surprised to be met at the locker room door by an angry father holding his notes from our last match. “Mike, why did my son only play 11 minutes last week?” inquired a loving dad who was not interested in what I was selling. I had parents who came to practice while under the influence of alcohol expecting to play along side the team as an assistant coach. I have heard foul mouthed ranting from some of the most mild mannered parents all in the heat of battle brought on by the excitement of bantam ice hockey.
“A parent’s greatest strength – their unwavering emotional support of their child and their willingness to make sacrifices for their child’s athletic advancement – is thus also their greatest weakness.” This quote is never more true than when you read the story of Patrick O’Sullivan.
As recently as December 2015, retired NHL player Patrick O’Sullivan contributed his heart wrenching story of abuse while a youth ice hockey player growing up in rural Canada (The Players Tribute). “My father used to beat the shit out of me. I don’t say that to be shocking, or to get your attention. I say that because it’s just a simple fact. He would throw punches.” O’Sullivan described physical beatings that left him nearly unconscious from a ritual of choking and punching. After nearly every game, he routinely endured physical and emotional torment while riding home alone with his abusive father. People were witnesses – his father held nothing back often starting the physical harangue in the parking lot. And for what? Finally at age 16, O’Sullivan had had enough and for once in his life stood up to a true bully – his father. Ultimately, Patrick was drafted into the NHL and played in over 300 games with several NHL clubs. In interviews after the publication of his story Patrick shared the desire to end parent abuse by encouraging witnesses to step forward and confront violent parents so that more children might not suffer. The road for him was a rocky one fraught with pain and embarrassment, and his father’s screed.
Mann, F. Plumlee, R. (2014) Passionate parents mean trouble for youth sports. Witchita Eagle, taken January 10, 2016. http://www.kansas.com/news/local/crime/article2101296.html#storylink=cpy
Murphy, S. (2008) How to be a successful youth sports parent. Blog post , taken January 11, 2016. http://www.momsteam.com/team-of-experts/shane-murphy-phd/youth-sports-parenting/how-to-be-a-successful-youth-sports-parent#ixzz3wz8hqRC7
O’Sullivan, P. (2015) Black and Blue. Webb site: The Players Tribute. Taken January 18, 2015. http://www.theplayerstribune.com/?s=o%27sullivan
I am reading Concussion – the novel by Jeanne Marie Laskas upon which the film starring Will Smith is based – released on Christmas day 2015. Smith portrays Dr. Bennet Omalu – forensic pathologist who first published the startling details of changes in the brains of those who suffer repeat head trauma. I am struck by the David and Goliath nature of the task – bringing medical discovery to the mainstream marketplace and the adversarial response of the medical establishment and the corporate giant National Football League.
There are still people in the brain injury field who attempt to discredit Dr. Omalu and the discovery of chronic traumatic encephalopathy. Indeed, the affliction did not begin with NFL football. I am sure over the years people with repeated concussions and subclinical injuries exhibited similar pathology when their autopsied brains were studied. Aging boxers have been known to exhibit soft neurological signs even Parkinson’s disease. An early study may have chronicled their symptoms as a common sequelae of boxers who experienced a career of getting blows to the head. Dr. Omalu implored the medical establishment to take notice of the incidence of depression, substance abuse and suicide among retired NFL players that may be correlated with the findings from autopsy studies of players who died as middle-aged men.
I have observed first hand just how difficult it has been selling concussion management to schools, coaches, and athletic directors for over 15 years. In 1993, my interest in mild traumatic brain injury was first set in motion by a series of cases that were referred to me by a group of physicians with whom I was associated. I collected data for several months using emergency department statistics to come up with numbers of persons who were treated for mild traumatic brain injury. I was interested in pediatric patients. What I found in review of months of emergency department visits was that many cases were not coded for ‘brain injury’ because of other afflictions like lacerations, fractures, and more.
What’s more unless someone were brought into the emergency department with altered mental status or unconscious from head trauma the true incidence of injuries to the brain were not carefully recorded. Arguably, the reason for this was a tendency to wrongly believe that in the absence of a documented loss of consciousness there was no reason to think brain injury nor was there any real concern for those few cases who were seen for concussion – as long as there was no loss of consciousness. Yet I was seeing cases from car crashes, falls, and football injuries that were having prolonged recovery times who were never diagnosed with mild TBI.
The squeaky wheel – gets a referral
For those patients who managed to get referred to the neurologist or neuropsychologist the symptoms they experienced were debilitating and often quite severe. It was not always linked back to their concussion – sometimes addressed as psychological or even psychosomatic in etiology. We began to see that a subset of concussion or Mild TBI cases went on to have a very unexpected set of symptoms including headaches, sound/light sensitivity, poor concentration, mood changes, and more that lasted for weeks and months. 5-10 % of cases of concussion remain symptomatic 8 weeks after first becoming injured and require supportive therapy.
What is now diagnosed post-concussion syndrome or PCS was frankly dismissed as a psychiatric illness like depression or anxiety or even an attempt at malingering as an intentional attempt to gain compensation years ago. PCS has no visual markers on computer brain scans or currently available lab tests. Like concussion it is an invisible injury that renders many people unable to work. Headaches, neck pain, fatigue, visual changes, irritability, sensitivity to sound and light, depression, and poor sleep hygiene were common.
Some physicians even stated “the symptoms would likely get better once the law suits were settled” when making a referral to me. Over 20 years later, I sometimes meet with same misattribution but in general there is greater understanding of the potential long-term effects of concussion. Omalu warns us that repeated injuries have a cumulative impact on aging brains. His serendipitous findings has raised awareness of the neurologic malfunctioning that may take place when athletes are exposed to repeated blows to the head while playing football. Many have gone on to commit suicide.
I was fortunate enough to be invited to the prescreening debut of the film Concussion a few days before it opened in Boston. It was sponsored by MomsTEAM. I was introduced to Brooke de Lench, Executive Director of MomsTEAM, Institute of Youth Sports Safety. He blog post was published in the Huffington Post the week before the film’s release. I enjoyed the film and found it a compelling caveat to my current knowledge and what I know to be true.
Sefton, M. (2014). Postconcusive Symptoms: Lingering symptoms following concussion. Blog post: https://concussionassessment.wordpress.com/consultation/post-concussion-syndrome-pcs/. Taken December 26, 2015.