Intro/Overview. Assessments in the MIND 22q11.2DS Clinic Neuropsychology, Developmental/Behavioral Pediatrics, Psychiatry

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1 Cognition, Attention and Anxiety: Implications for Everyday Functioning for individuals with VCFS/22q.2 Deletion Syndrome Tony J. Simon Ph.D. Cognitive Analysis and Brain Imaging Lab Inaugural VCFS Educational Foundation Webinar September 20, 20 Intro/Overview Cognitive Impairments several interacting areas of dysfunction Arousal, Stress and Anxiety coping modulates cognitive/academic/behavioral function risk/protection for psychiatric outcomes? Thoughts about developmental impact on wider outcomes Assessments in the MIND 22q.2DS Clinic Neuropsychology, Developmental/Behavioral Pediatrics, Psychiatry Case Studies & Evidence Based intervention strategies Interactive Discussion & Questions

2 Neuropsych/Cognitive Profile Standardized tests show a stable pattern for 22q.2DS population Full Scale IQ: 70-8 (±) Verbal Domains (VCI) > Nonverbal (PRI) (in most children) Receptive > Expressive language Rote memory strong, complex memory verbal and all spatial memory is poor. Working memory is poor Reading/Spelling are relative strengths, but comprehension poor learning to read goes OK but reading to learn is very challenging! Attention (selective and executive ) is impaired Experimental studies show: visuospatial, temporal, numerical issues How challenging is 0yrs old when functioning like 7.yrs old? how do all the factors involved interact to affect outcomes? Objects, Space & Numbers Space and Time are very abstract concepts that have scale but no actual values attached to them we use mental units to break them up meaningfully have to learn how much is a(n): inch/second, foot, hour numbers were invented to describe how many units What if your mental units don t match parts of the real world accurately?! space/time estimates will be wrong, numbers won t make sense digital camera analogy of mental representation -> Crowding This explanation guides the design for novel interventions Grant under NIH, game prototype now exists!

3 Crowding & Attentional Resolution From Cavanagh, 2004 Spatial Resolution & Comparison Tests ability to mentally represent & compare quantitative information Tests specificity/generality impairment spatial magnitudes & auditory pitch Task uses limited adaptive algorithm Target initially 0% of length of standard if /4 trials correct, reduce difference 0% else increase difference by 0% all stimuli followed by mask Q: First or second blue bar longer? Auditory pitch task tests specificity

4 Spatial Resolution & Comparison Adaptive task indicates reduced resolution of analog spatial but not auditory pitch representations Percentage of group % of group at 7% accuracy 00% 00% 90% 90% 80% 80% 70% 70% 60% 60% 0% 40% 0% 0% 20% 20% 0% 0% 0% 0% Adaptive Magnitude Comparison Task Percentage of each Dx group at 7% accuracy 22q (n=9) TD (n=22) 0% 7% 87% 9% 96% 98% 0% 7% 87% 9% 96% 98% Level Target/Standard Size Ratio 7 Temporal Resolution Tests resolution of temporal attention. Oddball alien flickers out of phase with other. Pick the oddball at different flickering speeds. At what speed, i.e. temporal resolution does detection performance drop?!"#$"%&'($$)#*$+' )""# ("# '"# &"# %"# $"#,2$4"#'!*6"' +,#-./)!0# **#-./)$0 24#-./(0# All groups well above 2% chance. All best at 2-4 cycles/sec. 22q.2DS group 2% worse!"# *#!# %# '# )"#,#"-)"%$+'./0'

5 Cognitive Control Go/No-Go Response Inhibition Task: Go trials (7%): press a button as quickly as possible to whack the mole (in its various disguises!) No-Go trials (2%): do NOT press button to avoid squashing the vegetable 9 Cognitive Control - Overall Results TD 22q TD 22q Overall TD 22q 8 Accuracy (%) Accuracy (%) (%) Accuracy TD 22q Response RT time (ms)(ms) Younger Older 2 4 Go trials: in order following No-Go Both groups monitor appropriately # preceding Go trials Unlike TD children, most children with 22q.2DS do not do better when more Go trials indicate an upcoming NoGo trial 0

6 Attention, Arousal & Behavior Attention functions to select among competing, salient inputs salience changes dynamically and is driven internally & externally External: what teacher is writing on the board what the kid next to me is doing Internal: how much do I want/need to understand this math? how much does math make make head/tummy hurt? how much yummier does that cookie look when dieting? Stress & Anxiety alter arousal & arousal alters salience threshold for what enters consciousness drops (survival) suddenly more things are competing for (impaired) attention spotlight of attention is pulled in multiple directions nothing is attended long/deeply enough for learning e.g. math Might this explain significant proportion of ADHD Dx? Biological Indicators of Stress Mock MRI scanner used to measure stress hormone (Cortisol) levels to mild stressor * * Average'salivary'Cor.sol'levels'before'mock4MRI'prac.ce'session'(Time'),'2' mins'after'time'''(i.e.'time'2)'and'total'cor.sol'output.'' Total'and'Time'2'Cor.sol'levels'significantly'higher'in'children'with'22q.2DS' Time''levels'trend'towards'sta.s.cal'significance.'Beaton'et'al.'unpublished 2

7 Anxiety & Functional Abilities N=78, r=0.0; p=0.74 Adaptive function: how well you complete age appropriate tasks Adaptive function is NOT related to overall IQ In our 22q sample! zzzz N=78,r=-0.27; p=0.07 Adaptive function IS related to anxiety levels Angkustsiri et al., in preparation Arousal, Anxiety & Inattention Color Key ADHD and Anxiety Anxiety and ADHD (Venn-Euler Diagram) Value Anxiety+ADHD ADHD Anxiety Neither q.2DS participants ADHD ANXIETY ETY Anxiety DHD ADHD Michelle Y Deng, Ph.D.

8 22q.2DS & Psychosis Gothelf (2007) Risk Factors for Schizophrenia study children w/22q.2ds, 29 baseline, 2yrs old (28/2) reassessed ~ yrs later no psychosis, anxiety high at baseline in both groups TABLE. Change in Psychiatric Morbidity Between Baseline and Follow-Up in Subjects With 22q.2 Deletion Syndrome and Comparison Subjects With Idiopathic Developmental Disability Subjects With 22q.2 Deletion Syndrome (N=28) Baseline Comparison Subjects With Developmental Disability (N=2) Subjects With 22q.2 Deletion Syndrome (N=28) Follow-Up Comparison Subjects With Developmental Disability (N=2) Psychiatric Disorder N % N % N % N % Psychotic disorders a Attention deficit hyperactivity disorder Oppositional defiant disorder Anxiety disorders b Affective disorders a Fisher s exact test, p=0.0. b In group-by-baseline-diagnostic-status analysis, logistic regression with psychiatric status at follow-up as outcome variable and psychiatric diagnosis by group interaction as predictor, β=0.42, follow-up (~8 yrs) 7/0 anxiety in 22q vs. 4/0 in DD! /0 psychosis in 22q vs none in DD, other things improve Small study, but shows impact of anxiety, perhaps on psychosis Psychotic Symptoms Common by Adolescence Study Measure N Age (yrs) Findings Feinstein et al., 2002 Baker & Skuse, 200 Debanné et al., 2006 Vorstman et al., 2007 DICA-P, KSADS-PL 28 2.'±'.9 CAPA 2 6'±'2 DICA-P, KSADS-PL 4 0.6'±'.2 KSADS-PL 60.4'±' with delusions or hallucinations. 2 vs controls had at least one schyzotypal symptom, unspecified. 2 with positive symptoms, auditory hallucinations specified for preadolescents. 6 with hallucinations, delusions, or paranoia.

9 Psychiatric Risk and Protection Anxiety'disorder* Genotype,*'CNVs Maternal'distress Rubella/Encephali.s Hypoxia CNS'damage 'Cogni.ve'impairment Allosta.c'load 'Au.s.c'symptoms Decline'in'VIQ* Social'withdrawal Substance'use No# Symptoms No Disorder At#Risk Psychoc# Disorder SSRIs Atypical'an.psycho.cs CBT Nutri.on Anxiety/Mood Disorder ='risk'factor ='protec.ve'factor Joel Stoddard, M.D. Gothelf'et'al.'Am'J'Psychiatry.'64:4'2007 Cannon'et'al.'Schizophr'Bull.':'2008 Summary Now able to integrate many research areas for translation/intervention mind/brain changes underlying cognitive impairments allostatic load of challenges & neurobiological stress/anxiety response modulate coping success (+/- family/community supports) cognitive control changes & common schizophrenia-related symptoms in adolescence may be risk/protection factors medical history & other subtyping explorations may identify further ideas about potential outcomes ALL of these will be affected by background genes, experience etc but combined basic & clinical research are starting to indicate ways to explain, treat and perhaps alter outcomes 8

10 Thanks MOST important: Kids who participated & their families!! Majority of the work presented here was done by: Margie Cabaral, Freddy Bassal, Heather Shapiro, Ling Wong, Elliott Beaton Ph.D., Siddarth Srivastava Ph.D., Michelle Deng Ph.D., Joel Stoddard, M.D., Danielle Harvey, Ph.D., Kathy Angkustsiri M.D., Nicole Tartaglia M.D., Ingrid Leckliter Ph.D., Janice Enriquez Ph.D. With important contributions from: Tracy Riggins Ph.D., Yukari Takarae Ph.D., Mendoza M.A., Leeza Kondos & others UC Davis Center of Excellence in Developmental Disabilities