In this article, María José García Rubio, PhD in clinical and health psychology, explains what hydrocephalus is and how to apply a cognitive stimulation program to this disorder.
What is hydrocephalus?
Infantile hydrocephalus is a neurodevelopmental disorder of global urgency because of its consequences and because of the high incidence sustained by low-income countries such as many of those in Eastern and Southern Africa.
Specifically, the 10,000 reported cases per year of infantile hydrocephalus globally rival the 200,000 cases of hydrocephalus reported in Africa alone in this population.
Hydrocephalus involves an excess of cerebrospinal fluid (CSF) in the brain before birth, although there are also cases where hydrocephalus has been caused at birth or even after birth.
As the name suggests, the term “hydrocephalus” comes from the combination of the Greek words for “water” and “head”. In this particular case, the water would be the CSF that maintains and protects the brain in such a way that if it accumulates due to a deficit in the brain, it generates a disproportionate pressure.
Although the focus of this entry is on how cognitive stimulation is linked to the pediatric hydrocephalus disorder, the following is a brief description of the origin of the disorder in order to better understand the associated cognitive treatment.
What causes hydrocephalus?
As anticipated above, excess CSF is the key factor in hydrocephalus. In this regard, it is worth remembering that the central nervous system (CNS) consists of the brain and spinal cord.
The CNS is essential for complex tasks such as perception, the performance of voluntary and involuntary movements, the expression and production of language, emotions, and other cognitive abilities such as memory, attention, planning and/or inhibition, among many others.
Due to its complexity, the CNS has other support and sustaining systems such as the ventricular system, whose main function is to maintain an appropriate circulation of the CSF on which the brain floats.
Likewise, CSF is generated by the choroid plexus, a network of cells that extends along the ventricles. In people without hydrocephalus, CSF flows from the plexus to the ventricles to nourish and support CNS cells.
In the pediatric population with hydrocephalus this process is interrupted, i.e., there is a kind of “clogging” and hence the excess CSF.
Why does this interruption of flow occur in cases of hydrocephalus?
There are several causes of infantile hydrocephalus, one of the most common being aqueductal stenosis. This is a condition in which there is a narrowing of the duct connecting the four ventricles, so that CSF stops flowing.
Hydrocephalus can also be the consequence of other disorders such as spina bifida and/or myelomeningocele. In addition, hydrocephalus can also be acquired, i.e. caused by an accident involving head trauma for example.
What is the neuropsychological profile of hydrocephalus?
So far there is no specific profile of the infantile patient with hydrocephalus because the incidence at least in medium-high income countries is not high, which means that the disorder is less studied.
Neuropsychological consequences
Nevertheless, there is literature on the neuropsychological consequences following infantile hydrocephalus in low-income countries.
Overall, motor impairments have been shown to be the most frequent in this population. This can be explained on the basis of the extension of the motor cortex and the implication that excess CSF has on it.
Together with the worsening of motor skills, it has been observed that the pediatric population with hydrocephalus has a greater predisposition to a low intelligence quotient (IQ), and perceptual and sensory problems such as partial lack of vision or hearing.
Other studies have concluded that the profile associated with childhood hydrocephalus is heterogeneous with impairment in memory, attention and planning. Regarding language, there is consensus in considering it as the most preserved cognitive sphere in patients with pediatric hydrocephalus, although more research is required.
Taking into account the heterogeneity of the neuropsychological profile associated with hydrocephalus, what impact would the application of a cognitive stimulation program have on this population?
Cognitive stimulation is the set of techniques and tools applied to improve the cognitive performance of a patient, based on direct intervention on their abilities such as memory, attention, and language, among others.
In general, the application of this type of stimulation responds to specific requirements linked to the type of diagnosis and the cognitive deficit of the patient observed after the neuropsychological evaluation.
In pediatric hydrocephalus the implementation of a cognitive stimulation program is not an easy task; this is especially due to the heterogeneity that hydrocephalus implies in neuropsychological terms.
In fact, so far the authors have not reached a consensus on the cognitive stimulation protocol to be followed in the pediatric hydrocephalus population.
In these cases, professionals apply different cognitive tasks adapted to the deficit, age and severity of the hydrocephalus, among other factors. However, there are some indicators that have proven to be effective in clinical practice.
Stimulation by intervention area
For memory stimulation, many professionals use digital tasks on platforms such as NeuronUP on the recognition of similar objects, and spontaneous retrieval of previously learned stimuli.
Attention, on the other hand, is also one of the most stimulated areas in infantile hydrocephalus. In most cases attention is stimulated by tasks involving sustained and selective attention such as visual search or “find the differences” tasks.
In short, planning is another area in which patients with hydrocephalus benefit from appropriate cognitive stimulation.
In this sense, they are often asked to break down some tasks or routines (e.g., the steps they take to get dressed and/or have breakfast), or through digital tasks to be able to create a plan, follow it and achieve the goal.
Finally, stimulation of the sensory-motor skills that are affected in the vast majority of cases with infantile hydrocephalus is recommended. For this stimulation, professionals usually resort to exercises involving sensory detection and conscious perception, for example.
In the case of motor stimulation, the focus is on voluntary and involuntary movements to achieve initiation of voluntary walking, control of muscle tone and movements, and/or balance, among other motor milestones.
Conclusion
In summary, the cognitive stimulation exercises proposed here are good recommendations to start working with infantile patients with hydrocephalus, at least in the first sessions.
However, it is important to emphasize that each cognitive stimulation program should be adapted to the patient’s conditions, which in turn are subordinated to the type, severity, and age at diagnosis of hydrocephalus.
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Worksheet to work on selective attention with adults: Counting and Selecting
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