HOPE and DREAM: A Two-Clinic NICU Follow-up Model

Neuropsychology's Role in Multidisciplinary Follow-Up Care of Neurologically Complex Infants and Toddlers

BACKGROUND

Adverse effects on brain development prenatally and during early childhood can disrupt cognitive development, with earlier neural insults often proving to be particularly detrimental. As such, infants and toddlers with neurological conditions are at increased risk for medical and neurodevelopmental complications. Pediatric neuropsychologists are well suited to evaluate brain-behavior relationships and identify emergent delays in these patients. The roles of pediatric neuropsychology in the care of neurologically complex young children are reviewed and discussed by highlighting a novel neonatal intensive care unit (NICU) follow-up clinic model.

METHODS

The Developmentally Ready: Engagement for Achievement of Milestones (DREAM) Clinic is a multidisciplinary NICU follow-up clinic designed for the care of neurologically complex young children. The DREAM Clinic is led by neonatal neurology and supported by pediatric neuropsychology, neonatology, physical medicine and rehabilitation, and pediatric psychology.

RESULTS

The review of pediatric neuropsychologists' contributions to the DREAM Clinic elucidated that pediatric neuropsychologists are valuable care partners to both medical providers and families in this multidisciplinary setting.

CONCLUSIONS

The DREAM Clinic provides a model for the structure, feasibility, and importance of involving pediatric neuropsychologists in the multidisciplinary developmental follow-up care of neurologically complex young children.

Prediction of short- and long-term outcomes using pre-operative ventricular size in infants with post-hemorrhagic ventricular dilation

PURPOSE

Post-hemorrhagic ventricular dilation (PHVD) leads to developmental delays in premature infants, yet the optimal timing of neurosurgical interventions is unknown. Neuroimaging modalities have emerged to delineate injury and follow the progression of PHVD. Fronto-temporal horn ratio (FTHR) is used as a marker of ventricular dilation and can be a standardized tool to direct the timing of neurosurgical intervention. Our study determined a pre-operative FTHR measurement threshold to predict short- and long-term outcomes.

METHODS

This is a retrospective cohort study of premature infants with severe intraventricular hemorrhage (IVH) who developed PHVD requiring neurosurgical intervention and were treated in a level IV NICU between 2012 and 2019. Receiver operating characteristic (ROC) curve and area under the curve (AUC) analyses were performed to evaluate the accuracy of pre-operative FTHR for predicting developmental delay. In-hospital outcomes and developmental assessments were analyzed.

RESULTS

We reviewed 121 charts of infants with IVH and identified 43 infants with PHVD who required neurosurgical intervention. We found FTHR measurements were an excellent predictor of cognitive and motor delay with an AUC of 0.89 and 0.88, respectively. An average pre-operative FTHR of ≥ 0.67 was also associated with worse lung and feeding outcomes. There was excellent inter-observer reliability of individual components of FTHR measurements.

CONCLUSIONS

Early intervention for PHVD is ideal but not always practical. Identification of ventricular size thresholds associated with better outcomes is needed to direct timing of neurosurgical intervention.

Factor analysis of neuropsychological domains in a preschool clinic

INTRODUCTION

The clinical practice of preschool neuropsychology assumes that our assessment tools are measuring underlying neuropsychological functions, and that these functions are negatively impacted by early life neurological injury, disease, and disorder. This study hypothesized that general intellectual capacity and specific cognitive skills, both "broad" neuropsychological domains and "specific" subdomains within those broader clusters, would be differentiable in a preschool-age clinical population.

METHODS

Using neuropsychological data from 580 children (6 and 71 months) seen for a clinical neuropsychological evaluation in the Preschool and Infant Neuropsychological Testing (PINT) Clinic, exploratory factor analyses (EFA) were conducted. Results: A one-factor model provided a good fit when considering verbal, nonverbal, and adaptive functions. Consideration of one- versus two-factor solutions for broad neuropsychological domains indicated that a 2-factor solution provided a significantly better fit for the data. Factor 1 was defined by motor, language, and nonverbal reasoning abilities; Factor 2 was defined by inhibitory control and attention. Further consideration of specific neuropsychological functions also supported a 2-factor solution. Factor 1 ("thinking") was defined by nonverbal reasoning, receptive language, and expressive language; Factor 2 ("processing") was defined by impulse control, inhibitory control, inattention, visual-motor integration, and visuo-constructional abilities. Motor skills cross-loaded onto both factors. Secondary analyses suggest these models provide the best fit for preschool-aged children with > 70 overall intellectual functioning and no comorbid medical diagnosis.

CONCLUSIONS

In a clinical sample of preschool-age children, neuropsychological assessment data appears to assess a general level of intellectual capacity or functioning. Further differentiation between assessing "thinking" (knowledge and reasoning skills) and "processing" (cognitive attention and processing of information) can be considered clinically. Next steps include more recent clinical sample replication, consideration of whether neuropsychological profiles are detectable in the preschool-age range and whether the results of early life assessment are predictive of future functioning.