& Program Visits - Apr, 2001 Issue #80
Intermountain Hospital Adolescent Residential Care
Lorrain Trusley, Intake and Assessment
The Behavioral Management Center
Donald Bars, Ph.D
Visit Report on March 9, 2001
By Loi Eberle, Educational Consultant
Editor of Woodbury Reports
Recently I visited the Adolescent Residential Care units at Intermountain Hospital and the Behavioral Management Center, both in the city of Boise, Idaho. The impression I received was that these resources are appropriate when an adolescent is experiencing problems that are beyond the scope of a therapeutic boarding school, especially if there is an indication that
neuro-psychiatric issues are involved. While these settings are indeed a medical model, they offer a lot of flexibility, it appeared, in their treatment approach.
When I visited the residential and acute adolescent units at Intermountain Hospital, I found them to be attractive, spacious, and comfortable. Yes, it certainly is a hospital setting, yet the staff conveyed a sense of casual friendliness. Mildy McDaniel gave me the tour of the premises, showed me the various nursing stations, group therapy rooms and classrooms and introduced me to the staff.
In addition to the well-kept units and grounds, and friendly staff, one thing that caught my eye was a wall chart for the adolescents who were on the units. Mildy translated the abbreviations that were written next to the various resident’s names. She explained how various treatment approaches were being used for the individual residents, based on how well they were responding to a particular technique. I could see for myself and it was verified by her remarks, that they dealt with each adolescent as an individual, rather than insisting that “one therapeutic technique fits all”. In a similar fashion, there was a high stimulation and a low stimulation classroom, appropriate for students with different learning styles and needs. Although I did not witness any classes in session, I definitely saw a difference in the two environments.
In addition to counseling therapy and academics, there is also occupational therapy and physical activity for the adolescents, whose length of stay is based on their individual needs. Some adolescents only are there for assessment, while others remain for a number of months to do their therapeutic work.
Dr. F. La Marr Heyrend is the medical director of the adolescent unit at Intermountain Hospital. He also works closely with Dr. Donald Bars, who does the psycho-electrophysiological evaluations at the Behavioral Management Center. The Center is housed in a small portable building next door to the hospital and is scheduled to be replaced soon by a newly constructed building.
The psycho-electrophysiological assessment done at the Behavioral Management Center is based on EEGs done in the typical way, using the international 10/20 method for noninvasive electrode placement. The EEG shows the brain’s activity when stimulated by auditory and visual stimuli. The raw data from the EEGs is then quantified, which involves removing artifacts due to eye movement, muscle tension, etc. The remaining data is subjected to a mathematical formula called a Fast Fourier Transformation, an algorithm developed by Jean Baptist Fourier, in 1872. [For a summary of their work, refer to “Explosive Behavior - Research on Neurological Predisposition” in Woodbury Reports, June 2000, # 70].
Dr. Bars discussed the computerized EEGs, showing me a variety of examples. He explained how each person responds to the evoked potential stimuli in a unique way. Sometimes the computerized EEG shows that the various lobes in a person’s brain process stimuli in a way that is significantly different from the way in which most brains are shown to process. For example, certain lobes are much more active or inactive. Dr. Bars and Dr. Heyrend explained that based on their experience, certain kinds of brain activity shown in the EEGs seems to correlate with certain kinds of problematic behaviors or emotional states in the individual. Although it seems somewhat anecdotal at this time, Bars and Heyrend are in the process of correlating behavior and brain wave activity in a large data base of people they have tested over the past few years. There has been similar work done by Dr. Frank Duffy at Harvard, in Boston, Massachusetts and Dr. Mathews, National Medical Director of the Comprehensive Neurobehavioral Systems in Austin, Texas.
According to Dr. Bars, some types of brain wave patterns predict certain behaviors. He also felt the information about brain activity can help to explain why some people don’t respond to certain kinds of therapy. In other words, he explained, some people “know how to act” but due to the way their brain reacts to various stimuli activity, they are not able to control their behavior in the way that know they “should”. In some circumstances this causes raging behavior that is difficult for them to control.
They explained that in such cases medications can make the brain activity more manageable. They explained that the way certain people’s brains operate when under stress is that they are unable to inhibit certain reactions to stimulation, because their brains are using all the available energy processing other responses. In such cases medication can help modulate the brain’s activity. Once the brain is able to process information in a more useable way, then it is possible to address the behavior using counseling therapy to teach better social and self-management skills. If a person’s out of control reactions can be brought to a point where they can talk about it, they are no longer run by these behaviors.
Dr. Bars also described how certain kinds of brain wave activity seemed to cause some drugs to have negative effects. He gave the example of people with ADD who show a lot of frontal lobe activity in their brain wave patterns. He suggested that they seem to not do well with stimulants, because that part of the brain is already over-simulated. In fact, in such cases, the stimulants can cause further behavior problems. In cases however, where a certain part of the brain is
under active, then stimulants can cause positive results. He feels this explains the variable effectiveness of this type of medication.
Dr. Bars also showed me the brain wave patterns of chronic drug abusers. During the period of substance abuse, various parts of the brain were not operating in the typical way, some areas being almost completely inactive. He showed the brain wave patterns observed in the same people after a period of one year with no substance abuse. In some cases, depending on the drug being abused, the brain returned to relatively normal activity. Chronic alcohol and heroin abuse seemed to show the greatest amount of long term, or focal damage; that is, certain areas in the brain remained inactive. I did not see any scans from methamphetamine users, but given other information I’ve encountered, I’m curious if similar results might be found.
Dr. Bars also spoke of how stress is damaging and can cause the brain to be less efficient in its inhibitory responses. We also discussed whether people could learn to bring their brain wave activity under control through means other than drugs. He did say there has been some success using biofeedback, although it is difficult to maintain the behavior over a long period of time. We discussed the need for long-term medication in adolescents who seem to benefit from its use. There are those who feel that once the brain is functioning more efficiently, it may start to self- regulate as it matures, eventually out growing the need for further medication. Others suggest that certain people will always benefit from the use of medication.
Certainly the resources available at Intermountain Hospital’s Adolescent Care units and at the Behavioral Management Center can provide insight and assistance in cases where an adolescent is unresponsive to other therapeutic settings.
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