Pediatric Neuropsychological Assessment November 20, 2003 What is it? Who can benefit? Reasons for making a referral Referral Process NP Testing Feedback Options Crowding Hypothesis Presented by Richard DiPrima, Psy.D. Licensed Clinical Psychologist Neuropsychology Senior Instructor University of Rochester Medical Center

What is Pediatric Neuropsycholgy? (American Psychological Association, Division 40 - Clinical Neuropsychology) A specialty profession that focuses on brain functioning in children. A pediatric neuropsychologist is a licensed psychologist with expertise in how learning and behavior are associated with brain structures and systems. Formal testing of abilities such as memory and language skills assess brain functioning. The pediatric neuropsychologist conducts the evaluation, interprets the test results, and makes specific recommendations. A NPE assists in better understanding a student’s current level of functioning. (Like a SNAPSHOT) This information is used to assist a student’s teachers, therapists, and physicians provide treatments and interventions that meet his/her unique needs.

What is a Pediatric Neuropsychological Evaluation ? (American Psychological Association, Division 40 - Clinical Neuropsychology) In a NPE, brain function is objectively measured to better understand how the brain is effectively directing an individual’s behavior and learning. This involves a specialized assessment of verbal and nonverbal abilities and general intellectual functioning including: Attention & Concentration Learning and Memory Language skills (Expressive & Receptive) Visuospatial skills Motor coordination Executive function (Organization, Planning, Inhibition, Flexibility) A pattern of relative strengths and weaknesses is used in important decision making to assist schools with providing appropriate educational programs for students.

What is a Pediatric Neuropsychological Evaluation ? Cont. A NPE is typically extensive and often time-consuming and not all students referred for a NPE will benefit from this type of assessment. Therefore, the evaluator will carefully consider, through consultation with the referral source, the appropriateness of each referral. The following information should serve as guidelines for determining whether a NPE could be beneficial.

When May a Student Benefit from a NP Referral? Students are typically referred by a doctor, teacher, school psychologist, or other professional because of one of the following reasons: Difficulties with learning, attention, behavior, socialization, or emotional control. After a brain injury from an accident, birth trauma, stroke or other physical stress. When recent or long standing, but poorly understood, changes in a student’s cognitive and behavioral functioning are noted. When the pattern of difficulties observed in the student have not responded well to previous interventions (i.e., special education services, medication or classroom interventions). The student continues to demonstrate difficulties in academic progress (i.e., failing to acquire reading skills), despite interventions.

Students that May Benefit from a NP Referral? (Page 2) A student with past or current history of the following: neurological involvement (epilepsy, brain tumor, stroke, muscular dystrophy, cerebral palsy, focal deficits, etc.) genetic disorders (Turner’s or Kleinfelter’s Syndromes, etc.) head trauma, physical abuse and/or substance abuse neurotoxin exposure (lead, mercury, carbon monoxide), nutritional deficiencies or infectious diseases childhood cancer survivors students that have difficulties with memory, attention or learning in the presumed absence of any other significant cognitive difficulty significant discrepancy between verbal and nonverbal skills

Who May NOT Benefit from a NPE? Students with profound and pervasive cognitive deficits that have been formally screened and found to have Moderate to Severe Mental Retardation or a known developmental disorder such as Autism or Down Syndrome. Students whose behavior is so problematic that assessment is either invalid or grossly unreliable such as students with severe oppositional and/or conduct disorders or who are floridly psychotic. Students who are over medicated should not be evaluated until their medication is within normal limits. Students who have been adequately evaluated in the past, are already receiving appropriate remedial services and treatment, and have shown improvement in their functioning. NOTE: It is important to recognize that each case has its own unique circumstances and concerns. Therefore, there can be exceptions and the above conditions may not necessarily apply. These should serve as guidelines for determining whether a NPE could be beneficial. Although a NPE often coincides with the triennial evaluation, it is not part of the triennial assessment, but instead is supplemental and completely voluntary.

How Does a NPE Differ From a School Psychological Evaluation? School assessments are usually performed to determine whether a student qualifies for special education programs or therapies to enhance school performance with focus on achievement and skills needed for academic success. Generally, they do not diagnose learning and behavior disorders caused by altered brain function or development.

Referral Process Most referrals are made through the patient’s PCP and/or neurologist for purposes of payment reimbursement by insurance companies. In school settings, the referral source (teacher, parent, etc.) talks with the school principal to ascertain approval for payment by the district. The referral source completes the Request and Consent Forms for NPE signed by parent/legal guardian. Once the forms are sent to the Mental Health Department Program Coordinator and approved, they are forwarded to the evaluator. The evaluator then begins the process, through consultation with the referral source, of determining the appropriateness of each NP referral and whether the student would benefit from this service.

What does a NPE involve? A multifaceted and thorough evaluation may involve the following: Discussing with the referral source specific concerns about the student being referred and gathering additional information by having teachers complete specific forms and/or questionnaires. Unobtrusively and indirectly observing how the student interacts in the classroom. Ascertain possession of signed consents for a Developmental Neuropsychological Evaluation from a parent/legal guardian or student over 18 years of age before any direct contact with a referred student. Talking with the parents of the student to assess functioning in the home and obtaining additional information by having parents complete specific forms and/or questionnaires. Clinical interview with the student and parent.

What does a NPE involve? (Page 2) A multifaceted and thorough evaluation may involve the following: Obtaining a thorough developmental history. Review available school records and/or central records, medical records and any academic or previous psychological testing. Evaluation of student’s current level of neuropsychological and behavioral functioning, including general intellectual capacities, attention, concentration, learning, memory, language skills, visuospatial skills, motor coordination, achievement and executive function skills of organization, planning, inhibition, and mental flexibility. NOTE: Some of these measures may have been recently assessed by other psycho-educational professionals and it will be important for results of these components to be made available for review.

What will NPT Results Tell Me? By comparing the referred student’s test scores to scores of individuals of similar ages, a profile of the student’s strengths and weaknesses is found and used to assist those involved in the student’s care in the following ways: NPT results provide a better understanding of the student’s behavior and learning in school, at home, and in the community. NPT results may explain why a student is having school problems. EX: A student may have difficulty reading because of an attention problem, a language disorder, or a reading disability. Specific interventions may be recommended to draw upon the student’s objectively found strengths and remediate relative weaknesses based on the student’s learning style. NPT results can help detect the effects of developmental, neurological, and medical problems, such as epilepsy, attention deficit hyperactivity disorder, dyslexia, etc.. NPT may be done to obtain a baseline against which to measure the outcome of treatment or the student’s development over time. Different disorders result in specific patterns of strengths and weaknesses. These profiles can help identify a student’s disorder and the brain areas that are involved. EX: NPT results can help differentiate between an attention deficit and depression or determine whether a language delay is due to a problem in producing speech, understanding or expressing language, social shyness, or cognitive delay.

Feedback Options Feedback can be tailored based on the individual needs of each patient, student, teacher, parent, etc.. Typical feedback options include the following: All NP reports are given directly to the parent/legal guardian either through the mail with a number included for contacting examiner with any questions or during a face-to-face feedback session. A referral source may obtain a copy of the NP report with a Consent to Release and Obtain Information form that is signed by a parent/legal guardian or student 18 years of age or older and witness. Teachers and parents may also wish to have a more formal feedback meeting that includes representatives from the student’s educational team.

Crowding Hypothesis (Strauss, Saltz, & Wada, 1990) When damage to the Lt hem occurs early in life, the Rt hem can mediate speech and language. This interhemispheric reorganization facilitates language recovery (i.e., after perinatal CVA) w/ paradoxical impairment in non-language domains. Transfer of function occurs w/ heavy cost: Expense of non-speech functions likely dt competition in developing brain for space & consequence from “crowding” the two hemispheric functioning into the one preserved Rt hemisphere.

Crowding Hypothesis Take Home Messages The Lt hem typically provide the substrate for speech and language functions. This substrate for speech & language matures earlier than the substrate for non-verbal functioning. With early damage to the Lt hem, the brain reorganizes to develop the substrate for speech and language in the Rt hem with a paradoxical more diffuse representation of the non-verbal functions attributed to the Rt hem. This impairment in non-language domains are likely a consequence of “crowding” the two hemispheric functioning into the one preserved Rt hemisphere. Ideomotor apraxia: Difficulty with selection, sequencing, and spatial orientation of movements involved in gestures. Both phonolocially correct spelling

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