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Courtenay Rourke Ainsworth, Ph.D. Pediatric Neuropsychologist Licensed Clinical Psychologist courtenayainsworth@gmail.com Psychoeducational Testing, Learning Disabilities, and School Consultation
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Pediatric Evaluations School Case Study- team approach including assessment of vision, hearing, social & emotional status, intelligence, academic skills, communication skills, motor abilities Psychoeducational- IQ, achievement, parent & teacher behavioral checklists, observation Neuropsychological- cognitive profile in the context of brain/behavior relationship Neurodevelopmental- assessment of milestone acquisition & trajectories; not predictive of later IQ
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Conditions & Issues Commonly Referred for Neurodevelopmental/Neuropsychological Assessment Neurological conditions such as stroke, epilepsy, brain tumors, disorders of movement (e.g., cerebral palsy) Head trauma Attention-Deficit/Hyperactivity Disorder Behavioral problems Learning disorders Developmental delay Socialization difficulties
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Other Conditions/Issues (continued) Chromosomal/Genetic disorders Toxic exposure (in utero & environmental) Medical conditions such as metabolic disorders, HIV infection, liver disease, renal disease, sickle cell anemia Perinatal trauma
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Uses of Neuropsychological Assessment Differential diagnosis School-based psychoeducational evaluation will not provide diagnosis Baseline status secondary to neurological disease, injury, or abnormality affecting cerebral function Progression of disease/recovery of function over time; measurement of treatment response Determining cognitive strengths & weaknesses for educational placement Clarify significance of pathology on “real life” functioning (e.g., academics, social)
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Uses of Neuropsychological Assessment Provide information relevant to management, rehabilitation, and treatment planning (e.g., strategies to help compensate for deficits; need for modified school program) Capacity for functional independence such as driving, decision-making, & independent living Legal/forensic issues- Litigation around a patient’s cognitive status
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Neurodevelopmental Testing Used to assess infants and young children in order to examine early development to see if it is on track
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Pediatric Neuropsychological Evaluation Intellectual Functioning Academic Achievement Attention and Concentration Verbal and Visual Memory Problem Solving Skills Receptive and Expressive Language Visual-Perceptual Abilities Sensorimotor Skills Personality and Emotional Status Behavioral Functioning
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The Neuropsychological Evaluation Portable: 4-7 hours Individually tailored; hypothesis testing Objectively scored Standardized, valid, and reliable Can be modified Quantitative and qualitative interpretation Task performance is analyzed to determine component processes
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Intelligence Testing Wechsler Intelligence Scale for Children-IV Verbal Comprehension Index Perceptual Reasoning Index Working Memory Index Processing Speed Index 120+ Superior 110-119 High Average 90-109 Average 80-89 Low Average 70-79 Borderline 69 - Mental Retardation
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Vocabulary What is a clock? What does garrulous mean? Similarities In what way are an apple and a banana alike? In what way are reality and a dream alike? Information At what temperature does water boil? What is the capital of France? Comprehension Why do people wear seatbelts? Why do we put stamps on letters? WISC-IV Verbal Questions
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Academic Achievement Reading- word identification, comprehension, non-word decoding Math- calculation & application Spelling words to dictation Written expression Academic fluency- timed reading, math, & writing
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WJ – Reading Fluency
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0 3 4 2 WJ – Math Fluency
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Memory Functions Immediate verbal/auditory retention span Learning over trials Efficacy of retrieval- spont. & cued Long-term memory Remote memory *Not assessed in a psychoeducational evaluation
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Memory Evaluation Children’s Memory Scale California Verbal Learning Test/CVLT-C Rey-Osterreith Complex Figure Test Encoding Storage Retrieval
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Verbal Memory Tests Associated with left temporal-limbic function Narrative Memory (Children’s Memory Scale) Structure and semantic context Immediate & Delayed Memory Recognition Serial Learning Tests (California Verbal Learning Test) Attention Learning- benefit from repeated trials Chunking/clustering Immediate, Cued, Delayed Memory Recognition
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“Frontal” Errors on Memory Testing Impoverished learning strategies Intrusions and perseverations Poor retrieval strategies Difficulty with temporal tagging (proactive & retroactive interference) California Verbal Learning Test particularly helpful
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Visual Memory Tasks Associated with right temporal-limbic function Brief Visuospatial Memory Test Learning trials Delayed Memory (30 minutes) Recognition Rey Complex Figure Copy Immediate (3 minutes) Delayed (30 minutes) Recognition
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Rey Complex Figure
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Evaluation of Attention/Concentration Test of Everyday Attention for Children Conner’s Continuous Performance Test Trail Making Test *Not assessed in a psychoeducational evaluation
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Trail Making Test- A
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Trail Making Test: B
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Executive Functioning *Associated with frontal-subcortical circuitry Goal formulation Initiate, maintain, switch, & inhibit Mental flexibility Planning & organization Decision making Self-monitor, self-correct, & persist Nonverbal problem-solving *Not assessed in a psychoeducational evaluation
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Executive Function Tests of Executive Function Wisconsin Card Sorting Test Similarities, Interpretation of Proverbs Children’s Category Test Tower of London Critical for adaptive, independent living
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Language Functions Auditory & verbal comprehension Vocabulary Verbal fluency, volume, rate Articulation Naming Pragmatic skills, prosody, gestures
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Evaluation of Language Function Verbal/Semantic Fluency Peabody Picture Vocabulary Test Expressive One Word Picture Vocabulary Test Boston Naming Test Sentence Repetition Clinical Observation
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Visual Perceptual Skills Visuoconstruction Patterns/sequences Location in space Facial recognition/Facial expressions Visual abstract reasoning Personal space Integration/organization Attention to visual details
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Visual-Spatial Tasks Judgment of Line Orientation Visual Motor Integration Test of Visual Perceptual Skills-Revised Test of Facial Recognition
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Judgment of Line Orientation
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Visual Motor Integration
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Visual Motor Integration
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Motor Grip Strength Dynamometer Fine Motor Tapping Speed Coordination/Dexterity (Grooved Pegboard) Gross Motor Running, skipping, jumping, balance, throwing, catching, up/down stairs
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Psychosocial Functioning Personality Emotions Behavior Family dynamics Social network Situational influences
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Behavioral Assessment Behavioral Assessment Behavior Observation School Testing Behavior Rating Scale/Checklist Presence or absence of behaviors Intensity and frequency of behaviors Child Behavior Checklist (CBCL) Behavioral Interview Vineland Adaptive Behavior Scales
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Child Behavior Checklist
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Neuropsychological Report Content: Background, presenting concerns Previous testing Behavioral observations; validity of results Performance on each neuropsychological domain via the assessment tools utilized Summary- profile of strengths/weaknesses Diagnoses
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Neuropsychological Report Recommendations IEP or Section 504 Plan Classroom accommodations Outside of school Psychotherapy Medication referral Resources such as books and websites Feedback- family, child, school, referral
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Learning Disability Definition: LD is a neurological disorder that affects the brain's ability to receive, process, store, and respond to information
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Learning Disorder: Subtypes Specific Learning Disabilities (Area of Reading, Mathematics, and/or Writing) DSM-IV: Reading Disorder, Mathematics Disorder, Disorder of Written Expression, Learning Disorder-NOS Verbal Learning Disability Dyslexia Dysgraphia Nonverbal Learning Disability DSM-IV: Learning Disorder- NOS
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Ability-Achievement Discrepancy Model 1968-SLD federally designated category 1976-Discrepancy model primary criterion in LD Diagnosis of exclusion Wide variability to what constitutes a discrepancy Limited capacity to correctly evaluate ability-achievement difference scores Variability in measures used to define differences Instability in discrepancy scores over time IQ-Achievement discrepancy can occur for reasons other than LD; no specific test to rule out other causes Differentiating LD from low achievement
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Recent Efforts to Change LD Identification Process 1999 - USDE began evidence-gathering for change in procedures for evaluating LD 2001 - Working group white papers & LD Summit in D.C. H.R. 1350 - no requirement for assessment; SLD assigned for failure following Response-to-Intervention (RtI) Tier 1, 2, 3 However, little evidence on effectiveness of “research-based” intervention Not all teachers created equally to implement interventions and monitor progress Earlier intervention has better neurodevelopmental outcome (vs. waiting for RtI tiers)
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Dyslexia terminology Phoneme: fundamental/smallest unit of sound in a language (e.g., /t/, /d/) Grapheme: fundamental unit of written language (e.g., ‘ph’ of phoneme vs /f/) Morpheme: smallest linguist unit with meaning (comprised of phonemes) Free: ‘dog’ Bound: ‘un’ (occurs with other morphemes e.g., ‘undone’) Derivational: add semantic information (‘ness’ -> ‘happiness’) Inflectional: modifies word’s tense, number, or other aspects (‘s’ cat-> ‘cats’) Lexicon: “mental vocabulary” with syntactical rules Shared properties (e.g., action verbs) Generate “new” words (‘able’ -> actionable vs cryable) Language Imageability: concrete versus abstract Dog- living, 4 legs, domesticated, dachsund, had a dog, furry, barks
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Developmental Dyslexia Type of Reading Disorder (DSM-IV classification) Type of Verbal Learning Disability (educational terminology) Presumed genetic origin with neurologic findings Genetics: 9 chromosomes found linked to susceptibility of disorder Average or above average intelligence Verbal IQ lower than Performance IQ Verbal Memory lower than Visual Memory Dysfluent or inaccurate word recognition Phonetic decoding difficulties Poor spelling/written language Sometimes reversal of letters (single & within words) when reading and writing
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Developmental Dyslexia Prevalence of dyslexia ranges from five to nine percent of school-aged children high as 17 percent Main manifestation is a difficulty in developing word-level reading skills in elementary school children Reduced ability to associate visual symbols with verbal sounds Grapheme-> Phoneme Correspondence
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Dyslexia Deep dyslexia (large perisylvian lesions extending to frontal lobe) production of semantic errors (e.g., knight when shown castle) better able to read words of high imageability nouns better than modifiers & functors can’t read nonwords Phonological dyslexia (superior temporal/angular gyrus/supramarginal gyrus) translation from print to sound (e.g., read ‘pat’ as ‘bat’) can’t read nonword letter strings few semantic errors Surface dyslexia (widespread/poorly localized L hemisphere lesions) inability to read words with irregular correspondence (e.g., /c/ in cat vs /c/ in ice)
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Coslett, 2003 Visual errors: skate -> ‘scale’ Morphological errors: scolded-> ‘scolds’ or governor -> ‘government’ Imageability Many do better at reading words with high imageability (e.g., chair, table) vs low/abstract concepts (e.g., destiny, wish) Deficits at reading functor words (pronouns, prepositions, conjunctions, interrogatives) Especially switches of ‘that’ read as ‘which’ Reading non-words (e.g. flig ->’flag’) cannot employ print to sound correspondences Over-reliance on lexical reading? Possibly a deficit at the level print to sound conversion (phonological dyslexia) AND at the level of semantics Some Related Features…
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Reading and Spelling Spelling errors due to deficit with learning letter-sound correspondences, tend to misspell words, or leave vowels out of words Letter order reverse the order of two letters especially when the final, incorrect, word looks similar to the intended word (e.g., spelling "dose" instead of "does") Highly phoneticized spelling "shud" for "should" Difficulty distinguishing among homophone (e.g., "their" and "there“; “passed” and “past”) Vocabulary small written vocabulary on context of a large spoken vocabulary Handwriting slower writing speed poor handwriting; irregularly formed letters
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Mathematics Difficulty with word problems (i.e., descriptive mathematics, engineering, or physics problems that rely on written text rather than numbers or formulas). also have difficulty: remembering mathematical facts (e.g., multiplication tables) learning the sequence of steps when performing calculations (e.g., long division)
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Compensation Many dyslexics possess excellent long-term memory Some research suggests that particularly young girls, tend to memorize beginning readers May be unable to read individual words or phrases However, may learn to memorize all words versus just the irregular words “isle” (as in island)
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Testing for Dyslexia Sight word reading Nonsense words Language tests (receptive & expressive) Reading fluency Pattern of spelling errors Oral reading sample Spontaneous writing sample
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Mathematics Disorder Mathematical ability is substantially below the level normally expected based on age, intelligence, life experiences, and educational background Affects the ability to do calculations as well as the ability to understand word problems and mathematical concepts Description difficulty reading and writing numbers difficulty aligning numbers in order to do calculations inability to perform calculations inability to comprehend word problems
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Mathematics Disorder Signs of mathematics disorder in a child's schoolwork: problems counting difficulty memorizing multiplication tables inability to grasp the difference between such operations as addition and subtraction poor computational skills; many errors in simple arithmetic slowness in performing calculations difficulty arranging numbers in order (from smallest to largest, for example) inability to grasp information on graphs difficulty copying numbers or problems inability to grasp the concept of place value inability to align two or three digit numbers to do calculations difficulty understanding word problems inability to understand mathematical symbols
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Disorder of Written Expression Learning disability in which a person’s writing ability falls substantially below normally expected range based on the individual’s age, educational background, and measured intelligence Poor writing skills must interfere significantly with academic progress or daily activities that involves written expression (spelling, grammar, handwriting, punctuation, word usage, etc.)
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Dysgraphia A neurological disorder characterized by writing disabilities- inappropriately sized and spaced letters, and wrong or misspelled words, despite thorough instruction Causes difficulty with processing information, organizing thoughts, and going through the process of putting the words down onto paper Often children with dysgraphia hate writing, show variable letter size and spacing, and sometimes orient letters incorrectly Often able to express themselves well verbally, however seem unable to write at a level that reflects the complexity of their thoughts (e.g., will verbalize, "The apatosaurus was gigantic, but was primarily a herbivore" but writes, "The dino was big“)
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Nonverbal Learning Disability (NLD) Cluster of neuropsychological, academic, and social-emotional characteristics that reflect primary deficiencies in non-verbal reasoning A signature neurocognitive pattern on testing Byron Rourke Hallmark: Difficulty learning from visual environment Clinically, this LD classification resembles an adult patient with a head injury to the right hemisphere, both symptomatically and behaviorally
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Nonverbal Learning Disability Neuropsychological Deficits VCI > PRI on WISC-IV Nonverbal memory, executive functions, pragmatic language, tactile/visual perception Academic Deficits Math calculation/reasoning, abstract reading comprehension, handwriting, specific aspects of written language Social/Emotional/Adaptational Deficits Social perception & interaction Increased risk of depression & anxiety
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NLD Continued “Reverse syndrome” of dyslexia Difficulty producing in situations that require speed and adaptability Involves performance processing Mild abnormalities in right hemisphere Between .1% and 1% of population Poor coordination Exceptional rote memory
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NLD: Proposed Etiology Dysmyelination of the white matter fibers, primarily in the right hemisphere “Developmental” manifestation Observed in cases of closed head injury, hydrocephalus, congenital absence of corpus callosum Right hemisphere more susceptible to early neurologic insult
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Intervention Strategies Use verbal strengths to compensate Hands on/experiential learning Encourage kinesthetic sports Social skills training Preferential seating Previewing/outlining instructions Model/reinforce on-task behavior Instructions presented in single steps/slower pace Guided practice Reduce visual stimuli on page Present classroom rules in positive form Cue before transitions
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School Consultation (Mike Kiser, Ed.D., J.D.) Criteria and process for obtaining school services under the Individuals with Disabilities Education Act (IDEA) Eligibility requires a qualifying disability that adversely affects a child’s educational performance Free and Appropriate Public Education (FAPE) must: Meet child’s unique needs Prepare child for further education, employment and independent living
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IEP Process Request case study evaluation in writing Evaluation domains established and evaluations conducted: health; vision; hearing; social/emotional; general intelligence; academic performance; communication; and motor abilities Team meets to review evaluations and determine eligibility Must have a qualifying disability The disability must affect the ability to benefit from educational program School not required to address medical issues that do not affect education School may have to provide a medical service if necessary to benefit from education
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IEP Process If eligible, develop an Individualized Education Program (IEP), which includes: Educational needs Goals, including objectives/benchmarks Any accommodations needed Any related services needed (e.g., social work, speech, occupational therapy, and physical therapy) The least restrictive environment (LRE) in which child can benefit from educational services (placement) Placements include general education with support, general education with resource classes, self-contained classroom in public school, public or private day program, and residential
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IEP Eligibility Categories Disabilities that make the child eligible for services if affect education: Autism (including Asperger’s Syndrome and Pervasive Developmental Disorder-NOS) Deaf-Blindness Deafness Emotional Disturbance (including psychiatric disorders): Attachment disorder, Obsessive Compulsive Disorder, Depression, Bipolar Disorder, Oppositional Defiant Disorder, Anxiety Disorder Hearing Impairment Intellectual Disability (Mental Retardation) Multiple Disabilities Orthopedic Impairment Other Health Impairment (e.g., ADHD, epilepsy, sickle cell anemia, and Tourette's syndrome) Specific Learning Disability Speech/Language Impairment Traumatic Brain Injury Visual Impairment
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School Consultation Services available to students with disabilities IEP provides special education services Goals/objectives Support services Special Education Resource Social work/counseling Speech and language Occupational therapy Physical therapy Transportation Accommodations Addressing unique learning styles and needs Addressing behaviors Functional Behavioral Analysis (FBA)/Behavior Intervention Plan (BIP) Placement in LRE Accountability Section 504 Accommodations Plan provide accommodations only
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School Consultation Possible accommodations under a 504 Plan could be: Structured learning environment (e.g., preferential seating) Repeated or simplified instructions Behavior management or intervention strategies Modified testing procedures- small group; oral testing; extended time; test read to student Tape recorders, spell checkers, calculators, computers, word processor, etc. Modified or adjusted homework, workbooks, second set of textbooks Textbooks on tape
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School Consultation Strategies for obtaining services RtI followed by Case Study; OR obtain outside, private evaluation Include evaluator in school meetings, particularly if: School staff members not supportive of providing services Evaluators can make recommendations for classroom accommodations and school services Disputes (e.g., Conducting case study evaluation, eligibility, IEP content, and complying with the IEP) are adjudicated in a Due Process hearing
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School Consultation Some educators do not understand emotional and sensory issues Do not recognize disability when appearance is that of a typical student Assume volitional conduct when student is bright Verbally and physically aggressive students least likely to receive services Withdrawn and disengaged students are commonly ignored Soft strategies for obtaining services Evaluations Education Participation of experts Compromising Hard strategies for obtaining services Due process hearing, including mediation
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School Consultation Working with parents and schools Address the fears of many parents of retaliation Give the parents a constructive place to vent Remind school staff members and parents that the focus is the child, not a position or “principle” Don’t intimidate school staff members, which takes the focus off the child Rehashing the past is not helpful to the child and should be left for litigation Burned bridges must be repaired Some school cultures are focused on finances Some school staff members are much more child-centered than others Educators often need educating about disabilities Higher grade levels mean less flexibility Higher grade levels mean more punitive approaches to problem behaviors, absences and failure to complete work Non-school etiology (e.g., dysfunctional family) does not mean that the child does not have a right to services Be respectful, but firm