What is a Neuropsychological Evaluation?

All right. Hello, my name is Helen Tam, and I'm a Pediatric Neuropsychology Fellow in the Institute for Learning and Academic Achievement here at the NYU Child Study Center. Welcome to today's webinar titled, What is a Neuropsychological Assessment? Over the next half hour or so, I'll be talking a little bit about what neuropsychological assessments are, their goals and purpose, and how they may be helpful for parents and kids. You can submit questions at any time today by typing them into the questions pane of the control panel that's on the right side of your screen. We will answer questions at the end of our presentation. Okay, so the hope is that by the conclusion of this webinar, you'll have some information about what the field of neuropsychology is, what neuropsychological assessments entail, why an individual might seek out a neuropsych assessment, and how such an assessment or evaluation can be helpful for determining recommendations and services for a child who might be struggling in school, at home, or in the community. So first off, neuropsychology is a subspecialty of psychology that focuses on understanding the relationship between how the brain works and how a person thinks, feels, and behaves, particularly as related to differences in brain development or the presence of brain injury. Researchers in the field of neuropsychology evaluate these questions by combining tests of thinking with research techniques that allow them to measure brain structure or brain activity. So the brain is a dynamic organ that is continuously changing, and so the study of neuropsychology is applicable across the lifespan, starting as early as toddlerhood, when you may begin to experience challenges or weaknesses in motor development, language development, or social development, all the way through to older adulthood, when individuals may experience cognitive decline as a result of dementia. Clinical assessments for neuropsychological functioning consist of a comprehensive evaluation of the development of an individual's learning profile and cognitive strengths and weaknesses. So assessments can occur as early as two years of age, and ones that occur at that young an age are usually referred to as developmental effects. Neuropsych assessments can be administered at any point thereafter. In our clinic at the Child Study Center, we focus on school-age populations and typically see kids from ages four through 21. The time it takes to complete an assessment depends on a number of variables, including the age of the individual, the referral question, and the standards of practice within each individual clinic. So the assessments for younger kids, such as toddlers and kids in kindergarten, tend to be shorter than those assessments that are for older kids. There are typically three parts to an assessment. You'll have an initial interview to collect information about the person's developmental, medical, and academic history, testing period that can be broken up or completed during a single day, and a feedback appointment to review the results. The time commitment to complete all of these parts can vary anywhere between six to 13 plus hours and can take place, again, in a single day or across multiple days. In addition to the feedback session, patients will also receive a report that summarizes the findings from the assessment and provides written recommendations regarding how an individual or their family may move forward with the information that they obtained from the neuropsych assessment. Neuropsychologists can also participate in advocacy meetings, such as IEP meetings, and be available for consultation with tutors, therapists, teachers, other service providers, anybody who could benefit from a better understanding of a child's cognitive strengths and weaknesses. The reports can vary in length, depending, again, on the age of the individual, the referral question, and practice procedures within any given clinic, and can range from a few pages in length to over 20 pages in length. So from here on out, I'm going to be focusing the rest of this webinar on neuropsych assessments for school-aged children. The goals of a neuropsych assessment for kids is really to help parents, educators, and other service providers develop a better understanding of how the child learns and to figure out why a child may be experiencing difficulties learning or with acquiring certain new skills. This then allows the child, or this then allows us to consider different teaching methods that might be more effective and work best for the child's specific learning style. It can also help the child feel better about learning and developing an understanding of how they can use their strengths to kind of overcome the struggles that they experience in the classroom, and that there are lots of other children out there facing similar difficulties. The utility of a neuropsych assessment really comes from the ability of the neuropsychologist to take all the information collected over the course of the assessment and apply it towards making recommendations that would be most beneficial for the child's learning needs, social-emotional needs, and their personal goals. This can be in the form of ideas for new intervention or prevention strategies that have evidence-based to them and that have not been previously tried, or through suggestions about how to tailor the child's existing services and accommodations to better suit their needs. In order to develop a good understanding of a child in a limited amount of time, it's important for a neuropsychologist to gather a large amount of information about a child's performance and behavior across different settings. So the initial interview, again, is an opportunity to gather information about the child's medical history, developmental history, social-emotional development, and academic history. We also make sure to have a chance during the evaluation period to speak directly with each child about their experiences at home and in school and about their strengths and their weaknesses, what they feel like they're good at and what they feel like they're struggling with. Brief interviews with teachers and other providers are also helpful for the purposes of getting additional details about the child's behavior across different environments and from the perspective of others who interact with the child on a regular basis. We often hear that children behave differently in different settings, and it's important for a neuropsychologist to try to figure out what aspects about each of these environments help to support the child's learning and education needs. When possible, a school observation is also included where a neuropsychologist or a colleague will go to the child's classroom and observe them in that setting. Finally, a review of the child's previous evaluations, report cards, medical or therapy documentation, and special education documentation such as 504 plans or IEP plans are critical to help the neuropsychologist understand the child's history of performance, services that have been rendered, and the degree to which each of these services did or did not help with the child's game new skill. All of this information is considered alongside the cognitive and academic assessment to form a picture of the child at a specific point in their development. During the cognitive and academic assessment, children are given a battery of paper and pencil and computerized tests to measure their skills across multiple cognitive domains. These include intellectual functioning or your general overall reasoning skills, language, which includes communication skills, grammar and syntax, social pragmatic language. It assesses learning and memory, so how quickly and efficiently can a child learn new information and retain it over a short period of time, both in the verbal domain as well as in the visual domain. Attention, so we look at the degree to which a child can maintain focus and attention on long and tedious tasks as compared to other kids their age. Executive functioning skills include things such as planning, organization, the ability to shift between tasks, problem-solving skills, and self-regulation. Fine motor speed and dexterity is also assessed as these abilities might play a role in things such as the development of handwriting skills, the ability to button or zip close. Visual processing and visual motor integration kind of looks at the ability for a child to distinguish between angles and lines and differentiate between figures that are closely related to each other, and the ability for a child to copy these figures, which could translate into the ability for a child to copy notes from the board or be able to take notes effectively. Neuropsych services will also evaluate academic performance, although different clinics will evaluate these sets of skills to different degrees. Questionnaires from various respondents are also collected from teachers, from parents, from other providers to evaluate the child's social, emotional, and behavioral functioning, and the ability for the child to function independently is known as adaptive functioning, and questionnaires are obtained regarding those skills too. So is the child able to function independently at home, complete chores, navigate their environment, including school and home and the community? That's all captured by evaluations of adaptive functioning. So a child's performance and behaviors, again, across all of these areas are compared to other children their age, so they're being assessed against their peers. So what are some indicators that a neuropsychological evaluation might be helpful for your child? The first indicator to look for is whether or not your child has been struggling in school and things don't appear to be getting better over time. This alone, though, may not warrant participating in such a time and resource intensive process, such as a neuropsychological evaluation, unless some other factors are also present. These include whether or not there is a suspicion of or an increased risk for a learning disability or a cognitive deficit. And I'll go into what some of these risk factors might be on the next few slides. Another additional indicator is if your child is already receiving some services in school or outside of school, but these interventions have produced poor results in terms of skill development. So in such cases, additional information regarding the children's learning and cognitive profile would help explain why this might be and would help, again, direct the child support team in terms of identifying and refining the types of services that the child is receiving so that they're more appropriate in terms of their learning needs. A neuropsych assessment might be helpful also for the purposes of diagnostic clarification that could potentially open up new doors and avenues in terms of available services and treatment interventions that wouldn't otherwise be. Research has shown that there are a number of risk factors that could increase the likelihood that a child may have a learning disability, a cognitive deficit, or struggle with attention and executive functioning skills. These include having experienced a concussion or brain injury, the presence of early learning problems, such as delays in obtaining speech and motor milestones, or poor academic progress, such as once a child reaches school age, right? That might also be a risk factor. A diagnosis of ADHD or autism spectrum disorder is also a risk factor. Both of these have a lot of data supporting brain-based differences in development and so may leave families more inclined to receive an assessment or seek out an assessment. Research has also shown that difficulties with attention, learning, and executive functioning are highly heritable, and so a family history of ADHD, autism spectrum disorder, or a learning disability should also be taken into consideration. Although rare, sometimes parents may see an unexplained decline in cognitive functioning. This can occur as related to medical illnesses or a side effect of a medication that could be impacting neurological functioning. Either way, a marked decline in functioning is definitely an indicator that a comprehensive assessment might be beneficial. So there are quite a few medical illnesses that have been tied to neurological development and functioning. Some of the obvious ones are brain injury, brain cancer, neurological disorders such as epilepsy, neurodegenerative disorders such as multiple sclerosis. Research has also shown that fetal exposure to substances that are toxic to brain development, genital conditions that might limit the amount of oxygen that the brain has access to while in utero, and genetic syndromes that might affect the development of brain structure are also likely to impact neurological functioning. Additionally, dysregulated sleep or sleep apnea, nutritional deficits or metabolic disorders have also been linked to changes in cognitive functioning, particularly as related to attentional control. Here is a brief list of some of the disorders that have been linked to increased risk for challenges with cognitive and behavioral outcomes. If you're concerned about a specific illness, please refer to your medical specialist or pediatrician and ask questions about whether they believe a neuropsychological evaluation may be appropriate given your child's medical condition and performance in school. So parents are not alone in terms of monitoring how their child is developing. Luckily, there are often lots of people involved in a child's life who can help identify potential areas of concern. In addition to parents, teachers and school personnel can be helpful in terms of monitoring a child's progress across the course of a school year. If your child is working with a learning specialist, be sure to keep in regular contact with them to ensure that your child is progressing in a way that would be expected given the remediation that they are receiving. Psychologists and therapists should also be trained to recognize the potential for a learning disability or cognitive disorder and can alert you if they believe that there is an area of concern that they feel like needs additional evaluation or assessment. Early on, pediatricians are regularly assessing for cognitive, motor, social and language development for any potential red flags for the presence of a neurodevelopmental disorder, such as ADHD or ASD. Other medical providers may suggest a neuropsych evaluation if they suspect that cognitive functioning may be impacted by a specific medical diagnosis or treatment. And finally, neuropsychologists also receive referrals from advocates and attorneys who are working with families who have been struggling to work with the school to get appropriate services in place for their child. If you as a parent have questions about whether or not an evaluation is warranted, I encourage you to ask around to those others who are involved in monitoring the development of your child's learning, educational, social, and medical arenas to see whether they believe such an assessment would be beneficial. So you may be wondering at the end of the day, what does all of this information about my child's specific cognitive strengths and weaknesses mean? How is this information helpful, right? Specific cognitive weaknesses and or social, emotional or behavioral challenges may negatively impact the child's ability to access academic information and material in the absence of accommodations and support. So for instance, if your child has a hard time seeing the board from the back of the room, the recommendation would be for your child to go see an optometrist to evaluate their visual acuity and to prescribe glasses if they need them. The same thing goes for attention and learning difficulties. If your child is having a hard time focusing, then they need the tools to help them access the information that is being presented in the classroom to make sure they're not missing any of the information that they should be learning. If a child has challenges related to handwriting and fine motor skills, they need access to accommodations that would allow them to produce work as commiserate with their knowledge of the content material that might be difficult for them to translate onto paper due to these weaknesses with handwriting. Once we understand why a child is struggling, we can provide better and more appropriate interventions for them that are specifically suited for their needs. Additionally, difficulties with work production in the presence of good cognitive skills can negatively impact the student's mood. Helping the child understand why he or she is struggling or may seem different from the rest of the kids in their class can also help improve the child's self-concept and self-esteem. It's important to note that just because your child has been referred for a neuropsychological evaluation does not mean that your child is in need of special education services. While neuropsychologists often provide recommendations around school supports and class placement, this is not always called for or always necessary. Keep in mind, though, that if vet school is a major component of your child's life, and if a child is experiencing difficulties with learning or attention or socialization, school is the place where these things are going to be most likely to be problematic. Based on their understanding of the child and their education and social-emotional needs, neuropsychologists can provide recommendations about school or classroom placement and whether a school that focuses on language-based learning disabilities for instance, might be the best place for your child. In addition, neuropsychologists will often provide feedback regarding the types of school-based services and accommodations that would be most appropriate for your child, focusing on their individual needs, such as whether they need additional remediation in either math, reading, or writing skills, whether they need additional support for executive functioning skills or accommodations such as extended time on tests or scribes. Supplemental services outside of school, such as tutoring, speech-language therapy, occupational therapy may also be offered. If social-emotional challenges are viewed as playing a role in the child's presentation, then psychotherapy and psychiatry referrals would be made. Additional questions may also arise during the course of a neuropsych assessment that are outside of the purview of a neuropsychologist and that require further evaluation from other specialists and providers such as neurologists or individuals who specialize in certain areas such as tick disorders or OCD. Finally, neuropsychologists should also provide parents with resources such as websites or books to help connect them with additional information and available resources in the community such as local organizations that are available for them. Besides neuropsych assessments, there are other types of assessments and evaluations the child can be referred for. The differences between each of these types of assessments are their goals and their points of emphasis. So for instance, hearing and vision assessments really focus on the functioning of the ears or the cochlea and the eyes. Speech and language assessments are directed at a detailed analysis of articulation, receptive language, expressive language, and pragmatic language skills and are really focused solely on speech and language production and understanding. Psychoeducational assessments are aimed at identifying academic weaknesses and are commonly administered by school psychologists. Of note, school psychologists can't, through a psychoeducational assessment, diagnose a child with a learning disability. Psychodiagnostic and psychiatric assessments delve deeper into a child's social, emotional, and behavioral functioning for the purposes of identifying the presence or absence of mental health disorders. Assessments for assistive technology, occupational therapy for fine motor skill development, and physical therapy for gross motor skill development are available to determine the degree to which these additional types of services or accommodations within the school or outside of the school will be helpful for your child. So here are a couple of resources that might be of interest to parents. The first is a link to Brain Awareness Week, which is supported by the Dana Foundation and it's a week-long event that occurs every March that promotes the celebration of the brain and all of its glory for individuals of all ages. The second link is to the American Academy of Clinical Neuropsychology, which has additional resources available regarding neuropsych assessments, as well as lists of providers available in your area. For families interested in learning more about dyslexia and ADHD, the websites for the International Dyslexia Association and the Children and Adults with ADHD website, or CHAD, are great places to start. Okay, so now I'm gonna take questions. Okay. So one question we received is, do you need a neuropsych evaluation to receive a diagnosis of autism spectrum disorder? There are some neuropsych providers who specialize in autism spectrum disorder, and they can do both a neuropsych and cognitive evaluation as well as a diagnostic assessment for ASD. Diagnostic assessment for ASD is not always included in all neuropsych assessments, and you also don't need a neuropsych assessment to just get the ASD. So there are providers who just do the ASD portion of the assessment. But there are also providers who will give you both. How do you get parents to not view a neuropsychological assessment as labeling or stigmatizing their child? That's a good question. Again, as I mentioned, it's important to really emphasize the fact that just because you're referred for a neuropsych assessment or the child has received one, that they will necessarily need special education services or support. In fact, a lot of the times that's not true if there really is not a reason for additional assessment or support. And maybe there are other avenues that can be pursued. So it's important to kind of recognize that the neuropsych assessment is really just getting a better understanding of a child's cognitive strengths and weaknesses and that no additional diagnoses may even come out of it. Are this type of tests covered through insurance? If not, how extensive is all this testing? They are fairly resource intensive and not all providers of neuropsych assessment accept insurance. In fact, most, I believe, do not. And they can be quite costly. And so I recommend that you talk to different providers in your areas to see what their rates are and evaluate the need. Again, this is why I mentioned earlier that just because a child is struggling in school does not necessarily mean that they should go through a neuropsych process unless there are other indicators that would suggest that this might be helpful for them. Compared against results of kids their age, how often is data for kids their age updated? That's a good question. It depends on the different tests. They are updated approximately every five years for the good ones. And so they are being regularly updated. And we, good neuropsychologists will always use the most updated version. And you should ask that question to the neuropsychologist that you're going to to make sure that they're using the most updated version with the most updated norm. What would be considered dysregulated sleep? Okay. So the National Sleep Foundation has a website and a list of recommended sleep hours for individuals of different ages. So if your child is having trouble winding down at the end of the night and they're having trouble falling asleep and in that way not getting enough hours that they need, that might be a way in which it's dysregulated. If your child is waking up in the middle of the night frequently and having trouble falling back to sleep, that can be a sign of sleep dysregulation. Or if your child is waking up really, really early in the morning and having trouble going back to sleep, that can also be a sign of sleep dysregulation. But again, I refer you to the National Sleep Foundation website for more information on that. How would you handle an assessment differently for a child with ADHD and with limited communication skills? So there are specialized tests for kids who have limited verbal ability. There are non-tests that are administered that are completely nonverbal or aim to be that way. To the best of our abilities, there are different types of tests and neuropsychologists will design the battery in a way that is most suited for the needs of the child. Now, that's not to say that we are able to accommodate all different types of disabilities, but we definitely do our best to do as much as we can. So for the visually impaired, for the hearing impaired, for the language, for kids who have low language skills, there are adaptations to most of the tests that have been normed and that can be applied to kids of varying ages. And one question, what is the difference between a neuropsych evaluation and a psycho-ed evaluation? So again, the neuropsych evaluation includes a comprehensive evaluation of many different cognitive skills, including attention and learning and memory and executive functioning that aren't typically included in a psycho-educational evaluation. Psycho-ed evaluations typically only include an assessment of IQ and achievement, and it doesn't necessarily touch on those other areas. Okay, so thank you guys very much on behalf of the Child Study Center. Thank you for joining me today. Once you leave the webinar, you'll receive a survey and we would appreciate it if you can complete it. You will also receive a follow-up email within a day or two with a link to the recording of today's presentation. We hope you can join us for our next webinar, Building Organizational Skills and Executive Functioning Skills in Children with ADHD with Dr. Richard Gallagher. That's on Tuesday, April 4th at 1 p.m. Thanks again, bye.