Courtenay Rourke Ainsworth, Ph.D. Pediatric Neuropsychologist
Licensed Clinical Psychologist
Psychoeducational Testing, Learning Disabilities, and
School Consultation
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
Conditions & Issues Commonly Referred for Neurodevelopmental/Neuropsychological
Assessment
Neurological conditions such as stroke, epilepsy, brain tumors, disorders of movement (e.g., cerebral palsy)
Head traumaAttention-Deficit/Hyperactivity DisorderBehavioral problemsLearning disordersDevelopmental delaySocialization difficulties
Other Conditions/Issues (continued)
Chromosomal/Genetic disordersToxic exposure (in utero & environmental)Medical conditions such as metabolic
disorders, HIV infection, liver disease, renal disease, sickle cell anemia
Perinatal trauma
Uses of Neuropsychological Assessment
Differential diagnosis School-based psychoeducational evaluation will not
provide diagnosisBaseline 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)
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
Neurodevelopmental Testing Used to assess infants and young
children in order to examine early development to see if it is on track
NEPSY-II NEPSY-II
Pediatric Neuropsychological Evaluation
Intellectual FunctioningAcademic AchievementAttention and ConcentrationVerbal and Visual MemoryProblem Solving SkillsReceptive and Expressive Language Visual-Perceptual AbilitiesSensorimotor SkillsPersonality and Emotional StatusBehavioral Functioning
The Neuropsychological Evaluation
Portable: 4-7 hoursIndividually tailored; hypothesis testing Objectively scoredStandardized, valid, and reliableCan be modifiedQuantitative and qualitative interpretationTask performance is analyzed to determine
component processes
Intelligence Testing
Wechsler Intelligence Scale for Children-IV Verbal Comprehension Index Perceptual Reasoning Index Working Memory Index Processing Speed Index
120+ Superior110-119 High Average90-109 Average80-89 Low Average70-79 Borderline69 - Mental Retardation
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
WISC-IV Matrix Reasoning
WISC-IV Matrix Reasoning
WISC-IV Coding
Academic Achievement
Reading- word identification, comprehension, non-word decoding
Math- calculation & applicationSpelling words to dictationWritten expressionAcademic fluency- timed reading, math, &
writing
WJ – Reading Fluency
0 3 4 2
WJ – Math Fluency
Memory Functions
Immediate verbal/auditory retention span
Learning over trialsEfficacy of retrieval- spont. & cuedLong-term memoryRemote memory
*Not assessed in a psychoeducational evaluation
Memory Evaluation
Children’s Memory ScaleCalifornia Verbal Learning Test/CVLT-CRey-Osterreith Complex Figure Test
Encoding Storage Retrieval
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
““Frontal” Errors on Frontal” Errors on Memory TestingMemory Testing
Impoverished learning strategiesIntrusions and perseverationsPoor retrieval strategiesDifficulty with temporal tagging (proactive &
retroactive interference)
California Verbal Learning Test particularly helpful
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
Rey Complex Figure
Evaluation of Attention/Concentration
Test of Everyday Attention for ChildrenConner’s Continuous Performance TestTrail Making Test
*Not assessed in a psychoeducational evaluation
Trail Making Test- A
Trail Making Test (Part B)
Trail Making Test: B
Executive Functioning
*Associated with frontal-subcortical circuitryGoal formulationInitiate, maintain, switch, & inhibitMental flexibilityPlanning & organizationDecision makingSelf-monitor, self-correct, & persistNonverbal problem-solving
*Not assessed in a psychoeducational evaluation
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
Wisconsin Card Sorting Test Wisconsin Card Sorting Test (WCST)(WCST)
Language Functions
Auditory & verbal comprehensionVocabularyVerbal fluency, volume, rateArticulationNamingPragmatic skills, prosody, gestures
Evaluation of Language Function
Verbal/Semantic FluencyPeabody Picture Vocabulary TestExpressive One Word Picture Vocabulary
TestBoston Naming TestSentence RepetitionClinical Observation
Visual Perceptual Skills
VisuoconstructionPatterns/sequencesLocation in spaceFacial recognition/Facial expressionsVisual abstract reasoningPersonal spaceIntegration/organizationAttention to visual details
Visual-Spatial Tasks
Judgment of Line OrientationVisual Motor IntegrationTest of Visual Perceptual Skills-RevisedTest of Facial Recognition
Judgment of Line Orientation
Visual Motor Integration
Visual Motor Integration
Facial Recognition
Motor
Grip Strength Dynamometer
Fine Motor Tapping Speed Coordination/Dexterity (Grooved Pegboard)
Gross Motor Running, skipping, jumping, balance, throwing,
catching, up/down stairs
Psychosocial Functioning
PersonalityEmotionsBehaviorFamily dynamicsSocial networkSituational influences
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
Child Behavior Checklist
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
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
Learning Disability
Definition: LD is a neurological disorder that affects the brain's ability to receive, process, store, and respond to information
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 DisabilityDyslexiaDysgraphiaNonverbal Learning Disability
DSM-IV: Learning Disorder- NOS
Ability-Achievement Discrepancy Model
1968-SLD federally designated category 1976-Discrepancy model primary criterion in LDDiagnosis of exclusion Wide variability to what constitutes a discrepancyLimited capacity to correctly evaluate ability-
achievement difference scoresVariability in measures used to define differencesInstability in discrepancy scores over timeIQ-Achievement discrepancy can occur for
reasons other than LD; no specific test to rule out other causes
Differentiating LD from low achievement
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, 3However, little evidence on effectiveness of “research-
based” interventionNot all teachers created equally to implement
interventions and monitor progressEarlier intervention has better neurodevelopmental
outcome (vs. waiting for RtI tiers)
RtI Tiers
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
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
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
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)
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…
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
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)
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)
Testing for Dyslexia
Sight word readingNonsense wordsLanguage tests (receptive & expressive)Reading fluencyPattern of spelling errorsOral reading sampleSpontaneous writing sample
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
Descriptiondifficulty reading and writing numbersdifficulty aligning numbers in order to do
calculationsinability to perform calculationsinability to comprehend word problems
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
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.)
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“)
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
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
NLD Continued
“Reverse syndrome” of dyslexiaDifficulty producing in situations that
require speed and adaptabilityInvolves performance processingMild abnormalities in right hemisphereBetween .1% and 1% of populationPoor coordinationExceptional rote memory
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
Intervention Strategies
Use verbal strengths to compensateHands on/experiential learningEncourage kinesthetic sportsSocial skills trainingPreferential seatingPreviewing/outlining instructionsModel/reinforce on-task behaviorInstructions presented in single steps/slower
paceGuided practiceReduce visual stimuli on pagePresent classroom rules in positive formCue before transitions
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
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
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
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
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
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
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
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
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