Courtenay Rourke Ainsworth, Ph.D. Pediatric Neuropsychologist

Licensed Clinical Psychologist

courtenayainsworth@gmail.com

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 AssessmentBehavioral 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 servicesDisputes (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