Transcript Psychological and Neuropsychological Testing

Educational Needs and
Services for Children
with Epilepsy
David H. Salsberg, Psy.D., DABPS ©
Rusk Institute of Rehabilitation
The Stephen D. Hassenfeld Children’s Center
for Cancer and Blood Disorders
NYU Langone Medical Center
Parents and Professionals
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When to become concerned
What professionals do you consult with
What evaluations are available
How to prepare
What to do with the information
Special Education or not
Interventions
Myriad of Labels/Diagnoses, Tests,
Scores, and Interventions
WPPSI-III, WISC-IV, WIAT-II, NEPSY-II…
LD, PDD, ADD, ADHD, SI, ED, APD, TBI…
PT, OT, ST, IEP’s, EI, CPSE, CSE, 504 …
Educational Implications for
Children with Epilepsy
Etiology of Seizures
underlying causes/conditions
 Seizures frequency/control
 Medications and effects
 Age at Onset
 Secondary effects
missing school
availability for learning
emotional/family/psychological
All can contribute to a variety of learning and attentional
difficulties in children.
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Issues in Educational Planning
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Seizure plan
Nurse
Health paraprofessional
Medications and effects
Effects on learning
Attention
Fatigue
Stigma and Social Considerations
Dietary or activity restrictions
Emotional and family issues affect educational planning
When to take notice
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Developmental lags noted
Discrepancy between skill area and “norm” or expected
Discrepancy between child’s own individual strengths
and weaknesses
Signs/expressions of frustration; low self-esteem
Social skills difficulties
Mood/behavior changes
Academic and achievement difficulties
Birth to 3
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Start with Evaluations –
specific or more comprehensive?
Early Intervention – funded
Private therapists
Need team – integrated approach
Center-Based Program / Home program
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When in doubt refer for evaluation
Need to refer early
 If too early to qualify – need to monitor
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Need to intervene earlier or can miss
developmental window of opportunity
Imperative in language skills development
Ages 3 - 5
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Start with Evaluations –
Specific or more comprehensive?
Therapy specific treatments
CPSE – Board of Education/District
Preschool options
SEIT
Crucial to evaluate early enough to make
decisions prior to Kindergarten.
School Age
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Schools start with pre-referral interventions
Evaluations – specific or more comprehensive?
Committee on Special Education (CSE)
Pros and cons of evaluations, classifications,
Section 504, legal issues
Therapies
School Placement considerations
Primary Evaluations
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Psychological
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History
Intelligence Testing
Behavioral Assessment
Emotional/Personality
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Psychoeducational
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Neuropsychological
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Psychological
and Full Academic
Achievement
All of the above and further
exploration of areas of
strengths and weaknesses
Developmental Evaluations
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Developmental snapshots to guide current
treatment planning and diagnosis
Needs ongoing monitoring and reassessment of
treatment plan
Not correlated with later IQ
Limitations of diagnoses/labels at an early age
Goal of Neuropsychological Testing
Go Beyond IQ and academic scores to provide a
complete picture of the child’s cognitive,
learning and social/emotional functioning across
many domains related to brain function.
Should be functional perspective with clear and
practical recommendations.
Testing Professionals
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Psychologists
School/Educational (Master’s, Doctorate)
Clinical Ph.D., Psy.D.
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Neuropsychologists
Other Disciplines/Team
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Neurology
Pediatrician/Developmental Pediatrician
Nursing
Psychiatry
Physiatry
Physical Therapy
Speech and Language Therapy
Occupational Therapy
Special Educators/learning specialists
All have specific scopes of practice
Pediatric Specialization
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Experience
Rapport
Knowledge of educational system
Limits of overly specialized, diagnosis focused
evaluations, clinics
Specific Issues in Epilepsy
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All of the above
Experience with Epilepsy and range of learning,
attentional and psychological issues
Timing and locations of evaluations
Reason for referral may dictate or limit
evaluation (i.e.: pre-surgical evaluation)
District/School vs.
Independent Evaluations
Independent evaluation:
 Parental control
 Timing/flexibility of evaluation
 Goal should be to evaluate the child holistically not
just to get an evaluation done
 Specific recommendations
 No conflict of interest
Needs to provide appropriate documentation and
recommendations to be accepted and useful
Be sure to understand timing/procedural issues
Variability in Reports
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Tester:
Training
Style
Organization/Setting
Tests used
Who person is writing for
Referral Question
Variability in Tests Used
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Examiner’s choice/comfort level
Availability of Tests
Age of child
Clinical Judgment
Preparation for Evaluation
- Parents
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Educate yourself regarding learning issues and process
Delineate areas of concern/goals of evaluation
Understand clinician’s scope of experience and
practice and ability to assess with a team
Should not focus primarily on single label
Expect written report with practical recommendations
that is also geared toward specific goal (ie: funding,
admission…)
Assure ongoing communication/follow-up
Parents should receive feedback and then written
report before school, district
Preparation for Evaluation
- Child
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Present evaluation in non-threatening, relevant and
developmentally appropriate manner
Coordinate terminology and evaluation process with
clinician
Consider classroom/therapy observations
Discuss specific behavioral/stylistic issues with clinician
Provide work samples, book bag, outside of school
examples of concerns
Child should receive some form of feedback at the end
Factors Impacting Testing
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Why referred?
Motivation/Attitude
Rapport
Time Frame of testing
Disabilities
Need to know what each test measures/doesn’t measure
Age
Culture/Language
Qualitative information necessary with scores
Medication
Seizure status
In hospital
Overall Cognitive Functioning
Intelligence Testing - IQ
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In neuropsychological and/or educational
evaluation IQ test is used as starting point
Normative Comparison
Limitations of overall scores
Limitations of IQ as a construct
IQ Scores
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IQ scores are often used as marker – need to
make sure it is a good one!
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Overall scores do not take into account
variability in scores, especially Full-Scale IQ
Discrepancy Based LD Evaluation
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Discrepancy between IQ and achievement
Discrepancy between child and same age/grade
peers
*Discrepancy between child’s own abilities and
what should be expected
What is clinically meaningful should translate to
what is educationally and legally relevant
IQ Scores
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In an effort to broaden the construct of IQ
newer IQ measures incorporate numerous skills
Most notable – WISC-IV – can have high
“traditional” IQ areas (Verbal, Performance) and
have Full-Scale IQ lowered by Processing Speed
and Working Memory
General Abilities Index – not always used but
should be in many cases
Preschool
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Wechsler Preschool and Primary Scale of
Intelligence-III (WPPSI-III)
Ages 2:6 – 7:3
Limitations of ERB
School Age IQ
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Wechsler Intelligence Scale for Children-Fourth Edition
(WISC-IV)
Ages: 6 – 16:11
Stanford Binet Intelligence Scales – 5th Edition
Ages 2:0 – 89:11
Wechsler Adult Intelligence Scale-Fourth Edition
(WAIS-IV)
Ages: 16 and up
Wechsler Abbreviated Scale of Intelligence (WASI)
Ages: 6 and up
Speech and Language
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Neuropsychologists screen these areas in relation to full
battery – gather from Speech-Language Evaluators
Speech/Oral-Motor not the same as Language
Need to gather audiological testing information
Look at expressive and receptive skills in a variety of
contexts
Auditory Processing - APD
Adds valuable information to IQ scores
Augmentative Communication
Visual-Motor/Visual-Perceptual
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Parts of evaluations overlap w/ OT, especially in
neuropsychological evaluation
Visual-Perceptual
Neglect / Inattention
Visual-Motor
Apraxia
Sensory Integration
Assistive Technology
Gross-Motor - PT
Other Areas of Neuropsychological
Evaluation
 Attention and Concentration
(In 1:1 structured testing setting)
 Memory
visual; verbal; procedural; recall vs. recognition
 Executive Functioning:
Planning, organization, sequencing, working
efficiently, flexibility, impulsivity
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Executive Functioning/Attention and Concentration
Impulse control
Distractibility
Attention: Focused; selective; sustained/vigilance
Auditory/Visual
Not only attention – but organization, consolidation,
etc…
Planning, organization, time management
Mental flexibility
May not manifest until older
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Memory
Most common complaint – but influenced by
attention/executive functioning skills
Visual
Verbal
Procedural
Recall vs. recognition
Short-term vs. long-term
Long-term – usually intact – but retrieval strategies may
be impacted
Academic Achievement Tests:
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Limitation of brief screening of single-word reading,
spelling and arithmetic in diagnosing learning problems.
Reading: decoding, sight words, comprehension, speed,
fluency…
Need different tests for reading comprehension
Teacher estimates are too subjective.
Importance of, but also limitations of GradeEquivalents.
Standard Scores may be based on age or grade – very
important.
Problems in Diagnosing LD
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Discrepancy analysis
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Qualitative/subtleties of difficulties
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Structured 1:1 setting
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Difficulties do not always manifest themselves
yet or on certain tests.
Personality/Emotional Testing
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Projectives
Rorschach (Exner Comprehensive System Scoring)
Thematic Apperception Test
Roberts Apperception Test – 2
Sentence Completion
Clinical Interview
Objective measures
MMPI-A or MMPI-2
BASC-2
PIC/PIY
All dependent on cognitive skills
Rating Scales – limitations but widely used – be careful – needs
to correspond with clinical observation, other data….
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Depression
Anger
Anxiety
Reality Testing
Defenses
Coping abilities/style
Motivation
Self-esteem/confidence
Frustration tolerance
Emotional functioning needs to be given more concern
before behavioral manifestation
Family/Developmental issues
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Independence/Dependence
Depending on age of onset may not have a goal
of returning to previous level of independence
and autonomy/achievement.
Parents often more protective - furthering these
difficulties
Fantasy of all-protective parent/safe world
potentially impacted
Social Issues
Adaptive Functioning
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Activities of Daily Living
Measures:
Vineland-2
ABAS-II
Observation
Interviews
Needed for diagnosis of Mental Retardation
Individuals with Disabilities Education
Improvement Act of 2004 (IDEA 2004)
Purpose:
To ensure that all children with disabilities have
available to them a free appropriate public
education that emphasizes special education and
related services designed to meet their unique
needs and prepare them for further education,
employment, and independent living. 20 U.S.C.
Sect. 1400(d)
Individuals with Disabilities
Education Act
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All children with disabilities receive a free
appropriate public education (FAPE)
A school district must provide special education
and related services (PT, OT, Speech, Special
Education, Counseling, Health paraprofessional)
at no cost to the child or his/her parents.
Only required to provide what’s appropriate – not
optimal or best
Parental Referral to Local Education
Authority
Write a letter to the Chairperson of your Committee on Special
Education requesting an evaluation for possible special education
needs.
Federal and New York State law requires that Districts complete the
evaluation process within 60 school (business) calendar days.
All communication with your district should be in writing, and you
must have proof of delivery of all communication.
Your School District cannot refuse to evaluate your child upon your
request.
Evaluation
Parents must consent to an initial evaluation.
A variety of assessment tools and strategies must be utilized to
gather relevant functional, developmental, and academic
information about the child. This includes information provided
by the parent.
No single measure or assessment may be used as the sole
criterion for determining whether a child is a child with a
disability or to determine an appropriate educational program.
Must be appropriate to be used with that child.
Copies of results of all assessments performed must be provided
to the parents, at no cost.
Identification/Development of an IEP
Determination of eligibility
Classification
Program Recommendation
Present Levels of Academic Performance
Goals/Objectives
Related Services
Classification
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Section 504 - Section 504 of the American with
Disabilities Act requires recipients to provide to
students with disabilities appropriate educational
services designed to meet the individual needs of
such students to the same extent as the needs of
students without disabilities are met. A 504
Accommodation does not require an IEP, but
simply provides for classroom modifications
and/or related services
CPSE – Preschooler with Disability
CSE – 13 Classifications
Classification
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Autism
Deafness
Deaf/Blindness
Emotional Disturbance
Hearing Impairment
Learning Disability
Mental Retardation
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment including Blindness
*Can have very different implications for services and placement
Placement
This is performed at the CSE meeting, except in New
York City, where this is done by the placement office.
You do have the right to view any placement proposed
for your child.
Charge and goal is for the least restrictive environment
(LRE)
School Placement
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Section 504 – Not CSE
Public School General Education with related services
Therapies
Special Education Teacher Support Services (SETSS)
Paraprofessional
Inclusion /Co-teaching/CTT
12:1
12:1:1, 8, 6….
NPS – approved schools
http://www.vesid.nysed.gov/specialed/privateschools/
Carter Funding
Dispute Resolution
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Independent Educational Evaluation (IEE)
Parent has the right to an IEE if they disagree with an evaluation
obtained by the district
Upon request by a parent for an IEE, a District must either file a
due process complaint to show that its evaluation is appropriate or
ensure than an IEE is provided at public expense
Mediation
Voluntary; must be conducted by a qualified and impartial mediator;
must be paid for by the District, who maintains a list of qualified
mediators that are assigned on a rotational or random basis; It is
binding
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Impartial Hearing – Impartial Hearing Officer
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Appeals – State level first
ADHD/ADD
Hyperactivity
 Impulsivity
 Distractibility
Issues to Consider
 Developmental
 Gender Bias
 Overly diagnosed/overly simplified
 Medication issues in Epilepsy
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PDD
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Autism
Rett’s
 Childhood Disintegrative Disorder
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Asperger’s
PDD-NOS
Wide variability in presentation
Learning Disabilities
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Specific
Dyslexia, Dysgraphia, Dyscalculia
Non-Verbal Learning Disabilities
More General
Gaps in abilities/IQ and achievement
Developmental
Track over time/different demands
Sensory Integration
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Organizing, integrating and interpreting sensory
input in a variety of modalities including: touch,
movement, body awareness, visual, and auditory
information.
Developmental
Does it impact functioning?
Overlaps and/or interacts with other diagnoses
conditions
Auditory Processing
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Difficulties in processing orally presented
information even though hearing is within
normal limits
Beware of “knee-jerk” label
Audiologist needs to diagnose
Age expectations – These skills develop between
ages 5-7.
Interventions/recommendations
Overlap with other diagnoses
Recommendations
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School placement
Therapies/Interventions
Compensatory techniques and strategies
Modifications in the Environment
Accommodations/Expectations
Assistive Technology
Medication/Treatments
Some sound good but may not help (e.g. tape recording
lectures requires >2x to listen and transcribe; laptop in
class – only if great/fast typist…)
Summary
Need to incorporate all objective data, scores
from testing, observations, outside therapists,
history, emotional/personality variables, family,
and school data in order to make well thought
out decisions for children.
Need to know rights and law as well.
Parents Know Best
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Trust your instincts
Be involved / carry-over
Educate yourselves
(pros and cons of internet)
Work closely with medical team
Know your rights (Advocacy/Lawyers)