Monday, June 14, 2010

Neuropsychological Evaluation

The topic of a Neuropsychological Evaluation is one
that comes up often in the ACC support group I
belong to.

The topic came up during the creation of the ACC
Reading and Comprehension document and although
the Neuropsychological Evaluation information was
included in that document, I believe it is worthy
to stand alone as a separate blog post in an effort
to view it more easily and in the hopes that it will
spark additional input and information from others.

The information gained from a Neuropsychological
Evaluation is valuable in terms of helping a child
who has Agenesis of the Corpus Callosum in the
educational setting.

In their article titled: Neuropsychological Assessment:
An Important Tool for Managing ACC"
Lynn K. Paul, Ph.D., and Warren S. Brown, Ph.D., say:

"Despite the similarities, each individual
with ACC has unique characteristics. The goal
of neuropsychological evaluation is to clarify
the particular pattern of strengths and
weaknesses present in the case at hand and
then to target specific abilities for intervention."

"(The length of evaluations vary.) A comprehensive
evaluation includes testing attention, memory,
sensory-motor skills, visual perception, language,
intellect, reasoning, social behavior, personality,
and emotions. It is particularly important in ACC
to assess pragmatic language, problem-solving
skills, and social communication."

Parent of child with partial ACC said:

"People are not always aware that some traditional
tests of reading comprehension sometimes do not show
how serious a problem can be. (You will not have that
problem with a neuropsychologist, I'm sure.) In the
public schools the testing for us always came out
pretty good, but was obviously (to me, not them) not
accurate. With the neuropsych we were able to get a
much better evaluation as well as a specific diagnosis
of LD for reading comprehension, in addition to
the OHI."

OHI = Other Health Impairment
LD = Learning Disability


Many parents who have a child with ACC highly
recommend having a Neuropsychological Evaluation.

The Evaluation can be costly, however, parents
report that the information gained from having
a Neuropsychological Evaluation for their child
is invaluable and worth the cost.

A Neuropsychological Evaluation can accurately
assess a child in the area of reading and
comprehension, diagnose problems, provide specific,
detailed information and suggest intervention

In addition, a Neuropsychological Evaluation will
also thoroughly assess the child and give insight
and intervention methods in all educational areas,
cognitive as well as behavioral.

In her document titled "Educational
Suggestions For Children With ACC: A Beginning"
Kathryn Schilmoeller, Ph.D. and parent to grown son
with ACC wrote:

"If I were in a position of advocating for Matt
in the public schools at this point, I would urge
the school to have a neuropsychological evaluation
done. We found such an evaluation to be invaluable
in terms of giving us some concrete suggestions
for the teachers working with Matt. My only regret
is that it took us until Matt was 15 to figure out
that that would be helpful. In our case, after the
testing was completed, Gary and I first had a
session with the neuropsychologist to go over the
results and ask questions. Then we had the
neuropsychologist attend a PET (pupil evaluation team)
meeting to go over the results. We video-taped this
session so that the video would be available for
his current teachers to review and new members of
Matt's team to view as they started working with
him. The school paid for all of this as part of
his triennial review."

Is there a particular age that is best for a child
to have a Neuropsychological Evaluation?

Second Parent of a child with ACC writes:

"I have heard mixed opinions on when a neuropsych
eval is worthwhile. My neuropsych said really
earlier than about 8 or 9 is just too soon, but
others have said as early as 4. Also, for my
child we are on a 2-3 yr plan. Lets set up 3yr
goals and then re-evaluate. Maybe right before
high school. Then again right before graduation.
He stressed, for my child, not to set goals too
long range. We do not know what the future holds
so let's not try to set our sights on college,
let's look at middle school and jump off the High
School bridge first then the college bridge.
It made it all look so much less daunting!"

Third Parent of a child with ACC writes:

"My son had a private neuropsych eval when he was
about 6 1/2 years old and in first grade. We
arranged this ourselves and finally convinced the
insurance to pay for it (after countless phone
calls and help from the doctor's billing office).
Having him evaluated was one of the best things
we've done on this ACC journey. The eval gave us
additional insight into my son's learning style
and needs. It also gave us a "professional's"
opinion that we could take to the school to
convince them that we did indeed know what we
were talking about. We found it very helpful as
we were crafting his initial IEP, halfway through
first grade. I pull out the page of recommendations
every time we have a meeting with the teacher or
the school."

Fourth Parent of a grown child with ACC shares
her viewpoint of a Neuropsychological Evaluation:

"We found that her neuropsychological
evaluation was extremely helpful. In her case,
it did pinpoint her reading difficulties (for
the first time), giving her a diagnosis of
"learning disabled for reading comprehension"
to go along with her OHI diagnosis provided by
the MRI. But that was just a small part of the
findings. The report also included all the
pertinent results of all other testing she had
had done over the years, as well as input from
teachers and from us.

She had been tested twice at school, and she also
had a private evaluation. They all found that her
academic levels were all at or above grade/age level.
Her IQ scores were quite variable, from high average
to borderline mental retardation. They didn't evaluate
anything else. None of those findings were helpful
at all. Her problems were attributed to "temperament"
or "anxiety," both of which were ludicrous to anyone
who knew her at all.

The neuropsych testing included similar intelligence
and academic testing, but other kinds as well. It
was far more detailed and accurate, assessing and
discovering learning deficits and problems that the
public school and previous private evaluations had
not. And the IQ results were far more reasonable,
in the low average range. She was also found to have
significant deficits in problem-solving and
higher-order thinking skills and "executive
functioning"--frontal lobe--skills.

She was evaluated within the year after her initial
ACC diagnosis, at age 17. I have heard that about
age 7 is the lower end of the age range for this
kind of assessment, and I think that would have
been the perfect age for her. This is when her
problems really began showing up, and when we started
looking for answers. I think that if we'd have had
it done that early, we would surely have wanted
another one when she reached 7th grade or at least
by high school, to track progress, to see if there
were any other findings that would become apparent
by that age, and to address recommendations for the
type of learning required for secondary success.
Of course this is all just speculation on my part.

The report outlined ways she could learn best and
gave recommendations for teachers."

This same parent goes on to tell additional
ways that having a Neuropsychological Evaluation
benefited her daughter:

"Even though we got this report so late in her
school career, I'm very glad that we had it done.
We used it to help her qualify for SSI benefits,
and were told by the person managing the case
that the evaluators were extremely impressed by
its thoroughness, which was far beyond anything
they'd have had done. She would never have
qualified on the first application without it,
and I doubt she'd have qualified even on appeal
if not for the information it contains. It was
also just what she needed to qualify for
accommodations and help from the college. So
for those two post-high school uses, she got it
just in time."

To give an example of some very specific information
contained in a Neuropsychological Evaluation for one
particular child who has ACC, I am including pertinent
sections of that child's Evaluation and findings.

The Psychologist wrote:

"My evaluation consisted of an initial interview
with Jamie's parents, (names parents), a review of
school and medical records provided by (names parents),
standardized behavior rating scales completed by
Jamie's parent and several teachers, and a selected
battery of tests with Jamie. Following the evaluation,
I had the opportunity to discuss my findings at length
with (names parents) during a feedback conference."

The specific tests used in the Evaluation were:

Wechsler Intelligence Scale For Children-Fourth Edition:

Full-Scale IQ
General Ability Index
Verbal Comprehension Index
Perceptual Reasoning Index
Working Memory Index
Processing Speed Index
Subtests Block Design
Digit Span
Picture Concepts
Letter-Number Sequencing
Matrix Reasoning
Symbol Search

Woodcock-Johnson Pyschoeducational Battery-Third Edition
Test of Achievement:

Broad Reading
Brief Reading
Basic Reading Skills
Letter-Word Identification
Reading Fluency
Passage Comprehension
Word Attack
Broad Math
Brief Math
Math Calculation Skills
Math Fluency
Applied Problems
Brief Writing
Writing Samples
Academic Skills
Academic Applications

Gray Oral Reading Tests-Fourth Edition:

Oral Reading Quotient

Comprehensive Test of Phonological Processing:

Phonological Awareness
Rapid Naming

Additional Tests Administered:

Wisconsin Card Sorting Test

Boston Naming Test
Controlled Oral Word Association Test
Grooved Pegboard
Delis Kaplan Executive Function System
Wide Range Assessment of Memory and Learning-Second Edition
Child Behavior Checklist
Child Behavior Checklist-Teacher Report Form

The Psychologist wrote:

"Jamie's composite performance on the Gray Oral
Reading Tests-Fourth Edition, a functional reading
measure tapping oral reading skill development,
was below average (Oral Reading Quotient = X).
Jamie experienced particular difficulty on
variables from this measure related to fluent
reading, while his reading comprehension composite
fell in the low end of the average range.
Evaluation of memory functions indicated that
Jamie experiences significant difficulty with the
initial acquisition and retention of newly presented
information. His memory weaknesses are in excess of
what would be expected from a child with his level
of cognitive ability, and his weakness with the
acquisition of new information extends to both
verbal and nonverbal memory modalities. Jamie's
composite verbal memory performance from the Wide
Range Assessment of Memory and Learning-Second
Edition which correlates with the declarative
memory demands often placed on a child in the
classroom clustered far below average compared
to others his age (Verbal Memory Index = X).

Jamie is somewhat slower to complete activities,
and he is sometimes slower to organize his response
to specific tasks. Like general language weakness
and memory issues, these issues of performance
efficiency also likely stem from his neurological
conditions including agenesis of the corpus callosum
as well as epileptogenic activity. Given the extent
of Jamie's agenesis of the corpus callosum, cortical
dysplasia, and the additional complicating factor of
epileptic activity in his brain, from a cognitive
perspective it is remarkable that Jamie has developed
as well as he has.

From my perspective, I would strongly encourage
the educational team to consider Jamie's
primary disability as one that is characterized
by Jamie's neurological conditions including agenesis
of the corpus callosum, cerebral dysplasia, and
the presence of epileptic activity in Jamie's brain.
Due to the direct correlation between these
neurological conditions and Jamie's neurocognitive
functioning which forms the basis for Jamie's
educational development, I believe that Jamie can
be appropriately considered as meeting
special-education eligibility criteria under the
handicapping condition of Other Health Impairment
(OHI). Because this is most explanatory of Jamie's
struggles, I believe that the educational team
should consider making OHI the primary code for
Jamie. As I discussed with (names parent),
children with neurological abnormalities often do
not fit neatly into a pre-existing special-education
category such as Learning Disability (LD). While
Jamie was determined eligible under this code based
on the available information at that time, new
information regarding his neurological conditions
is now available that should supercede the LD code.
Clearly Jamie does not exhibit a learning disability
in the sense that Jamie's current level of academic
skill attainment is significantly discrepant from
Jamie's overall level of cognitive ability. Because
Jamie's neurological conditions directly result in
weaknesses in academic skill development I do not
think that a discussion of Learning Disability as
traditionally defined is particularly relevant to
Jamie's case, as Jamie's learning difficulties
clearly stem from known neurological issues that
directly affect those neurocognitive processes
important for efficient learning. Due to the nature
of the neurological processes involved and given
that epileptogenic activity is an active and dynamic
process, Jamie may sometimes perform in a manner
that is quite inconsistent from one day to another.
Due to difficulty remembering some things, it would
not surprise me if parents and educators had the
experience of Jamie seeming to know something
one day and not recalling it very well the next.
On the topic of memory inefficiency, it is
important to understand how this can impact a
child's performance at school. First, it is
important to recognize that memory inefficiency
can limit the amount and completeness of the
information that the child is able to initially
take in. Sometimes multiple exposures of the
information, and multiple modalities of information
exposure, are necessary to give the child their
best opportunity to successfully encode the information
presented to them. Similarly, children with
inefficiency of learning and memory due to
neurological issues are at significantly greater
risk for being inconsistent in their retention
and later recall of information. Sometimes,
altering the way a question is asked can be
successful in accessing information that the
child has retained but is not able to spontaneously
draw out of their memory (e.g., asking a multiple-
choice question versus a fill in the blank question).

Additional strategies for dealing with Jamie's memory
inefficiencies include:

• Multiple repetitions of information is a
necessary, though sometimes mundane, component
of ensuring that information is satisfactorily
encoded and retained. For children, often the
trick is to be creative in getting the child to
pay attention and put forth effort on an otherwise
tedious task. Sometimes incentives (rewards) can
be offered to a child to help keep them motivated.
Other children simply need frequent breaks in order
to stay motivated to repeat information over and
over. Making the activity of repetition novel and
fun can go a long way in boosting a child's
motivation to go over information multiple times.
Incorporating hands-on activities, using manipulatives
(objects), and using music are some ways that a
child's interest in an otherwise mundane activity
might be boosted.

• Priming - discussion of related topics and how
these may relate to the information at hand. Priming
is especially useful during recall tasks. Previewing
is a type of priming that is done before exposure to
the information in order to activate neural networks
that may then link to the information at hand. Using
recognition memory tasks is also a method of priming.
For example, if a child has trouble spontaneously
reproducing their spelling words, using a multiple
choice format is sometimes helpful.

• Using authentic (real-life) tasks - experiential
learning is typically more efficient than situations
in which the student is given information and expected
to remember it. Experiences that are most salient and
meaningful to Jamie are likely to be remembered best.
Unfortunately, pure skill-based academic tasks
(e.g., reading skills) can be somewhat difficult to
translate into experiential tasks, though reading
practice is easy to translate into meaningful daily

• Rhymes, chants, and music - this can be especially
helpful for memorizing and retaining relatively small
amounts of factual information.

• Movement - involving movement into learning and
rehearsal of information can sometimes be effective.
For example, some people study effectively by pacing
and rehearsing information aloud to themselves.

• Minimize anxiety - if a child becomes excessively
anxious and/or perceives himself to not be competent
to remember something or retrieve some information
from memory, clearly this can interfere with optimal
performance. Thus, anxiety-producing conditions should
be kept to a minimum. For example, some children become
very anxious during timed activities. A little anxiety
can enhance performance, but more than a little anxiety
can interfere with task performance. For Jamie, it will
be important to identify and minimize conditions that
unnecessarily or artificially create anxiety when this
is not inherent to the task (e.g., allowing Jamie to do
math calculations but not necessarily imposing a
stringent time limit if this tends to create a great
deal of anxiety for Jamie)."

This is only a glimpse of the child's Neuropsychological
Evaluation. The complete Evaluation consists of
a total of sixteen pages. It contains very detailed
information regarding background history, test
results, behavioral observations and results of
behavior rating scales as well as detailed
conclusions and recommendations.

test scores have been replaced
with an "X" for privacy.


Neuropyschological Evaluation-FAQs

Any additional
information/comments from you
pertaining to Neuropsychological Evaluations
and your own experience is greatly appreciated.

1 comment:

  1. My son, who has both ACC and CAH (the only one, worldwide, with both), had two neuropsych evaluations, and, while extremely helpful, since he had already qualified under OHI, the school seemed to only look at his IQ scores, falling at the higher end, and dismissed the other scores falling at the lower end (his processing scores). I felt that they just drew a line down the middle, felt he was just fine, and needed no additional services. It maddens me that they still will not give him any SLP therapy, and they do not see a missing link in his brain as a COMMUNICATION problem!! He was kicked out of developmental preschool at age 4, because he was doing so well, we went through due process and lost, although the adjudicator said, I don't necessarily disagree that your child needs services, I just can't make law. I feel I have been fighting the system for 10 years!


I am very interested in reading your comments and
look forward to hearing from you. Thank you.