Neuropsychological Testing
S. L. Crum, B.S., M.S., Ph.D.

So, someone told you to seek out a pediatric neuropsychology evaluation. What does this mean?

Well, to begin with neuropsychology is a subspecialty field in Psychology. It focuses on the relationships between brain processes and behavior. A pediatric neuropsychology evaluation uses standardized tests in order to observe behavior and map a child’s pattern of cognitive development and deviations from typical patterns. Like other evaluations it looks at a child’s strengths and weakness, but, is applies knowledge of brain organization, development and the effects of various insults or injuries to the brain to both the assessment and interpretation process.

So, what tests are used?

This is a question that parents often ask. The fact is, however, that some of the same tests may be used in neuropsychological assessments as are in regular psychological evaluations. And psychologists with no training in neuropsychology may use neuropsychological measures without the necessary knowledge of brain behavior relationships. The difference is that the neuropsychologist who is conducting the evaluation is trained to assess how the child obtains their score, in other words, they are trained to look at the processes involved, as well as the patterns of scores and how they relate to brain functioning.

For example, the school psychologist may be able to identify that your child has problems paying attention, but be unable to differentiate whether this is due to anxiety, impaired echoic storage, an inability to understand what was being said in the first place, distractibility, or an absence seizure disorder. The neuropsychologist specifically strives to make these differentiations.

Because of this goal, a pediatric neuropsychology evaluation will look at a wider range of skills than a typical psychological or psychoeducational evaluation; and will look at those skills and processes in more detail in order to break them down into component parts and discover where the problem lies. For instance, one child with an attentional problem, may orient to the teacher, hear and understand what she says, but, then become rapidly distracted by other sounds. Another child may not initially focus on the teacher longer enough to hear and comprehend the direction. Still, another may orient, focus, but, not be able to sustain that attention, when there is a visual distracter or when a decision needs to be made.

The important factor is not the particular tests being employed, but the skill of the evaluator, so you want to ask to see a number of their previous evaluations with identifying information omitted. You want to make certain they assess attention functions, memory functions, sensory integration, auditory, visual, tactile, olfactory and taste perception, receptive and expressive language, academic functioning, social and emotional functioning, and higher level functions such as reasoning, planning, ability to connect cause and effect. The scope of the neuropsychological evaluation is much broader than typical evaluations, and it attempts to correlate the findings with brain functioning. This is the defining aspect of a neuropsychological evaluation. For instance, a child who cannot do math because they have a problem with attention due to under stimulation of the sensory motor cortex may need very different interventions from a child who has trouble with math because left hemisphere damage impedes sequential processing. This is why the neuropsychological evaluation looks at body side comparisons and brain functioning rather than simply the child’s level of performance.

You may have a child who appears to be acting out in total defiance. But, the neuropsychological evaluation may reveal a deregulation of emotional control suggesting that once a feeling is triggered your child has little control over it. In this case, a mood stabilizer might be very helpful. Conversely, if your child is acting out because their level of tension and anxiety is too high and they don’t know how to deal with that, relaxation training might be recommended or even an Anxiolytic. The important factor is that the recommendations will be based on data that tells important information about the relationships between how your child’s brain is working and how your child is behaving.

Recently, a director of education told me “We don’t need to know why he is having trouble paying attention. Just that he does”. In fact, this is a very detrimental attitude. Perhaps the child is not paying attention because his brain is working too slowly and he is unable to pay attention. In that case, giving negative consequences would be useless, as might be positive reinforcers. On the other hand, perhaps the brain is working fine, but the child isn’t paying attention because he is anxious about problems at home. Or, maybe the child isn’t paying attention because the work is too easy and boring, or too hard and overwhelming. Or, maybe the child is attempting to pay attention, but, can’t process the auditory information because his temporal lobes are not functioning properly. In all of these cases, different interventions are needed in the classroom and at home. This is why a good neuropsychological evaluation can be so valuable when your child is struggling academically, emotionally or behaviorally.

Who is this type of evaluation beneficial for?

You want to pursue a neuropsychological evaluation when:

· There is some question about diagnosis that is unresolved.

· Your child has already had academic interventions, psychological, medical or other interventions and they have been unsuccessful.

· There is a need to document your child’s current levels of performance prior to surgery or medication treatment or other therapeutic interventions.

· If you need to document your child’s development over time in order to monitor progress.

What should I learn from my child’s neuropsychological evaluation?

· You should receiving information about your child’s diagnosis

· You should receive a good description of your child’s strengths and weaknesses and how they relate to behavior at home and in school.

· You should obtain a good understanding of what behaviors are related to cerebral dysfunction, what are related to the home environment, what are related to the school environment.

· You should receive information about your child’s current levels of performance, where there is potential for improvement and where improvement is unlikely.

· You should receive specific educational recommendations about how best to teach your child as a function of their strengths, and how best to remediate areas of weakness, and which deficits need to be compensated for due to an unlikeness to remediate.

· You should obtain an idea of what is reasonable to expect from your child. For instance, you wouldn’t expect a blind child to read a regular book, but, would instead teach the child to read a Braille book. Likewise, if your child had an auditory processing deficit, it might not be reasonable to expect your child to learn from classroom lectures, but it may be reasonable to expect your child to learn from reading.

· You should obtain specific recommendations for improving your child’s behavior management at home and in school.

Should this be covered by the school or my insurance?

If the assessment is being used to assist in medical diagnosis or to monitor medical treatment, it is covered by most insurers. If it is being used as the basis for an IEP, and you have requested an IEE it is covered by the school district. Otherwise, the responsibility lies with the parent.

When you are entitled to a neuropsychological evaluation as an IEE

If your child has been evaluated by the school district either to determine eligibility for special education services or as part of an annual or triennial evaluation, and you are in disagreement with the district’s evaluation, you are entitled to an independent evaluation by a provider of your choice at school district expense under IDIEA. Many districts; however are loathe to provide these evaluations precisely because they are more comprehensive than their own and often recommend a range of appropriate interventions, accommodations and modifications, that the district is resistant to providing. Therefore, they sometimes, try to talk the parent out of the necessity of the evaluation claiming that no additional information will be generated. Or, they might attempt to control the outcome of the evaluation by restricting the parent to obtaining the evaluation from certain evaluators who have worked with them in the past and tailored their recommendations to the district’s resources. At other times, they take the parent to due process and put the burden of proving the need for the evaluation on the parent. If you disagree with the district’s evaluation, notify them in writing and indicate that you want the IEP team to convene within ten calendar days to approve your request. This is the section of regulations you may wish to refer to:

Section 300.502 Independent Educational Evaluation

(a) General.

(1) The parents of a child with a disability have the right under this part to obtain an independent educational evaluation of the child, subject to paragraphs (b) through (e) of this section.

(2) Each public agency shall provide to parents, upon request for an independent educational evaluation, information about where an independent educational evaluation may be obtained, and the agency criteria applicable for independent educational evaluations as set forth in paragraph (e) of this section.

(3) For the purposes of this part—

(i) Independent educational evaluation means an evaluation conducted by a qualified examiner who is not employed by the public agency responsible for the education of the child in question; and

(ii) Public expense means that the public agency either pays for the full cost of the evaluation or ensures that the evaluation is otherwise provided at no cost to the parent, consistent with §300.301.

(b) Parent right to evaluation at public expense.

(1) A parent has the right to an independent educational evaluation at public expense if the parent disagrees with an evaluation obtained by the public agency.

(2) If a parent requests an independent educational evaluation at public expense, the public agency must, without unnecessary delay, either—

(i) Initiate a hearing under §300.507 to show that its evaluation is appropriate; or

(ii) Ensure that an independent educational evaluation is provided at public expense, unless the agency demonstrates in a hearing under §300.507 that the evaluation obtained by the parent did not meet agency criteria.

(3) If the public agency initiates a hearing and the final decision is that the agency's evaluation is appropriate, the parent still has the right to an independent educational evaluation, but not at public expense.

(4) If a parent requests an independent educational evaluation, the public agency may ask for the parent's reason why he or she objects to the public evaluation. However, the explanation by the parent may not be required and the public agency may not unreasonably delay either providing the independent educational evaluation at public expense or initiating a due process hearing to defend the public evaluation.

When you want to obtain a neuropsychological evaluation through your insurer

If you feel your district is likely to employ any of the above listed tactics, you may wish to consider the alternative option of obtaining a neuropsychological evaluation through your medical insurance. This would be a particularly good route to go if there are questions about diagnosis. The one caveat here is that no medical insurer will pay for an evaluation they consider educational because they are cognizant of the district’s responsibility to pay for these evaluations. Therefore, to obtain an evaluation through this route you need to build a case for medical necessity.

How to build a case for medical necessity

To build a case for medical necessity I recommend following these steps:

1-Ask all private and school therapists to provide you a written report indicating any areas they feel your child is not progressing well in. Select those that indicate the most areas of deficit and ask the therapists to forward these to all of your child’s medical providers.

2-Set up an appointment without your child present to speak to your pediatrician and other medical providers (psychiatrist, neurologist, psychologist). When you meet with each one bring in a list of areas that you feel your child is not progressing despite medical interventions such as medication therapy, speech therapy, occupational therapy, physical therapy, psychological counseling. This list should include specific examples of problems seen outside the school environment. For instance, you might say: “If am giving a direction, and the door bell rings, Joey forgets everything that was said.” Or you might say: “If I tell Joey to put his clothes away, he heads towards his room, but, forgets his goal along the way.” Or, “I told Joey that he was not allowed to hit girls, so he tripped one instead, clearly missing the larger message.”

Indicate that you believe there may be an underlying neurological cause for your child’s disability that has not been fully understood by your child’s medical providers, and therefore, is hampering their ability to direct you to the most appropriate interventions or methodologies. Tell them that you would like to request a neuropsychological evaluation to determine not only the nature, but, also the extent of cerebral dysfunction contributing to problems to include assessment of:

sensory perception in terms of iconic and echoic storage, olfactory perception, tactile perception and kinesthesia, immediate, intermediation and long term memory consolidation and retrieval, orienting response, selective attention, divided attention, sustained concentration, as well as to rule out hemi-attention, motoric impersistence, simple, complex and disjunctive psychomotor speed, multimodal sensory integration including auditory-motor and visual-motor functions, assimilation of novel information, concrete concept formation and utilization, define concepts formation (concepts that require a verbal explanation to be learned), elucidation of rules when dealing with novel stimuli, abstraction and application of higher order rules, cognitive control and executive functions including problem identification, information gathering, retrieval strategies, flexibility, ability to brainstorm, ability to identify patterns, ability to use compensatory techniques such as lists and charts, ability to analyze data and break problems down into solvable units, ability to restate problems in ways that are meaningful to the patient, estimating, predicting, projecting into the future, ability to use conservative focus to vary a single aspect at a time to eliminate non-critical attributes, ability to vary multiple aspects simultaneously in the process of problem solving, the capacity to utilize a model, the ability to reason backwards, the capacity to examine assumptions, the ability to recognize multiple possible solutions, the ability to select appropriate symbols for notation, the ability to conduct simultaneous scanning, as well as creative functions such as fluency, flexibility, originality and elaboration.

And to include a report which includes specific recommendations to the physician regarding:

· Appropriate therapeutic modalities (SLT, PT, OT, Neurofeedback, Biofeedback, Cognitive-behavioral psychotherapy, medication therapy, auditory processing training, social skills training, Neuroremediation (or cognitive rehabilitation), recommended methodology, frequency and duration to facilitate amelioration of the child’s neurological deficits.

· Appropriate accommodations and modifications (books on CD, computerized instruction, respite, day treatment program, residential program, social skills coach, employability skills coach, job mentor) that the parent(s) should implement at home and in the community to facilitate compensation for the child’s deficits and enable independent functioning.

Once your physician provides you with a letter of medical necessity specifically requesting all of the above, you can submit this to your insurer for a written pre-determination of benefits. This may take a while, but they will notify you of the number of hours for evaluation they will cover and the amount per hour they will cover. You can then bring this with you when you contract with a neuropsychologist, so they will know the applicable amount of deductible and copayment, and wait upon insurance reimbursement for the balance.

Through this approach, you are not only more likely to receive insurance coverage for the neuropsychological evaluation, but also a more complete evaluation as the examining neuropsychologist will be ethically obligated to test in all the areas noted by your physician, and to give recommendations regarding both appropriate therapeutic modalities, as well as on accommodations and modifications. This neuropsychological evaluation will then serve as the documentation which your physician needs to prescribe appropriate interventions at home and in the community.

Then you can contact the neuropsychologist and ask them for a separate summary report recommending only related services, instructional methodologies that are most likely to be successful with your child, accommodations and modifications. You can take second summary (which the neuropsychologist may charge you a few hundred dollars for) to the school district and ask for the school to address all the issues delineated issues. The school may choose not to consider this outside evaluation, but, at least you now have valuable information regarding what your child needs, as well as two excellent report to use in mediation or due process hearing.

What should I bring to the first appointment?

1. All your child’s medical records.

2. All previous evaluations by psychologists, teachers, OT’s, PT’s, SLT’s

3. Your child’s IEP’s or 504 plans

4. Any parent surveys or questionnaires you have been asked to complete.

Supplying all of the records is essential because a good neuropsychologist will integrate all this data with their findings. If they find something different than was reported in earlier evaluations, they will attempt to explain what has changed so you understand why the results are different. They also need to be able to track your child’s progress over time to see if your child is developing at an expected rate, or if perhaps there is regression.

How do I prepare my child for this lengthy evaluation process?

I like to tell children that they will be doing a whole range of tests and games – some with paper and pencil, some with objects like blocks, some on computer – that will help the psychologist and him and his parents understand a bit more about what is easy and hard for him so we can help him deal with day to day things easier. They might be asked to draw some pictures, to hop or jump, to make something with blocks or puzzle pieces. They might be doing some reading or some math. In short, they will be doing a little bit of a whole lot of different things.

Send your child with some bottled water and some non-sugar, non-caffeine snacks. Let your child know they can ask for breaks when they need them. Tell them that the night before they want to go to bed a little bit early so they feel well rested. Let them know that the neuropsychologist is working with mom and dad to help them help your child, so this is a person they can trust. Explain, you may be coming back for two or three sessions to do all the tasks, and after everything is done, the doctor, mom and dad will explain the results to him so he can understand himself a bit better.

Presented as a community service by,

Susan L. Crum, B.S., M.S., Ph.D.
Special Needs Coach
Able2Learn
Email: Able2learn@live.com
Voice and Fax: 863-471-0281
Website: specialeducationsupport.org