Courtenay Rourke Ainsworth, Ph.D.

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Psychoeducational Testing, Learning
Disabilities, and School Consultation

• Courtenay Rourke Ainsworth, Ph.D.
• Pediatric Neuropsychologist
• Licensed Clinical Psychologist
• courtenayainsworth_at_gmail.com

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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

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Conditions Issues Commonly Referred for
Neurodevelopmental/Neuropsychological Assessment

• Neurological conditions such as stroke, epilepsy,
  brain tumors, disorders of movement (e.g.,
  cerebral palsy)
• Head trauma
• Attention-Deficit/Hyperactivity Disorder
• Behavioral problems
• Learning disorders
• Developmental delay
• Socialization difficulties

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Other Conditions/Issues (continued)

• Chromosomal/Genetic disorders
• Toxic exposure (in utero environmental)
• Medical conditions such as metabolic disorders,
  HIV infection, liver disease, renal disease,
  sickle cell anemia
• Perinatal trauma

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Uses of Neuropsychological Assessment

• Differential diagnosis
• School-based psychoeducational evaluation will
  not provide diagnosis
• Baseline 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)

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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
  patients cognitive status

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Neurodevelopmental Testing

• Used to assess infants and young children in
  order to examine early development to see if it
  is on track

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Pediatric Neuropsychological Evaluation

• Intellectual Functioning
• Academic Achievement
• Attention and Concentration
• Verbal and Visual Memory
• Problem Solving Skills
• Receptive and Expressive Language
• Visual-Perceptual Abilities
• Sensorimotor Skills
• Personality and Emotional Status
• Behavioral Functioning

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The Neuropsychological Evaluation

• Portable 4-7 hours
• Individually tailored hypothesis testing
• Objectively scored
• Standardized, valid, and reliable
• Can be modified
• Quantitative and qualitative interpretation
• Task performance is analyzed to determine
  component processes

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Intelligence Testing

• Wechsler Intelligence Scale for Children-IV
• Verbal Comprehension Index
• Perceptual Reasoning Index
• Working Memory Index
• Processing Speed Index
• 120 Superior
• 110-119 High Average
• 90-109 Average
• 80-89 Low Average
• 70-79 Borderline
• 69 - Mental Retardation

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WISC-IV Verbal Questions

• 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?

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Academic Achievement

• Reading- word identification, comprehension,
  non-word decoding
• Math- calculation application
• Spelling words to dictation
• Written expression
• Academic fluency- timed reading, math, writing

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WJ Reading Fluency
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WJ Math Fluency
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Memory Functions

• Immediate verbal/auditory retention span
• Learning over trials
• Efficacy of retrieval- spont. cued
• Long-term memory
• Remote memory
• Not assessed in a psychoeducational evaluation

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Memory Evaluation

• Childrens Memory Scale
• California Verbal Learning Test/CVLT-C
• Rey-Osterreith Complex Figure Test

Encoding
Storage
Retrieval
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Verbal Memory Tests

• Associated with left temporal-limbic function
• Narrative Memory (Childrens 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

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Frontal Errors on Memory Testing

• Impoverished learning strategies
• Intrusions and perseverations
• Poor retrieval strategies
• Difficulty with temporal tagging (proactive
  retroactive interference)
• California Verbal Learning Test particularly
  helpful

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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

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Rey Complex Figure
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Evaluation of Attention/Concentration

• Test of Everyday Attention for Children
• Conners Continuous Performance Test
• Trail Making Test
• Not assessed in a psychoeducational evaluation

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Trail Making Test- A
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Trail Making Test B
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Executive Functioning

• Associated with frontal-subcortical circuitry
• Goal formulation
• Initiate, maintain, switch, inhibit
• Mental flexibility
• Planning organization
• Decision making
• Self-monitor, self-correct, persist
• Nonverbal problem-solving
• Not assessed in a psychoeducational evaluation

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Executive Function

• Tests of Executive Function
• Wisconsin Card Sorting Test
• Similarities, Interpretation of Proverbs
• Childrens Category Test
• Tower of London
• Critical for adaptive, independent living

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Language Functions

• Auditory verbal comprehension
• Vocabulary
• Verbal fluency, volume, rate
• Articulation
• Naming
• Pragmatic skills, prosody, gestures

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Evaluation of Language Function

• Verbal/Semantic Fluency
• Peabody Picture Vocabulary Test
• Expressive One Word Picture Vocabulary Test
• Boston Naming Test
• Sentence Repetition
• Clinical Observation

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Visual Perceptual Skills

• Visuoconstruction
• Patterns/sequences
• Location in space
• Facial recognition/Facial expressions
• Visual abstract reasoning
• Personal space
• Integration/organization
• Attention to visual details

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Visual-Spatial Tasks

• Judgment of Line Orientation
• Visual Motor Integration
• Test of Visual Perceptual Skills-Revised
• Test of Facial Recognition

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Judgment of Line Orientation
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Visual Motor Integration
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Visual Motor Integration
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Motor

• Grip Strength
• Dynamometer
• Fine Motor
• Tapping Speed
• Coordination/Dexterity (Grooved Pegboard)
• Gross Motor
• Running, skipping, jumping, balance, throwing,
  catching, up/down stairs

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Psychosocial Functioning

• Personality
• Emotions
• Behavior
• Family dynamics
• Social network
• Situational influences

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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

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Child Behavior Checklist
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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

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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

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Learning Disability

• Definition LD is a neurological disorder that
  affects the brain's ability to receive, process,
  store, and respond to information

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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 Disability
• Dyslexia
• Dysgraphia
• Nonverbal Learning Disability
• DSM-IV Learning Disorder- NOS

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Ability-Achievement Discrepancy Model

• 1968-SLD federally designated category
• 1976-Discrepancy model primary criterion in LD
• Diagnosis of exclusion
• Wide variability to what constitutes a
  discrepancy
• Limited capacity to correctly evaluate
  ability-achievement difference scores
• Variability in measures used to define
  differences
• Instability in discrepancy scores over time
• IQ-Achievement discrepancy can occur for reasons
  other than LD no specific test to rule out other
  causes
• Differentiating LD from low achievement

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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-Interve
  ntion (RtI)
• Tier 1, 2, 3
• However, little evidence on effectiveness of
  research-based intervention
• Not all teachers created equally to implement
  interventions and monitor progress
• Earlier intervention has better
  neurodevelopmental outcome (vs. waiting for RtI
  tiers)

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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 -gt
  happiness)
• Inflectional modifies words tense, number, or
  other aspects (s cat-gt cats)
• Lexicon mental vocabulary with syntactical
  rules
• Shared properties (e.g., action verbs)
• Generate new words (able -gt actionable vs
  cryable)
• Language
• Imageability concrete versus abstract
• Dog- living, 4 legs, domesticated, dachsund, had
  a dog, furry, barks

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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

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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-gt Phoneme Correspondence

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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
• cant read nonwords
• Phonological dyslexia (superior temporal/angular
  gyrus/supramarginal gyrus)
• translation from print to sound (e.g., read pat
  as bat)
• cant 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)

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Coslett, 2003
Some Related Features

• Visual errors skate -gt scale
• Morphological errors scolded-gt scolds or
  governor -gt 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 -gtflag) 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

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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

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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)

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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)

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Testing for Dyslexia

• Sight word reading
• Nonsense words
• Language tests (receptive expressive)
• Reading fluency
• Pattern of spelling errors
• Oral reading sample
• Spontaneous writing sample

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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
• Description
• difficulty reading and writing numbers
• difficulty aligning numbers in order to do
  calculations
• inability to perform calculations
• inability to comprehend word problems

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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

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Disorder of Written Expression

• Learning disability in which a persons writing
  ability falls substantially below normally
  expected range based on the individuals 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.)

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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)

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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

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Nonverbal Learning Disability

• Neuropsychological Deficits
• VCI gt 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

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NLD Continued

• Reverse syndrome of dyslexia
• Difficulty producing in situations that require
  speed and adaptability
• Involves performance processing
• Mild abnormalities in right hemisphere
• Between .1 and 1 of population
• Poor coordination
• Exceptional rote memory

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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

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Intervention Strategies

• Use verbal strengths to compensate
• Hands on/experiential learning
• Encourage kinesthetic sports
• Social skills training
• Preferential seating
• Previewing/outlining instructions
• Model/reinforce on-task behavior
• Instructions presented in single steps/slower
  pace
• Guided practice
• Reduce visual stimuli on page
• Present classroom rules in positive form
• Cue before transitions

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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 childs educational
  performance
• Free and Appropriate Public Education (FAPE)
  must
• Meet childs unique needs
• Prepare child for further education, employment
  and independent living

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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

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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

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IEP Eligibility Categories

• Disabilities that make the child eligible for
  services if affect education
• Autism (including Aspergers 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

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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

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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

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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

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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

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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
• Dont 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