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Lakeview Neurorehabilitation Center
Addressing Neuropsychological
Challenges in Student Performance
Gretchen Hunter, PhD
Neuropsychology Resident
March 17th, 2011
Overview
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Neuropsychological evaluation process for
school-age children
Common neurological disorders and cognitive
processing deficits that affect student
performance
Evidenced-based interventions
Neuropsychology
A clinical neuropsychologist is a professional psychologist
trained in the science of brain-behavior relationships. The
clinical neuropsychologist specializes in the application of
assessment and intervention principles based on the scientific
study of human behavior across the lifespan as it relates to
normal and abnormal functioning of the central nervous
system.
Pediatric neuropsychology applies this understanding within the
developmental context of children, particularly those with
neurodevelopmental disorders
Neuropsychological Assessment
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The goal of the assessment is the generation of
recommendations for habilitation, accomodations, or
modifications
Referrals come from parents, schools, pediatricians,
neurologists, etc.
Evaluation includes review of medical/educational records,
interview, completion of rating scales, feedback about
diagnosis/strengths/weaknesses
Areas assessed include
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Cognitive, sensory, language, learning and memory,
visual-spatial and constructional areas, executive
functions, academic achievement, and
emotional/behavioral
Measures
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Cognitive
Language
Bayley Scales of Infant
Development
Boston Naming Test
Differential Ability Scales
Comprehensive Test of Phonological
Processing
Kaufman Assessment Battery for
Children
Expressive and receptive vocabulary
tests
Ravens Standard Progressive
Matrices
Wechsler Intelligece Scale for
Children (also preschool, adult,
and nonverbal versions)
Woodcock Johnson Tests of
Cognitive Ability
Measures
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Visual-spatial
constructional
Learning and Memory
Beery Developmental Test of
Visual Motor Integration
California Verbal Learning Test
Clock Face Drawing Test
Rey-Osterreth Complex Figure
Test
Benton Visual Retention Test
Children's Memory Scale
Weschler Memory Scale
Measures
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Attention
Executive Function
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Continuous Performance Test
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Visual and verbal attention tasks
Behavior Rating Inventory of
Executive Function
Category Test
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Motor
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Finger Tapping Test
Delis-Kaplan Executive Function
System
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Grip Strength Test
NEPSY
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Grooved Pegboard Test
Stroop Color Word Test
Wide Range Assessment of Visual
Motor Abilities
Wisconsin Card Sorting Test
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Measures
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Academic
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Gray Oral Reading Test
Emotional/behavioral
functioning
Kaufman Test of Educational
Achievement
Behavior Assessment System for
Children
Wechsler Individual Achievement
Test
Conners' Rating Scales
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Woodcock Johnson Tests of
Achievement
Minnesota Multiphasic Personality
Inventory
Personality Assessment Inventory
Vineland Adaptive Behavior Scales
Attention-Deficit/Hyperactivity Disorder
Defined as a persistent pattern of inattention and/or hyperactivityimpulsivity that is more frequently displayed and more severe
than is typically observed in individuals at a comparable level of
development
Symptoms must be present before age 7, symptoms must be seen
in more than one setting, and must cause significant interference
in everyday functioning
Prevalence: 2-8% preschoolers, 5-10% children and adolescents,
4% of adults
Strong genetic component
Environmental factors: prenatal exposure to nicotine, exposure to
lead during early childhood, complications surrounding pregnancy
Neuropsychological deficits
Preschool
impulsivity, hyperactivity,
emotional-regulation,
noncompliance, inattention,
difficulty with interpersonal
relationships
Childhood
executive function, sustained
attention, distractibility, high
reactivity, hyperactivity,
impulsivity, emotionalregulation, noncompliance,
poor peer relations, academic
underachievement
Adolescence/adulthood
executive function
disorganization
planning
academic underachievement
sustained attention
poor peer relations
emotional immaturity
irritability
negative self-perceptions
aggression
sensation-seeking behaviors
increased risk for substance
abuse and antisocial
Interventions
Evidence-based
Inconclusive/Ineffective
Stimulant medications (e.g., Ritalin, Electroencephalogram biofeedback
Concerta, Adderall)
Traditional counseling approaches
(e.g., individual counseling, play
Behavioral parent training
therapy, cognitive therapy)
Medication plus behavioral
Academic interventions (e.g., peer
Behavioral classroom
tutoring, computer assisted
management/classroom
instruction)
modifications
Dietary modifications (e.g., elimination
Behavioral-focused treatment
of refined sugar, Feingold diet)
(social skills training)
Learning disabilities
Identified by:
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discrepancy between intellectual functioning and
academic achievement
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a pattern of strengths and weaknesses
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or a lack of response to intervention
Reading, mathematics, written expression
Genetic and environment causes
Reading Disability
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Deficits can include:
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Phonological awareness
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Automaticity of retrieval
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Processing speed
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Motor skills
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Language
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Memory
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Word recognition
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Reading comprehension
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Listening comprehension
Evidence-based practice for Reading Disabilities
Phonemic awareness
Explicit phonics instruction
Decoding
Orton-Gillingham
DISSECT: Word identification
strategy
Lindamood-Bell Reading
Paired reading
Earobics
Word building
Alphabetic skills
Stepping Stones to Reading
Ladders to Literacy
Daisy Quest
Vocabulary/comprehension
Story mapping
Strategy instruction
Reciprocal teaching
Graphosyllabic analysis
Fluency
Peer Assisted Learning Strategies in
Reading (PALS)
Oral repeated reading
Math disability
Deficits:
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Language
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Visual-spatial
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reading arithmetic signs, copying problems, placement of
numbers in columns
Learning and memory
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understanding directions in word problems
Recall of facts or procedures, visual-short term memory
Executive function
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Omission or addition of a step in the procedure, sequencing
steps, understanding mathematical ideas and concepts, shifting
between one operation and another, repetition of same number
Evidenced-based practice for Math
Disability
Early math skills
Middle school math
Mathematics Recovery
Cognitive Tutor Alegbra I
Number Worlds Program
Copy-Cover-Compare
Round the Rug Math
I CAN Learn Pre-Algebra and Algebra
Building Blocks
Metacognitive strategies
Computation
Saxon Middle School Math
Sequential direct instruction
The Expert Mathematician
Use of manipulatives
University of Chicago School Mathematics
Project
Mnemonic strategies
Self-monitoring and performance feedback
FAST-DRAW
Reciprocal peer tutoring
Autism Spectrum Disorders
Defined by deficits in social interaction, language and
communication difficulties, and restricted or repetitive
behavior patterns
4 to 6 per 1,000
Unknown etiology, thought to include both genetic and
environmental influences
Theory of mind
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Unable to understand the mental states of others
Weak central coherence theory
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Difficulty processing information, switching from details to
general concepts
Neuropsychological Deficits
Global decreased cognitive
Learning and memory
functioning with 40 to 60%
Rote memory intact, deficits in
below the average range (can
working memory
range from mental retardation
to superior intellect)
Processing speed
Language
Comprehension, expressive
skills, prosody, pragmatics
Visual-spatial
Difficulty with motor
components, speed of
processing, or memory
involved
Executive function
Disinhibition, perseveration,
impaired flexibility
Neuropsychological deficits
Emotional/behavioral
Imitation
Face recognition
Facial memory
Facial discrimination
Empathy, perspective
taking
Restricted interests, selfstimulating or self-injurious
behaviors
Attention
Hypervigilant and unable to
shift attention
Motor function
Perseverative or repetitive
behaviors, graphomotor
difficulties
Perceptual sensory functioning
Increased sensitivity
Evidence-based Interventions
Comprehensive
Treatment and Education of Autistic and
Related Communication Handicapped
Children (TEACCH) program
Learning Experiences and Alternative
Program (LEAP)
University of Colorado Health Science
Center (UCHSC)
Communication
Discrete trial training
Adult-directed teaching
Stereotypic behavior
Pivotal response treatment
Differential reinforcement
Social Interaction
Social stories
Video modeling
Peer-mediated training
Self-monitoring
Problem behaviors
Incidental teaching
Positive behavior support
Functional communication training
Risperdal
Picture Exchange Communication
System (PECS)
Inconclusive or Ineffective
Facilitated communication
Social skills training (generic)
Inclusive education
Punishment/overcorrection
Diet (gluetin or casein-free, nutritional supplements)
Auditory integration training
Sensory integration training
Haldol, Prozac, Ritalin, Concerta, Strattera
Traumatic Brain Injury
Penetrating/open
Object penetrates the skull (gunshot wound)
Focal injury, damage to surrounding tissue
Complications due to infection and hemorrhage
Closed
Brain undergoes acceleration/deceleration
Coup/countercoup injury, shearing of tissue, diffuse axonal injury,
swelling and pressure, miscroscopic lesions
Wide range of neuropsychological deficits
20,000 children have persisting disabilities from TBIs each year in US
Highest incidence is for males, age 15-24
Motor vehicle accidents, sports injury, falls, violence
Traumatic Brain Injury
Mild
85-90%
Limited or no loss of consciousness, headaches, dizziness, fatigue
7-30% experience persistent symptoms
Difficulties with social relationships, daily functions, emotional
functioning, and academic performance
Moderate to Severe
10%
Intracranial bleeding and hemorrhage, skull fractures, edema (swelling),
calcification (accumulation of calcium at sites of neuronal
degeneration) can obstruct blood flow
Impacts speech, motor function, cognitive functions
Neuropsychological deficits
Cognition
Attention and Executive function
Lower than controls
Sustained attention
Verbal is intact
Vigilance
Nonverbal and Processing
speed impaired
Planning
Memory and Learning
Inhibition
Metacognitive skills
Rate of learning
Behavioral regulation
Amount of acquired information
Set-shifting
Retrieval
Recognition
Working memory
Academic achievement
Across domains depending on
severity and type of injury
Neuropsychological deficits
Language
Psychosocial/behavioral
Expressive and receptive
Changes in personality
Recognizing the intentions of others
Agitation
Detecting sarcasm and humor
Impulsivity
Understanding nonliteral aspects of
story
Hyperactivity
Summarizing a story
Irritability
Interpreting metaphors
Word decoding speed
Reading comprehension
Emotional lability
Aggression
Anxiety
Depression
Conduct problems
Low self-esteem
Frustration over loss of skills
Withdrawal from others
Evidence-based Intervention
Family-centered rehabilitation (i.e., family
members involved in planning and
providing treatment)
Attention remediations programs (e.g.,
Amsterdam Memory and Training
Program for Children)
Educational or informational
interventions (e.g., providing
information to client/family about to
facilitate understanding of TBI)
Metacognitive Strategy Instruction
Ritalin, Concerta
General behavioral interventions
Functional analysis of behavior
Operant conditioning approaches
Contingency management systems
Positive behavior supports
Epilepsy
Seizure: sudden brief attack of motor, cognitive, sensory, or autonomic
disturbances that are caused by abnormal and excessive neuronal activity
in the brain
Epilepsy: Experience at least 2 unprovoked seizures (e.g., tumor, head
injury, infection)
5% of all children experience a seizure, 25% of those develop epilepsy,
Seizure types: generalized, localization-related, or undetermined
Ictal: seizure period itself, may last from 1 sec to 20-30 minutes
Postictal: period following a seizure
Etiology
Genetics, traumatic brain injury, environmental factors
Epilepsy
Generalized seizures
Loss of consciousness, rigidity with extension of extremities, rhythmic
contractions
Aura (abdominal discomfort, irritability, dizziness)
Complex partial seizures
Altered consciousness, changes in mood, cognition, memory, or behavior
Aura (sense of deja-vu or olfactory hallucinations)
Temporal lobe epilepsy: Associated with fear and rage, dissociative
symptoms (period of confusion, impaired memory, distorted sense of
time), automatisms (lip smacking, repetitive motor movements
Absence seizures
Momentary lapses of attention, automatisms, head drooping, eyelid
flickering
Neuropsychological deficits
Cognition
Age of onset, seizure control,
duration of disorder, seizure type
As a group don't differ from healthy
controls
Deficits tend to be specific rather
than global
Language
Associated with temporal lobe
epilepsy
Visual-spatial
usually spared except for myoclonic
or absence seizures
Learning and memory
Verbal and nonverbal memory
Short-term and long-term memory
Processing speed
Executive function
Cognitive flexibility and dishinibition
Attention
Motor skills
Gross and fine motor skills
Oromotor skills and articulation
Academic achievement
Neuropsychological deficits
Emotional/behavioral
Unclear if social stigma,
neuropsychological functioning,
or interaction is responsible for
difficulties
Social immaturity, poor social skills
Emotional lability
Anxiety
Depression
Negative self-esteem
Academic Achievement
Greater risk than other children for
demonstrating learning disabilities
Unclear how related (caused by
underlying brain dysfunction,
damage from seizures)
Evidence of lower academic
expectations by teachers
Chronic absences from school
More impairment in children with
generalized seizures
Temporal lobe epilepsy associated
with lower scores in reading speed
and comprehension
Evidence-based Intervention
Antiepileptic drugs
can have adverse effects
Surgery
Must fail on AEDs, can have
adverse effects
Prednisone
For cryptogenic epilepsies (LandauKleffner, Lennox-Gastuat
syndrome)
Vagus nerve stimulation
Ketogenic diet
High in fats, low in carbs
Strict diet, need to monitored
Biofeedback
Improved seizure control
Progressive relaxation strategies
Control for refractory seizures
Ritalin, Concerta, Strattera
Attention problems
Childhood Cancer
1 in 300 children under the age of 16
Most common types include: leukemias, brain and other nervous system
tumors, lymphomas (lymph node), bone cancers, soft tissue sarcomas,
kidney cancers, eye cancers, and adrenal gland cancers
Genetic and environmental causes have been identified: males more
frequent, family history of cancer, cured meat in the maternal diet during
pregnancy, pesticides, radiation
60-90% survive for 5 or more years
Treatment effects can cause cognitive decline
Direct and intravenous injection of neurotoxins
Radiation
Chemotherapy
Surgery
Neuropsychological deficits
Cognition
Not impaired initially but gradually
declines
Nonverbal reasoning may be
affected
Language
Vocabulary and comprehension
spared
Naming fluency/retrieval impacted
Visual-spatial
Usually impacted
Processing speed
Learning and memory
Short-term, working, verbal and
nonverbal memory affected
Recognition skills tend to be intact
Attention
Selective and sustained impacted
Executive functions
Sequencing, fluid abilities, problem
solving, and flexibility impacted
Evidence-based Interventions
Stimulant medications
Cognitive Remediation Program
Attention Process Training in
combination with brain injury
rehabilitation
Social skills training
Cognitive-behavioral therapy in a family
systems context
More effective if provide parents
with intervention
Teen Outreach Program
Survivor Health and Resilience Education
Surviving Cancer Competently
Intervention Program
Response-shift therapy
Reframing what is “normal” to
improve perceived quality of life
Specific Language Impairment
Developmental disorder defined by unexplained delayed language learning
in children with normal global intellectual functioning, hearing acuity,
and exposure
3 to 15% of children, often co-occurs with other disorders
Genetic influences
Environmental factors
Anoxia, perinatal infection, low birth weight, multiple ear infections
Specific Language Impairment
Types of language disorders:
Dysarthria: coordination of musclulature of mouth
Paraphasia: production of unintended syllables, words, or phrases
(i.e., pike instead of pipe)
Aphasia: difficulty articulating, comprehending speech, naming, or
repetition
Aprosodia: disorder of prosody, rhythm, emotional expression
Auditory processing disorder: deficits in recognizing patterns or
attaching meaning to auditory signals despite normal hearing
Neuropsychological Deficits
Verbal abilities
Language function
verbal fluency, prosody, pragmatics
Visual-spatial
mental rotation tasks
Learning and memory
Working memory, verbal memory,
visual-spatial memory
Processing speed
Motor function
Fine and gross motor skills
Achievement
Learning disability
Emotional/behavioral
Attention deficits, conduct disorder,
internalizing disorders,
aggression
Executive function
Metacognition, planning, problem
solving, self-regulation, setshifting, inhibition
Evidence-based Interventions
Phonological awareness
Reading
Explicit instruction
Fast ForWord
Parent-child shared reading
Phonemic awareness or
phonological processing
training
Computer-based
phonological awareness
training
Parent training
Hybrid language intervention
Mental imagery training