Peeling Back the Onion: The Value of a Neuropsychological Approach to Assessment

Neuropsychological assessment has historically been the province of evaluating individuals with some kind of brain trauma. However, in recent decades, the value of understanding cognitive processing skills and executive functions and their links to instructional practices for students has been acknowledged. In fact, academic subjects are considered to be byproducts of groups of cognitive processes that are necessary to learn and perform successfully in each subject area such that there is an arbitrary dividing line between the subjects and the brain processes themselves. In essence, the cognitive processes are the subjects.

A comprehensive evaluation of these processes implicated in learning and learning disorders includes assessing seven broad abilities and many more narrow abilities that are part and parcel of each skill area. It is essential to understand the part the different narrow abilities play in each ability domain in order to avoid making incorrect assumptions about students’ strengths and weaknesses. For example, an important broad ability, crystallized intelligence, measured by the WISC-V and required in reading, solving math problems, and generating narrative writing, is comprised of tasks that involve both the retrieval from long term memory of already acquired word definitions and identifying commonalities between dissimilar objects or ideas (i.e. concept formation). While each is part of this broad ability, each is also a very different skill. Consequently, if students score well when retrieving word definitions, but perform much less well in forming abstract concepts, then the overall broad ability score must be interpreted in this context. That is, if the overall ability score is Average because the scores on each task are combined, this does not necessarily mean that the student has Average crystallized intelligence. It may mean that a student has good rote recall, but weak abstract reasoning. Combining the scores masks the deficit. Peeling back the onion by differentiating between concept formation, an abstract reasoning skill, and long term recall, gives teachers and parents a roadmap about how to address students’ weaknesses by tailoring the approach to each student’s learning profile of cognitive processing strengths and weaknesses.

It is of equal importance not to omit assessment of any one of the broad ability areas. For example, many students who have difficulty reading suffer from dysphonetic dyslexia, a disorder of phonemic awareness where they are unable to decode or make connections between letters and sounds. Yet, there are some students whose decoding is not the issue. They may experience orthographic or surface dyslexia where they are unable to visually recognize the shapes and contours of letters and sounds or retrieve them from long term memory. Remember, reading begins visually although encoding happens phonetically. Students with undiagnosed surface dyslexia may unknowingly be prescribed a reading approach to correct a decoding problem rather than the difficulty with orthographic processing, resulting in rising frustration.

A competent neuropsychological evaluation will ferret out the subtleties that lie in the various narrow abilities that comprise each broad ability area. Most importantly, once the pattern of strengths and weaknesses is known, interventions can be targeted at the areas of deficit and utilize the areas of strengths to compensate. For professional evaluators, teachers, and parents, it is essential to understand before you do. Peeling back the onion may mean conducting either additional or targeted assessments to the areas suspected of being at the root of a learning problem. This kind of assessment approach, called cross battery assessment, is also individualized as it follows the principle of one size does not fit all. Peeling back the onion involves testing in the suspected area until you understand where the obstacles exist. Stopping the assessment prematurely may result in missing important information or clouding the interpretation of testing results.

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Let’s Make NJMTSS a Success

86713_5_80x100Coming in January, 2018, the state DOE will be pushing out its’ Multi-Tiered Support System (NJMTSS) initiative to bolster efforts to support ALL students.

It will be essential to infuse MTSS with a theoretical framework that will provide teachers, child study teams, and administrators with a way to understand how students learn and what obstacles block their learning and performance. The Cattell-Horn-Carroll (CHC) principles are our best science about the kinds of cognitive processing skills that are necessary to read, write, and do math. CHC posits that academic subjects are byproducts of these cognitive processing skills. When paired with the Pattern of Srengths and Weaknesses (PSW) method of assessing students’ cognitive processing and executive functioning profiles, a roadmap can be created to tailor a specific plan to address weaknesses and highlight strengths. Teachers, in particular, need a way to understand why students are having trouble reading, solving math problems, and generating narrative writing. CHC and PSW provides a way to create individualized educational plans tailored to each student’s needs.

I, along with members of for professional groups in NJ-the NJ Psychological Association, the NJ Association of School Psychologists, the NJ Association of Learning Consultants, and the Learning Disabikuty Association of NJ-have been working hard to spread the word by sharing what we know. We are training child study team members, teachers, and interested administrators. If you have an interest in learning more about CHC and PSW and how it can help your school team or increase your knowledge base, feel free to contact me.

let’s get a jump start on making NJMTSS a success to support all of our students.

Academic Anxiety and Keeping Kids Safe at School

Feeling safe at school involves much more than providing a physically safe environment. Kids need to feel safe academically as well. Over the last decades, increased academic demands-particularly those that do not take into consideration the basic facts about child development-result in placing pressure on students to perform tasks that they are not yet ready to do. A prime example of this is the pressure kids and parents experience regarding the need to read in kindergarten. While some children are ready to read, others require the gift of time. Yet, being unable to read or read fluently sends up red flags that propel teachers to have children sent for extra help, to be evaluated, and, even more significantly, to reflect back to kids either verbally or nonverbally the sense of worry about them being unable to master the skill of reading. While some children could benefit from these interventions, others simply have not acquired the requisite cognitive processing skills to achieve to classroom expectations. Another example of this is giving kindergarten children a multi-step directive after a read aloud that asks them to return to their seats, and write a story with a beginning, middle, and an ending! This task is way beyond most students this age and developmental level.

When kids feel unable to achieve mastery, they do not feel safe. School becomes a place where they feel worried and feel less than the peers who have been able to do things that they are not yet able to do. Pressures placed on teachers to have their students score well on standardized tests add to the sense of worry and pressure as they, too, do not feel safe with regard to their own evaluation as educators. For kids, school is their job. Adults know what it is like to report to a job each day that they do not like or one in which they feel they are underachieving. This is the same kind of feeling induced in kids. Worrying about being unable to do the homework or complete a worksheet in class induces in children a feeling of vulnerability.

Many years ago, Dr. David Elkind, a Harvard psychologist, wrote a book entitled, “The Hurried Child,” warning of the dangers of exposing children to stimulation that they are not yet able to developmentally digest. Just like giving an infant solid food before they are ready, students who are pressured to perform tasks that they are not yet ready to do will “spit” it back at us in the form of a wide range of behaviors, including withdrawal, oppositional behavior, anxiety, or even school refusal. Feeling afraid to say or do something at school because the stimulation in the form of academic pressure for mastery is developmentally overwhelming turns kids off to school and learning, worries parents and teachers, and can lead to any one of a number of non-constructive consequences. Self-esteem dips and worry can morph into sadness or depression. The kind of excitement and curiosity school is supposed to foster in students gets lost in the dust of the push for achievement no matter the cost.

This situation leads to schools producing learning and behavioral problems in school instead of a sense of safety and enthusiasm for learning. Add to this exposure to environmental stimulation in the media (i.e. see the classic study from the American Psychological Association about the effect of viewing TV violence on children) and technology that brings all kinds of overstimulating material directly into our homes and schools, and it is easy to understand how young children are developing a sense of worry at greater rates than we have seen before.

As adults, our primary job is to monitor and filter the stimulation to which our children are exposed in order to keep them safe. Technology and the well-meaning push for academic achievement have added to the burden of fulfilling this task. Nevertheless, it is adult’s prime directive when it comes to the children in our care.

Cognitive Behavior Therapy and Emotional Communication: A Necessary Marriage

While the prevailing evidence in the professional literature is that cognitive behavioral therapy is the gold standard in addressing problems like childhood anxiety disorders, the eminently reasonable principles of exposure and response prevention should be accompanied by what we know about emotional communication. That is, behavioral symptoms and the resistances to changing behaviors, even those that are not productive like compulsive actions or obsessive thinking, not only serve as the individual’s best attempt to cope, but also give us clues as to how to address them if only we take the time to decipher them.

For example, children who feel compelled to follow a ritual or have negative automatic thoughts that take a simple worry and transform them into huge fears, will be initially reluctant to give up these unproductive behaviors until they are convinced that they do not need them anymore. Meeting kids where they are-i.e. joining them-is the essential first step in rendering resistances to change no longer necessary. Here is an example in a case of selective mutism: the anxiety driving the resistance to not speaking must be respected by not pressuring the child to speak. Joining involves acting like the old sportscaster, Howard Cosell, and just broadcasting/describing what a child is doing with no questions asked. In this way, the child feels implicitly understood. The next step may be to ask forced choice questions that can be answered verbally by a yes or no or a nod of the head. In this way, we slowly scale the mountain of steps necessary to facilitate speaking. Joining or describing or mirroring are considered emotional communications-i.e. communications that help a child move progressively forward. Another important tool is object oriented talking. Here, we again take the focus off the ego (i.e. the child) by placing it elsewhere. This is an important emotional communication that can be powerful when applied correctly. For instance, if a child is not mastering an academic task at school, the emotionally responsive teacher may put the focus on herself/himself by asking about what he or she can do better to explain the work, assigning primary responsibility for the child’s lack of progress on the teacher.

The psychotherapy literature has long held that whatever approach is used, the relationship is the key. After all, why should anyone make themselves vulnerable by giving up a familiar albeit unproductive behavior if they do not feel that the person proposing such a change understands and listens to them? So when constructing a hierarchy of behavioral steps with the goal of extinguishing a behavior, it is important along the way to always be consulting with the child about the plan so it is a cooperative effort. I have found an important missing step is to inquire about how a proposed plan will fail before implementing it as this will yield important information before operationalizing a strategy. Making the child a partner, even if he or she is a reluctant partner, goes far in reaching the desired goals.

Training Teachers to Understand the Links between Cognitive Abilities and Learning Difficulties

            Teachers can greatly benefit from the advances in our knowledge about the connections between cognitive processing abilities and instructional strategies. Without this kind of framework to understand students’ learning problems, it is very difficult to craft an individualized learning strategy that targets the areas of deficit.

I have talked with many teachers who are working hard to understand why students in their classes are not learning. For example, many students experience problems in generating narratives. These difficulties can result from any one or more of a group of cognitive processing deficits. Specifically, students’ productivity can be affected by ability difficulties in generating adequate verbiage. This kind of problem is common in students who were not readers and did not accumulate a solid reservoir of vocabulary to use in oral or written language. However, producing narratives can be influenced by either difficulties in retrieving acquired/already learned information from long term memory or being unable to retrieve the information quickly enough. Either of these difficulties can result in the same productivity problem. Yet, in trying to fix the problem, you need to know which of these deficits are implicated and target your remediation efforts to the specific areas of deficit. Otherwise, you could be remediating the wrong area.

Similarly, I have talked about how a lack of knowledge about how to break down academic tasks into the cognitive processing skills that comprise them can lead to misdiagnosing the problem. For instance, a student who struggled to activate himself to produce a narrative was asked by the teacher to produce not only a greater quantity of verbiage, but also a qualitatively more sophisticated piece. The teacher did not realize that the student suffered from a shortage of adequate vocabulary because of reluctance to read over the years. The student also had a deficit in fluid reasoning, a skill that involves inferential thinking. Consequently, going beyond concrete writing was extremely difficult. Asking the student to produce in two ability areas in which he was deficient morphed into a behavioral problem.

Knowledge of the ability areas and the executive functioning skills that mediate the connection to these abilities can help teachers to understand and remediate learning difficulties and give them a framework that will inspire a sense of mastery and confidence in working with students with learning difficulties.

Living on the Edge: Emotional Attunement and Working with Kids

In the recent movie, “The Edge of Seventeen,” Woody Harrelson plays a teacher who, while eating lunch, finds himself face-to-face with one of his adolescent students who just wanted him to know that she planned to kill herself. Undaunted by this announcement, he states that he was just writing down a list of reasons about why he should do the same!

In this cinematic moment, Harrelson was actually demonstrating several fundamental principles of working with children and adolescents. First, he controlled his own emotional responsiveness to this student’s announcement instead of panicking, and second, he joined with her (and actually heightened the absurdity of the situation) to give her the impression that he was more like her. Both actions (not recommended for the pale at heart) resulted in taking the wind out of the student’s sails, and she acknowledged that she really wanted some attention and someone with whom to speak. Granted, his behavior was risky; however, he knew the student’s penchant for drama, and decided to exercise emotional attunement as a way of addressing her needs.

Children and adolescents, in particular, often present their parents, teachers, and therapists, with outrageous statements and behaviors meant to induce in them feelings to help them understand how they are feeling, and, in some instances, to test them to see if they can tolerate their emotional state. While all statements from kids need to be taken seriously, the key to working with them is to first be able to tolerate the emotions they are communicating long enough to understand them without having these propel you into actions that merely diminish your own discomfort while doing little for the kids who were making their best effort to communicate with you. This is not an easy task. It is similar to being a boxer who is challenged by a fierce heavyweight and needing to find a way not to go down after the first punch.

In this age of direct and faster therapeutic approaches, it must be remembered that the professional literature is in agreement that the most important ingredient of successful therapy is the establishment of a therapeutic alliance. Without it, there is no leverage-i.e. no reason for  child patients to allow themselves to be constructively influenced by you. The same process holds true for parents who are feeling frustrated by their kids. Unless kids feel that someone else is willing to hear their story, tolerate the emotions conveyed, and understand how to be accurately emotionally responsive (i.e. to determine what specific response is needed), they are unlikely to feel that the parent or therapist or teacher is the “right” one to be trusted with their innermost secrets.

Although it is certainly easier to do this in a movie when nothing is at stake, when it is your child or student, the stakes are higher. Learning how to be emotionally attuned and to be accurately emotionally responsive can be learned and a good therapist can teach it. Practicing these principles is like planting the seed that can grow into future successful encounters with your kids.

Screening for Dyslexia: What Dyslexia is and How to Assess It

86713_5_80x100            One of the most frequent questions I am asked is, “Can you perform a dyslexia screening?” While I evaluate children, adolescents, and even adults for the presence of dyslexia, it is important to be clear on the definitions of both dyslexia and screening.  Screening implies a brief assessment; however, dyslexia is a complex disorder comprised of ability and executive functioning deficits and any effective evaluation must test for each of these domains.

First, let’s define dyslexia. Dyslexia is a developmental disorder that is characterized by deficits in the cognitive processing areas of crystallized ability and auditory processing. These deficits are manifested by slow and labored reading, difficulty retaining letter-sound associations and decoding words, problems with spelling, trouble recognizing the shape and contours of letters and words, poor memory for and retrieval of learned words, low motivation for reading. Although some dyslexic individuals can understand what was read by using compensatory strategies like context clues, reading comprehension can be impacted because so much energy is devoted to decoding and storing words that processing is slowed and the main ideas are lost. Those individuals who have the added burden of a deficit in another ability area called fluid reasoning have more problems with comprehension because they do not have the capacity for higher order critical thinking. Executive functioning weaknesses manifested in dyslexia may include problems with verbal fluency (i.e. generating words), visual search and scan skills, short and long term memory, poor planning and organization (i.e. in written expression), and trouble with task completion.

Second, screening, according to Dr. Steven Feiffer, one of the leading authorities on dyslexia, recommends that screening should include testing for each of the deficit areas. He suggests a 90 minute screening that involves testing for: intelligence, phonemic awareness, rapid naming, verbal memory , reading fluency, orthographics, attention, executive functioning, and family history. It is important not to omit testing for any of these areas because there are different types of dyslexia. While many people think of dyslexia as a decoding problem (i.e. dysphonetic dyslexia), some individuals can effectively decode, but are unable to recognize by sight the way letters and words look (i.e. surface dyslexia). Moreover, others have both problems (i.e. mixed dyslexia).

Accurate assessment of the deficit areas is essential because instructional strategies must be targeted to these problems. That is, if an individual’s weakness is in orthographics, the visual recognition of letters and words, remediation that focuses on phonemic awareness will miss the mark. This is why screening should not be short sighted. It must touch on each of the above areas.