School Neuropsychology: Mind, Brain & Education
1 The Specialization of School Neuropsychology
REASONS WHY THERE IS A GROWING INTEREST IN SCHOOL NEUROPSYCHOLOGY
Recognition of the Neurobiological Bases of Childhood Learning and Behavioral
Disorders
Increased Number of Children with Medical Conditions that Affect School Performance
Past reviews of the literature reveal that LBW infants (infants born at less than
2500g) are at risk for neurosensory, cognitive/neuropsychological, behavioral, and
school/academic difficulties. Babies born prematurely exhibit neurodevelopment impairment,
the severity of which can vary significantly. For example, of babies born at 26 weeks, around
80% are likely to display some level of developmental delay or disability. About 34% will
show mild difficulties, 24% will show moderate problems, and 22% will experience severe
disabilities. The percentage of infants who have survived without neurodevelopmental
impairment increased 16% between 2000 and 2011. The advances in medical treatment and
care have led to better neurodevelopmental outcomes for infants born prematurely and with
LBW.
The advances in medical treatment and care have led to better neurodevelopmental
outcomes for infants born prematurely and with LBW. Younge et al. suggested that early
neurodevelopmental assessment is important for the timely identification of children at risk
for long-term neurologic impairment or developmental delay; however, early
neurodevelopmental assessment does not always reliably predict later functioning in
childhood. Many children will catch up to their peers by school age, whereas other children
will have persistent neurodevelopmental impairments. Conversely, some children without
signs of neurodevelopmental impairment in early childhood will have impairments that
manifest at school age. Prematurity and LBW should be considered as neurodevelopmental
risk factors and should be noted in developmental histories, and neurocognitive functions
should be monitored in the preschool and elementary years.
School neuropsychologists can play a major role in being the liaisons between the
school and the medical community, developing transitional/re-entry plans for school-aged
children returning to school after injury or insult, assisting with IEP (Individual Education
Plan/Program) development and monitoring, and general case management.
Increased Use of Medications with School-Aged Children
Polypharmacy in the treatment of childhood mental disorders may be appropriate for
four reasons: a) the child may have multiple distinct disorders for which there are different
and appropriate multiple medications, b) the symptoms of the disorder are only partially
treated with one medication, c) an additional medication is needed to reduce side effects of
the other medications, and d) in complex cases decisions to prescribe medications are
complicated by diagnostic uncertainty.
Increase in the Number of Challenging Educational and Behavioral Issues in the
Schools
Increased Emphasis on the Identification of Processing Disorders in Children
Diagnosed with SLD
, In the most recent version of the Individuals with Disabilities Act of 2004, the
definition of a SLD (specific learning disability) states: “a disorder in one or more of the
basic psychological processes involved in the understanding or in using language, spoken or
written, that may manifest itself in an imperfect ability to listen, think, speak, read, write,
spell, or do mathematical calculations, including conditions such as perceptual disabilities,
brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia” but does not
include “learning problems that are primarily the result of visual, hearing, or motor
disabilities, or intellectual disability, or emotional disturbance, or of environmental, cultural, or
economic disadvantage”.
The IDEA 2004 allowed states to move away from the use of discrepancy models for
the identification of SLD. One of the approved approaches for SLD identification is the
assessment of patterns of strengths and weaknesses (PSW) to determine the underlying
causes for an SLD.
THE NEED FOR NEUROPSYCHOLOGICAL ASSESSMENT IN THE SCHOOLS
Access to Neuropsychological Services in the Schools
Limited Usefulness of Some Neuropsychological Reports
Ideally, each school district should have access to a pediatric neuropsychologist who
would write reports that were both informative and educationally relevant and who would
consult regularly with educators and parents. Across the country, clinical neuropsychologists
are more plentiful than pediatric neuropsychologists, but most clinical neuropsychologists
are trained to work with adult populations, not school-aged children. A pediatric
neuropsychologist would typically be found working in a hospital or rehabilitation setting with
severely impaired children and generally would not have time for school-based
assessments. Therefore, access to neuropsychological services from a clinical
neuropsychologist for school-aged children is often difficult. Also, there is an obvious need
for more cross training between school psychologists and clinical neuropsychologists
(pediatric neuropsychologists included).
Summary: There is a documented need for neuropsychological services within the
schools. However, finding a neuropsychologist with an understanding of developmental
issues and the rules and regulations that guide educational practice is very difficult.
Traditional reports written by clinical neuropsychologists are often not very useful in the
schools. These reports tend to be too long and cumbersome, often describe the tests more
than the child, and often have recommendations not relevant for most school-based learning
environments. In addition, clinical neuropsychologists are not in a position to be held
accountable for evidence of the success or failure of interventions. School psychologists, on
the other hand, are directly responsible for outcomes and therefore are close at hand on a
daily basis to see the interventions through to fruition. School psychologists are ideal
candidates to broaden their competencies in neuropsychology to better serve educators,
children, and their families.
The Unique Contribution of School Neuropsychological Assessments
In general, neuropsychological assessments are the most comprehensive of
psychoeducational, psychological, and school neuropsychological assessments and often
encompass both the psychoeducational and psychological components. What makes school
neuropsychological assessments unique is the inclusion of more in-depth assessment of
individual neurocognitive constructs such as sensory-motor functions, attentional processing,
learning and memory, executive functions, and so on.
, School neuropsychological assessments are useful for:
1) Identifying processing deficits in a child that could adversely affect educational attainment
and the development of remediation and/or compensatory strategies to maximize the child’s
learning potential.
2) Describing a profile of a child’s neurocognitive strengths and weaknesses and relating
that information to the child’s learning and behavior in the school and home environments.
3) Documenting whether changes in learning or behavior are associated with neurological
disease, psychological conditions, neurodevelopmental disorders, or non-neurological
conditions.
4) Monitoring educational progress over time in children, particularly in children with severe
neuropsychological insults such as TBI.
5) Providing comprehensive assessment data that will increase the likelihood of success
with evidence-based interventions.
DEFINITION OF SCHOOL NEUROPSYCHOLOGY
“School neuropsychology requires the integration of neuropsychological and
educational principles to the assessment and intervention processes with infants, children,
and adolescents to facilitate learning and behavior within the school and family systems.
School neuropsychologists also play an important role in curriculum development, classroom
design, and the integration of differentiated instruction that is based on brain-behavior
principles in order to provide an optimal learning environment for every child.”
ROLES AND FUNCTIONS OF A SCHOOL NEUROPSYCHOLOGIST
CHAPTER SUMMARY
TEST YOURSELF
4 When to Incorporate Neuropsychological Principles Into a Comprehensive
Individual Assessment
COMMON REFERRAL REASONS FOR A SCHOOL NEUROPSYCHOLOGICAL
EVALUATION:
- High incidence neurodevelopmental disorders;
- A child with a known or suspected neurological disorder (e.g., traumatic brain injury
[TBI], acquired brain injury);
- Children with neuromuscular diseases (e.g., cerebral palsy [CP], muscular
dystrophy);
- Brain tumors;
- Central nervous system infection or compromise;
- Children with neurodevelopmental risk factors (e.g., prenatal exposure to drugs
and/or alcohol, low birth weight [LBW] and/or prematurity);
- Children returning to school after a head injury;
- Children with a documented rapid drop in academic achievement that cannot be
explained by social-emotional or environmental causes;
- A child who is not responding to interventions;
- A child with suspected processing weaknesses;
- A child with significant scatter in psychoeducational test performance;
, - Children with sports-related concussions..
High Incidence Neurodevelopmental Disorders
When a child is experiencing learning or behavioral difficulties, it is uncommon to
start with a neuropsychological evaluation. Typically, behaviorally defined
neurodevelopmental disorders such as intellectual disabilities, ADHD, and ASD are
evaluated using psychoeducational assessments. However, there are times when selective
neuropsychological measures can add to the understanding of these disorders.
Intellectual Disabilities (IDs)
IDs account for 6.92% of all disabilities in the US or 0.19% of the total student
enrollment. ID is defined as a permanent condition originating sometime between birth and
age 18. The child’s general intellectual functioning is significantly below average (roughly an
IQ of 70 or below) and the child has concurrent deficits in adaptive behavior. The need for a
neuropsychological assessment is rare when evaluating a child with an ID (only when
unusual performance for this group).
ADHD
An estimated children 2-17 years of age of 9.4% had received the diagnosis of ADHD
in 2016. The neuropsychological deficits associated with ADHD are inattention, poor
response inhibition and/or impulse control, and executive dysfunctions.
ASDs
About 1 in 68 children in the US has been diagnosed with autism. ASD is an
overarching term for previously separated forms of autism. Major diagnostic criteria:
1) Persistent deficits in social communication and social interactions;
2) Restricted, repetitive patterns of behavior, interests, or activities;
3) Symptoms must be present in the early developmental period;
4) Symptoms cause clinically significant impairment in social, occupational, or other
important areas of current functioning;
5) These disturbances are not better explained by ID (intellectual developmental disorder) or
global developmental delay.
Often impaired neuropsychological processes in children with ASD: EFs, attention,
WM, sensory-motor, and language.
Children with a Known or Suspected Neurological Disorder
! Children with a positive history of a head injury but that are not experiencing any
academic or behavioral difficulties should still be monitored: they can show adequate annual
yearly progress now, but they are at risk for future learning and behavioral problems (when
their brains mature and the academic demands of school become increasingly difficult).
Children with Past or Recent Head Injuries who are Having Academic or Behavioral
Difficulties
TBI or ABI: occurs when a sudden trauma causes damage to the brain. Closed head
injury: skull is not penetrated but force of blow causes damage; open head injury: an object
pierces the skull and enters brain tissue.
TBI is classified as mild, moderate, or severe, depending upon the extent of the brain
damage. Mild TBI symptoms include: no loss of consciousness or loss of consciousness for
1 The Specialization of School Neuropsychology
REASONS WHY THERE IS A GROWING INTEREST IN SCHOOL NEUROPSYCHOLOGY
Recognition of the Neurobiological Bases of Childhood Learning and Behavioral
Disorders
Increased Number of Children with Medical Conditions that Affect School Performance
Past reviews of the literature reveal that LBW infants (infants born at less than
2500g) are at risk for neurosensory, cognitive/neuropsychological, behavioral, and
school/academic difficulties. Babies born prematurely exhibit neurodevelopment impairment,
the severity of which can vary significantly. For example, of babies born at 26 weeks, around
80% are likely to display some level of developmental delay or disability. About 34% will
show mild difficulties, 24% will show moderate problems, and 22% will experience severe
disabilities. The percentage of infants who have survived without neurodevelopmental
impairment increased 16% between 2000 and 2011. The advances in medical treatment and
care have led to better neurodevelopmental outcomes for infants born prematurely and with
LBW.
The advances in medical treatment and care have led to better neurodevelopmental
outcomes for infants born prematurely and with LBW. Younge et al. suggested that early
neurodevelopmental assessment is important for the timely identification of children at risk
for long-term neurologic impairment or developmental delay; however, early
neurodevelopmental assessment does not always reliably predict later functioning in
childhood. Many children will catch up to their peers by school age, whereas other children
will have persistent neurodevelopmental impairments. Conversely, some children without
signs of neurodevelopmental impairment in early childhood will have impairments that
manifest at school age. Prematurity and LBW should be considered as neurodevelopmental
risk factors and should be noted in developmental histories, and neurocognitive functions
should be monitored in the preschool and elementary years.
School neuropsychologists can play a major role in being the liaisons between the
school and the medical community, developing transitional/re-entry plans for school-aged
children returning to school after injury or insult, assisting with IEP (Individual Education
Plan/Program) development and monitoring, and general case management.
Increased Use of Medications with School-Aged Children
Polypharmacy in the treatment of childhood mental disorders may be appropriate for
four reasons: a) the child may have multiple distinct disorders for which there are different
and appropriate multiple medications, b) the symptoms of the disorder are only partially
treated with one medication, c) an additional medication is needed to reduce side effects of
the other medications, and d) in complex cases decisions to prescribe medications are
complicated by diagnostic uncertainty.
Increase in the Number of Challenging Educational and Behavioral Issues in the
Schools
Increased Emphasis on the Identification of Processing Disorders in Children
Diagnosed with SLD
, In the most recent version of the Individuals with Disabilities Act of 2004, the
definition of a SLD (specific learning disability) states: “a disorder in one or more of the
basic psychological processes involved in the understanding or in using language, spoken or
written, that may manifest itself in an imperfect ability to listen, think, speak, read, write,
spell, or do mathematical calculations, including conditions such as perceptual disabilities,
brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia” but does not
include “learning problems that are primarily the result of visual, hearing, or motor
disabilities, or intellectual disability, or emotional disturbance, or of environmental, cultural, or
economic disadvantage”.
The IDEA 2004 allowed states to move away from the use of discrepancy models for
the identification of SLD. One of the approved approaches for SLD identification is the
assessment of patterns of strengths and weaknesses (PSW) to determine the underlying
causes for an SLD.
THE NEED FOR NEUROPSYCHOLOGICAL ASSESSMENT IN THE SCHOOLS
Access to Neuropsychological Services in the Schools
Limited Usefulness of Some Neuropsychological Reports
Ideally, each school district should have access to a pediatric neuropsychologist who
would write reports that were both informative and educationally relevant and who would
consult regularly with educators and parents. Across the country, clinical neuropsychologists
are more plentiful than pediatric neuropsychologists, but most clinical neuropsychologists
are trained to work with adult populations, not school-aged children. A pediatric
neuropsychologist would typically be found working in a hospital or rehabilitation setting with
severely impaired children and generally would not have time for school-based
assessments. Therefore, access to neuropsychological services from a clinical
neuropsychologist for school-aged children is often difficult. Also, there is an obvious need
for more cross training between school psychologists and clinical neuropsychologists
(pediatric neuropsychologists included).
Summary: There is a documented need for neuropsychological services within the
schools. However, finding a neuropsychologist with an understanding of developmental
issues and the rules and regulations that guide educational practice is very difficult.
Traditional reports written by clinical neuropsychologists are often not very useful in the
schools. These reports tend to be too long and cumbersome, often describe the tests more
than the child, and often have recommendations not relevant for most school-based learning
environments. In addition, clinical neuropsychologists are not in a position to be held
accountable for evidence of the success or failure of interventions. School psychologists, on
the other hand, are directly responsible for outcomes and therefore are close at hand on a
daily basis to see the interventions through to fruition. School psychologists are ideal
candidates to broaden their competencies in neuropsychology to better serve educators,
children, and their families.
The Unique Contribution of School Neuropsychological Assessments
In general, neuropsychological assessments are the most comprehensive of
psychoeducational, psychological, and school neuropsychological assessments and often
encompass both the psychoeducational and psychological components. What makes school
neuropsychological assessments unique is the inclusion of more in-depth assessment of
individual neurocognitive constructs such as sensory-motor functions, attentional processing,
learning and memory, executive functions, and so on.
, School neuropsychological assessments are useful for:
1) Identifying processing deficits in a child that could adversely affect educational attainment
and the development of remediation and/or compensatory strategies to maximize the child’s
learning potential.
2) Describing a profile of a child’s neurocognitive strengths and weaknesses and relating
that information to the child’s learning and behavior in the school and home environments.
3) Documenting whether changes in learning or behavior are associated with neurological
disease, psychological conditions, neurodevelopmental disorders, or non-neurological
conditions.
4) Monitoring educational progress over time in children, particularly in children with severe
neuropsychological insults such as TBI.
5) Providing comprehensive assessment data that will increase the likelihood of success
with evidence-based interventions.
DEFINITION OF SCHOOL NEUROPSYCHOLOGY
“School neuropsychology requires the integration of neuropsychological and
educational principles to the assessment and intervention processes with infants, children,
and adolescents to facilitate learning and behavior within the school and family systems.
School neuropsychologists also play an important role in curriculum development, classroom
design, and the integration of differentiated instruction that is based on brain-behavior
principles in order to provide an optimal learning environment for every child.”
ROLES AND FUNCTIONS OF A SCHOOL NEUROPSYCHOLOGIST
CHAPTER SUMMARY
TEST YOURSELF
4 When to Incorporate Neuropsychological Principles Into a Comprehensive
Individual Assessment
COMMON REFERRAL REASONS FOR A SCHOOL NEUROPSYCHOLOGICAL
EVALUATION:
- High incidence neurodevelopmental disorders;
- A child with a known or suspected neurological disorder (e.g., traumatic brain injury
[TBI], acquired brain injury);
- Children with neuromuscular diseases (e.g., cerebral palsy [CP], muscular
dystrophy);
- Brain tumors;
- Central nervous system infection or compromise;
- Children with neurodevelopmental risk factors (e.g., prenatal exposure to drugs
and/or alcohol, low birth weight [LBW] and/or prematurity);
- Children returning to school after a head injury;
- Children with a documented rapid drop in academic achievement that cannot be
explained by social-emotional or environmental causes;
- A child who is not responding to interventions;
- A child with suspected processing weaknesses;
- A child with significant scatter in psychoeducational test performance;
, - Children with sports-related concussions..
High Incidence Neurodevelopmental Disorders
When a child is experiencing learning or behavioral difficulties, it is uncommon to
start with a neuropsychological evaluation. Typically, behaviorally defined
neurodevelopmental disorders such as intellectual disabilities, ADHD, and ASD are
evaluated using psychoeducational assessments. However, there are times when selective
neuropsychological measures can add to the understanding of these disorders.
Intellectual Disabilities (IDs)
IDs account for 6.92% of all disabilities in the US or 0.19% of the total student
enrollment. ID is defined as a permanent condition originating sometime between birth and
age 18. The child’s general intellectual functioning is significantly below average (roughly an
IQ of 70 or below) and the child has concurrent deficits in adaptive behavior. The need for a
neuropsychological assessment is rare when evaluating a child with an ID (only when
unusual performance for this group).
ADHD
An estimated children 2-17 years of age of 9.4% had received the diagnosis of ADHD
in 2016. The neuropsychological deficits associated with ADHD are inattention, poor
response inhibition and/or impulse control, and executive dysfunctions.
ASDs
About 1 in 68 children in the US has been diagnosed with autism. ASD is an
overarching term for previously separated forms of autism. Major diagnostic criteria:
1) Persistent deficits in social communication and social interactions;
2) Restricted, repetitive patterns of behavior, interests, or activities;
3) Symptoms must be present in the early developmental period;
4) Symptoms cause clinically significant impairment in social, occupational, or other
important areas of current functioning;
5) These disturbances are not better explained by ID (intellectual developmental disorder) or
global developmental delay.
Often impaired neuropsychological processes in children with ASD: EFs, attention,
WM, sensory-motor, and language.
Children with a Known or Suspected Neurological Disorder
! Children with a positive history of a head injury but that are not experiencing any
academic or behavioral difficulties should still be monitored: they can show adequate annual
yearly progress now, but they are at risk for future learning and behavioral problems (when
their brains mature and the academic demands of school become increasingly difficult).
Children with Past or Recent Head Injuries who are Having Academic or Behavioral
Difficulties
TBI or ABI: occurs when a sudden trauma causes damage to the brain. Closed head
injury: skull is not penetrated but force of blow causes damage; open head injury: an object
pierces the skull and enters brain tissue.
TBI is classified as mild, moderate, or severe, depending upon the extent of the brain
damage. Mild TBI symptoms include: no loss of consciousness or loss of consciousness for
