Lecture 2 - Roles and Guides for the Pediatric Neuropsychologist

Question 1

List some of the Paediatric Neuropsychologist’s Roles?

Answer 1

MAIN: Identify deviations from expected patterns of development and to formulate a diagnosis and treatment plan based on this information

SUB-STEPS:

• Assessment of mental and behavioural abilities
• Identification of emotional/adjustment issues
• Formulation/interpretation of results within the context of background history, test scores, observations, emotional/adjustment issues, characteristics of the injury
• Communication of results implications and recommendations to child, family, health, and education professionals
• School (re) integration, determine level of support required
• Compensatory Strategies
• Make appropriate referrals (E.g., to services, health professionals)
• Reviews and ongoing support
• Development and implementation of rehabilitation/intervention programs

Question 2

What are the Aims of Paediatric Neuropsychological Assessment?

Answer 2

• Determine cognitive, behavioural and emotional impact of a known brain insult/disorder and make predictions about outcome
• Explore abnormal cognitive and/or behavioural and/or emotional presentations to determine underlying neurological processes
• Determine cognitive strengths and weaknesses for development of intervention plans
• Assist in the development of neuropsych interventions

Question 3

What information should a pediatric neuropsychologist gather?

Answer 3

• Medical history
• Birth and developmental history - Including through pregnancy (and drug use or illness during pregnancy)+ When did they sit, crawl, walk, use word combinations
• Educational history - how many schools have they been to e.g., lots of schools, disrupted schooling, loss of friendship
  + skipped grades?
  + Interventions they have had, strategies used that have worked or not worked
  + School reports (though these are often phrased very positively)
• Background history
  + self
  + family, family structure, do siblings have any issues?
  + social context
• Psychosocial contest
  + stressors
  + parental acceptance of child’s disability?
  +family functioning, resources
  + e.g., is the family not very structured - will that work for the child?

* Current concern
\+ whats the family/parent concern
\+child’s concern
\+ other professional
\+ school concerns
\+ consensus? or different perspectives?
\+ Current performance
\+ How do the results fit in with all of the above?

Question 4

As a clinical pediatric neuropsychologist, from what sources might i collect information from?

Answer 4

• Medical records
• Reports and reviews
• Questionnaires - e.g., child behaviour checklist is a good broad screening tool + BRIEF is also good for day to day executive functioning
• Interviews - face to face or phone; Talk to teachers if possible - really try for this one!! will get lots of information and lots of different perspectives from different environments.
• ALSO ASK THE CHILD - need to know how they feel and what motivates them, particularly when it comes to intervention.

Question 5

What factors do you need to consider when selecting tests for pediatric assessment?

Answer 5

• Some of the tests don’t span a wide age band, resulting in the need to administer different tests to different age groups and different ability levels

When choosing tests you need to consider:
* Referral question

• Areas of concern (but also consider likely strengths, as these can be utilised to overcome weaknesses)
• Putting concerns into context
• Child’s age (and attention span!, minimise tests and maximise information)
• Potential ability level and likely impairments
• Availability of normative data
• Disabilities (e.g., physical, sensory)
• Prior assessments

Question 6

What preparation is essential before assessing a child?

Answer 6

• Choose appropriate tests in advance
• Have a checklist of tests to administer
• Have all forms ready in a folder
• Have tests and equipment by your side
• Be prepared to be flexible!!!

Question 7

What are some general tips when interacting with children?

Answer 7

• Establish rapport
  + Get WRITTEN permission from parents to talk to the school., ask about information they would prefer you did not mention.
  + answer what you can to the child, that the child asks about or is interested in.
  + can ask child to draw while talking to parents or use play to make assessment more fun - can use this to make some assessment qualitatively of fine motor etc
  + NEVER SAY YOU WILL BE DOING IS ‘FUN GAMES” say that they are tasks, some easy some hard.
  + Clear up misconceptions e.g., no needles….etc
• Show respect; DON’T BE PATRONISING
  + Communicate with child, get down to their level
  + Validate their experiences/feelings (e.g., you look frustrated)
  + Let them know if tasks are not being timed (or are being timed) …maybe say ‘i’ll tell you when it is being timed’
  +Might takes anxious kids a while to separate from their parents (can get mum to leave handbag or hand keys); and mum could sit near by and can tell the child that you will go check on mum - it is normal to be able to separate by 4.
  +If parents MUST stay in the room - give instructions (no speaking, stay out of sight of child, don’t intervene even with behavioural issues etc) - debrief parents afterwards (give them a clipboard and a pen to write down any questions they have)
• Don’t give feedback (unless instructed by test manual)
  + BE AWARE - some parents don’t want children to know diagnoses etc
  + START by asking the child what mum/dad has told them about today.
  + Can ask parents before giving feedback, how they would like to give the feedback to the child.
• Be aware of subtle hints you may give
  + e.g., singling they got something right or wrong.
• Use positive reinforcement for effort “good work you tried really hard on that one” (or bribery e.g., stickers)
  + of they stop during a task to talk say something like “thats really interesting, lets talk about it when you finish what you are doing”
  + Can be helpful to make it concrete ‘we are going to do 3 more tasks and then have a break”…draw down 3 circles and say we will tick of a circle for each task we finish.
• Remain sensitive to their energy levels, motivation and mood (e.g., fatigue) - verbally acknowledge a child’s reactions
• Intersperse difficult/easy tasks
• Administer most important tasks early on
• Smooth transition between tasks
• Don’t rush
• Remain calm at all times

Question 8

What should you make note of (observations) during assessments with a child?

Answer 8

• Physical appearance
• Social and emotional maturity
• Language and communication
• Activity levels
• Mood
• Motivation/cooperation
• Attention
• Behaviour
• Fine and gross motor skills

Question 9

Is it OK to be firm and reschedule the assessment if the child is unwell or uncooperative?

Answer 9

YES. Don’t be afraid to….
* Be firm - you must remain in control

• Terminate/re-schedule the assessment if things aren’t working e.g., unwell or uncooperative
• Use positive reinforcement

Question 10

What are some Tips for assessing ‘Resistant/Aggressive’ Children?

Answer 10

• Sit yourself closest to the door
• ‘Lock’ the child in place
• Remove large/heavy objects from the room (these can be thrown)
• Be consistent with feedback regarding what is and is not appropriate
• Inform someone that you’re testing a potentially aggressive patient and don’t choose an isolated testing room
• Have time out if the child’s frustration escalates

Question 11

What are some Tips for assessing ‘Distractible/Hyperactive’ Children?

Answer 11

• Be quick and organised
• Remove distractions
• Don’t have extraneous materials on the desk
• Use lots of verbalisations
• Use their name
• Use a loud, animated voice
• Use verbal and/or physical redirection
• Keep instructions brief
• Lock’ the child’s chair in place
• Role model – ignore distractions yourself e.g. people talking in corridor

Question 12

What are some Tips for assessing ‘Withdrawn/Avoidant’ Children?

Answer 12

• Will need longer to gain rapport
• Address child’s concerns/eliminate false beliefs
• Start with an easy task or game
• Create a tone of positive enjoyment and challenge
• Praise effort throughout – *positive reinforcement/encouragement
• Reassure that it is normal to make mistakes
• Say it is not a test, no pass or fail
• Alternate easy and difficult tasks