Jacqueline Kaufman, Ph.D.
Department of Physical Medicine and Rehabilitation
University of Michigan Medical School
What I hope you get out of this

 A clear picture of the processes of
neuropsychological and psychoeducational testing
 Common pitfalls and barriers to fair and valid
testing for children with speech or sensory deficits
 How to be critical evaluators of test results both
internally and from outside sources of reports
 How to create access and reduce barriers for more
severely impaired children
 Practical matters related to educational planning for
children with speech/hearing challenges.
Psychologists
 A psychologist typically has a masters or
doctoral degree (PhD or PsyD). A
psychologist has studied how the brain
works (to varying degrees) and how this
affects the way a person thinks, acts or feels.
 School psychologists help children and
youth succeed academically, socially,
behaviorally, and emotionally. They
collaborate with educators, parents, and
other professionals to create safe, healthy,
and supportive learning environments.
What does a school
psychologist do?

 Provide counseling, instruction, and mentoring for those
struggling with social, emotional, and behavioral problems
 Increase achievement by assessing barriers to learning and
determining the best instructional strategies to improve
learning. May involve identifying and addressing learning
and behavior problems that interfere with school success
 Evaluate eligibility for special education services (within a
multidisciplinary team)
 Support effective individualized instruction
 Create positive classroom environments
What is a neuropsychologist?

 A neuropsychologist is typically a psychologist
who has additional training and experience in
understanding brain-behavior relationships
including functional neuroanatomy,
neurophysiology and medical conditions
affecting the brain and/or development.
 A neuropsychologist usually works with
psychiatrists, neurologists, neurosurgeons,
physiatrists and other medical specialists as a
team to coordinate a patient’s care. In the
academic setting they are frequently
researchers too.
Neuropsychology testing is a way
to “look at” the brain

 Studies the brain by evaluating behavior and cognition as the
output.
 Behavior measured in multiple ways with very
comprehensive evaluation (e.g. multiple tests along multiple
domains, surveys, direct observation, etc.).
 NP evaluations must evaluate function using a multidimensional approach.
 Also must consider factors such as age, gender, previous
illness, psychological status, etc. in evaluating brain function.
5y/o with trapped right lateral ventricle w/severe hydrocephalus, s/p fenestration.
Average to high average IQ, no deficits in neuropsych or behavioral functioning.
Measuring Behavior

Intellect (IQ)
Attention
Executive functions
Memory
Verbal functions
Visuoperceptual, visuospatial and visuoconstructive skills
and abilities
 Academics
 Motoric functions
 Psychological/behavioral
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Why have neuropsych testing?

 School psychologists will ideally conduct thorough psychoeducational
assessments looking at intellect and learning disability concerns.
 The focus of a psychoeducational evaluation is qualification for special
education, NOT identification of disability.
 Although some have added training, school psychologists are
traditionally not trained extensively in medical psychology and may
not know the details of the broader subset of disabilities.
 For children with various medical conditions and/or complex
developmental histories, basic IQ and academic testing often misses
the crux of the child’s needs or worse, mislead those parties making
treatment and placement recommendations*.
*The population of children who are deaf/hoh are at particular risk for both of
these concerns.
Why have neuropsych testing?

 Neuropsychologists, particularly in a medical center often
have specific expertise in complex medical conditions.
 Many conditions have expected profiles.
 Some conditions are great imitators; need experience with
these differentials (e.g. ADHD vs. sleep apnea, anxiety, low
iron)
 Testing in the school setting rarely covers topics such as
attention, memory, and executive functioning.
 School based testing often relies on hard ‘cutoffs’ rather
than multi-domain profile based diagnostics and decision
making; (domain score variability, more impaired
children may benefit from review of raw instead of
standard scores, fxnl performance, etc.)
What are some less certain
things with testing?

 Although we can often get quick/dirty measures of intellect and
academics with children who have signficant hearing/speech concerns,
this can be complicated.
 There are often suggestions and/or recommendations based on
cognitive findings that must be coordinated with suggestions from
audiology and SLP.
 Is sign/spoken language/total communication/other recommended?
 What is the prognosis for improvements in language? In learning? In
cognition?
 Which class setting is best for this child? HI-self contained? General
education? Partial mainstreaming? Other?
An ideal neuropsychologist working with children who are D/HOH will recognize
that these suggestions cannot happen in a vacuum; a holistic approach with good
communication is key!
What does the testing
look like?

Intelligence Measures
1) How are a seatbelt and a helmet alike?
2) What is a bird?
3) Why do we put on shoes before leaving the house?
A
B
?
C
D
Modifications to testing for
children who are D/HOH

 When possible, at least a brief nonverbal measure of intellect is
administered (e.g. Leiter, C-TONI)
 Risk for biases of exposure to language, even though nonverbal test
 Doesn’t test language skills (and school involves language!)




Sign language interpreter (how do we ask to identify shapes?)
Modification of instructions to include demonstration
Standard administration followed by testing of limits
Consideration of using raw scores instead of standard scores
(accounting that tests not developed for D/HOH)
 Using testing as baseline and monitoring rather than being slave to
standard scores
 Teaching of tests – teachable? Able to learn through example?
Pitfalls for inexperienced school
psychologists and neuropsychologists

 May observe oral communicator and assume no need for sign
interpreter. Alternatively, may assume allowing child to read
instructions is sufficient accommodation (it’s not ).
 Assume that because person can lip-read sufficiently in
conversation that oral based testing is valid.
 May believe if person adequate with oral skills then ok to test
orally even though primary language is sign.
 Using an interpreter for signers is important, though
inexperienced school/neuropsychologists may not recognize
that syntax and grammar are different.
 Many signs ‘give away’ the answer (e.g. “show me your nose”
or “which is the square?”); may not recognize these limitations
of traditional testing.
 Those with NVLD may test as cognitively impaired, and those
with language disorders may be overlooked if only using
nonverbal measures of ability.
Factors for consideration in neuropsych
testing (Hill-Briggs et al., 2007)

 Age at onset: was it early or late onset? Is it static, fluctuating or
progressive?
 Cause: genetic, acquired (high dose antibiotics), syndrome,
illness, unknown? This impacts how the disability looks and
how tests are interpreted
 Severity: mild/mod/sev/prof. Determines which tests we use,
response format.
 Aiding: HA, CI, other? When started, frequency of use, benefit?
Determines modality/format for testing.
 Primary communication mode: oral/ASL/total/MSE/cued?
Influences tests administered and may influence familiarity with
cultural exposure assumed in some tests.
 School setting: mainstream, dayschool, residential, HI, gen-ed?
Cultural information and exposure.
Common neuropsychological
observations and risks

 Mean nonverbal IQ for kids who are D/HOH w/o comorbid
conditions avg range; with one additional condition - low avg
 The same as hearing, IQ performance is in part a function of
access to education, and deaf children without educational
access will further have lower IQ. See also in cases of neglect.
 Native signers (deaf and hearing) appear stronger at visual
rotation skills than non-signers.
 Serial STM span skills lag more frequently in children with
HI; may be related to rehearsal strategies.
 Increased risk for sequencing problems (motor, visual-spatial,
verbal); could affect reading independent of language.
Reading Attainment

 Median reading level of deaf high school students (ages 1721) is grade 4 (half above/half below this).
 Predictors of success with reading include:
 Above average nonverbal IQ
 Educated/professional parents
 Early involvement with special education services (at or
before preschool!)
 Stronger spoken OR sign language skills; factors that
promote language comprehension aid in reading
acquisition.
 Remember – individuals who are D/HOH can also have
unrelated learning disabilities such as dyslexia! What’s
family history? Don’t get caught up in the D/HOH only.
Emerging literacy with CI
(Nittrouer et al., 2012)

 Nittrouer and colleagues (2012) studied a group (n=27) of children with CI
at the end of their kindergarten year to evaluate emerging literacy skills.
 Specific skills examined included phonological awareness, oral language
skills, and early executive functioning skills.
 Found that children with CI performed approximately 1 SD or more below
TD kids on all measures except reading fluency, speeded naming, and
syllable counting.
 Age of first implant was a significant predictor of success as was some
exposure to bimodal stimulation.
 Even for children who received early ID and treatment with implant there
was greater risk for literacy delays.
Requirements for optimal
literacy?

 Phonological processing – what is the correspondence between
the letter on the page and the sound it makes? Appears that
kids with CI have an edge over their non-implanted d/hoh
peers but not equal to hearing peers.
 Understanding of complex language patterns (e.g. figurative
language, complicated syntax, inference drawing in language,
grammar)
 Spelling skills ideally are strong. Children who have d/hoh
generally have weaker spelling.
 Stronger vocabulary skills are important for good literacy skills.
Prelingual deafness tends to be associated with poorer weaker
vocabulary skills.
Literacy in CI users

 There appear to be long term benefits for early CI users
on the development of literacy skills. Earlier implantation
is associated with better literacy outcomes.
 Stronger visual-perceptual reasoning skills appear to be
good predictors of literacy development in CI users.
 We see related issues in hearing peers; children with visualperceptual delays are later adopters of reading due to the
early visual-perceptual hump of learning letter sounds.
 Importantly, for any child with hearing loss, among the
chief predictors of reading acquisition is the presence of a
language (sign or spoken).
(Unfortunate) trends from the field

 School diagnoses child as cognitively impaired because does




poorly on standard IQ testing – want to put child in CI class.
School testing puts everything on hearing and fails to explore
other explanations (e.g. ADHD, dyslexia, behaviour, etc.)
Child isn’t given enough time after aiding or with services to
“prove” themselves before tracked out of general education.
Child is only D/HOH child in area – limited socializing is not
viewed as component of school services. Child may even look
autistic to some due to limited social opportunities.
CODP? What did their educational opportunities look like? Say
teachers don’t consistently communicate w/them because tough.
Suspicious because of own experience in school.
Should I request a neuropsychology
evaluation for a student?

 If you are worried about a student – yes – try to arrange for
them to be evaluated by a provider who is familiar with
children who are D/HOH. If not possible, speak extensively
with the school psychologist.
 Will any neuropsychologist be a safe bet?
 No – The provider should be aware of the pitfalls, familiar
with differences between sign and spoken language and have
a plan.
 Sometimes no experienced or reasonably knowledgeable
provider is available ‘in-network’ - consider an appeal to the
insurance for experienced provider.
Red flags for referral

 A child is not making expected progress with language
(spoken or manual) in spite of being adequately aided.
 A child is not keeping up with peers at school, with a critical
eye to monitoring literacy skill building.
 Social skills are not developing appropriately or the child
appears “odd” interpersonally, has an unusual appearance,
other.
 Testing through the school does not seem on the face of it to
match observed functional skills (e.g. either tested as more
skilled than appears true or tested too low).
 Attention, memory or executive function difficulties are
evident, particularly if there is another medical problem or
prior medical problem.
Red flags for referral

 The family would benefit from understanding strengths
and weaknesses in order to advocate for the child.
 If a child has a complex genetic condition or associated
craniofacial anomalies your threshold may be reduced for
referral.
 Consider a child with conductive hearing loss related to
complex craniofacial differences. While the HL itself carries
certain risks with language development, if the craniofacial
differences include isolated cleft palate the language risks
elevate further. Low threshold for referral of these kids.
 KEY: Don’t wait until these kids are failing or so far
behind that catching up is unattainable. Early testing and
careful monitoring are best.
Comorbid Impairments

 Speech and hearing impairments are commonly
observed in association with conditions that carry
multiple types of disability, particularly more severe
disabilities.
 For children with multiple or complex disabilities,
flexibility in assessment and care to identify
strengths/weaknesses becomes more important.
 How do we communicate ability and knowledge
with individuals who have speech/language and
hearing deficits that are more severe?
Neuropsych testing is inaccessible

 Though designed for the purpose of identifying
strengths/weaknesses in clinical populations,
neuropsych testing is largely inaccessible to those
with the greatest impairments
 How do you take a complex concept conveyed in a
neuropsychological test and break it down into a
digestible format for those who require AAC
support?
 Do the tests measure the same thing when they have
been modified to this degree?
The case of processing speed

 Simply put, PS is the rate at which we are able
complete mental problem solving tasks.
 PS may be very slow but associated with accurate
responding.
 PS measures are typically designed to be extremely
easy conceptually – focus on time of completion with
accurate responding.
Typical PS task
KEY
1
Fill in corresponding
shape as indicated in
the key above. Go as
quickly as you can
without making mistakes.
You’ll have 2 minutes.
2
3
2
3
1
5
2
6
Sounds great! So what’s the problem?
4
5
6
5
6
4
4
1
3
*
The heart of the problem:
Unfair disadvantage
and/or insurmountable
barrier for children with
motoric difficulties
including dysarthria.
Processing Speed

 Graphomotor (paper and pencil) responding, reaction
time tasks and at times verbal responding tasks are the
main mechanisms of measuring PS.
 For children with motoric and/or oral communication
difficulties, these demands will at minimum artificially
reduce PS scores, and at the worst will preclude
participation in testing of PS altogether.
 PS is multifactorial – It involves multiple anatomical
systems and neurophysiological processes.
Inspection Time

 Inspection time (IT) is a very simple information
processing construct which is measured by an
individual’s ability to see aspects of a stimulus given
a very brief time limit.
 IT is generally felt to be associated with a
“Visualization Speed” factor of PS.
 IT measures offer the unique opportunity to look at
an aspect of early PS without the confounds of
reaction time, paper/pencil or verbal responding.
A Standard Visual IT Task
time
A
B
C
D
E
F
Let’s look at what it would look like taking this test…
250 + 17ms
Training Tasks

 Because the task itself is potentially too complex
for some participants out of the gate, a series of
training steps have been developed.
 Training steps are conceptual and proceed in a
natural progression of cognitive complexity.
 Step-wise training will allow for analysis of data
for children who are not able to complete the
formal IT task – important for school planning
(what are the strengths for this child?).
Training 1 – Target Identification
Reinforced (Hint) Trials
Criterion (no hint) Trials
(7 of 10 correct)
Training 2 – “Simple” Target Matching
Training 3 – “Complex” Target Matching
Training 4 – “Simple” IT Task Trial
Exposure (different stimuli)
time
A
B
C
D
E
F
Initial trials with reinforcement and “hints” with criterion
trials (7/10 correct) without hints.
Training 5 – Final IT task training
time
A
B
C
D
E
F
Training on this run starts VERY slow, and gradually speeds up
to warm the kids up and prepare for the actual task.
How is inspection time relevant?

KEY
1
2
3
2
3
1
5
2
6
4
*
5
6
5
6
4
4
1
3
We have to be aware of how any why we would modify our assessment strategies
Instruction accommodation

 While assessment accommodations are critical, it is
equally important to accommodate unique learning
demands for children with disabilities.
 A common pitfall is modifying instruction to allow a
student to learn material but doing so in ways that work
for TD students’ learning style.
 Although the end point goals for learning may be the
same, the pathways to learning may differ for children
with hearing and speech/language differences.
Practical Supports

 In the classroom there are a number of environmental and
teaching supports that are recommended for students with
d/hoh that also aid children with speech/language delays:
 Preferential seating – remember this may not be right next to
the teacher!
 Frequent cues, prompts to attend
 Breaking instructions into component parts; step-by-step
 For limited language users, pictorial representations and checkoff lists are important.
 Show me, don’t just tell me strategies including hand-overhand instruction.
Practical Supports - reading

 For readers with limitations (e.g. slow, lower reading
level than peers, comprehension challenges):
 Copies of lecture notes and outlines of material (as
long as child can read them and understand!)
 Pre-reading questions – predictive reading questions
 Core vocabulary list for more complex material as a
reference
 Consider “follow-along” or listening reading options
such as Bookshare.org – write it into the IEP!
 Students need practice learning how to use technology
for reading support
Practical Supports - Reading

 Reading fluency improvements
 Read books that are below the natural reading level
 For older students consider challenge in reading “baby
books” as a teen. Orca Soundings series targets older
reluctant readers
 Allow magazines, comic books, etc. to count for
reading assignments (reading is reading)
 Cooperative reading, dog-reading programs,
“volunteer” reading for younger children make
reading less stressful and build fluency.
 Focus on phonics – not just sound blending but also
elision skills and speeded naming skills
Practical Supports - transitions

 Children are constantly transitioning; don’t wait
until age 14 to start the transition planning with
students.
 Is the student at a point of literacy at the end of
middle school?
 If yes, continue bolstering skills
 If no, continue working on skills but implement “plan
B” accommodations to allow time to practice their use.
 Recordable pens, audio books, dictation systems (e.g.
Dragon Naturally Speaking), word processing
programs with auto-correct and graphic organizers.
Practical Supports - transitions

 Students with disabilities are often viewed as
“perpetual children” and provided less instruction
about adulthood when they often require additional
instruction.
 Independent living skills training
 Body awareness and health, accessible sexual
education, drug and alcohol information
 Modifications of AAC devices to shift towards more
adult themes including opportunities for use of
vernacular, swearing, sexual topics and romantic
interactions
Transition Planning

 At 14y/o all IEP’s should include formal transition planning; this
should flow directly from the Present Level of Academic
Achievement and Functional Performance (PLAAFP)
 What are the student’s transition service needs?
 What does the student want to do and how does the student want to
live after high school (post-school goals)?
 What is the student’s present level of functioning in relation to his or
her post-school goals?
 What transition services are needed to assist the student in reaching
his or her post-school goals related to training, education,
employment, and, where appropriate, independent living?
 Is the student expected to graduate with a regular diploma during the
IEP term.
 Will any outside agencies provide needed transition services?

Transition Planning

 Identify goals for life after high school and develop a plan
to achieve them
 Provide school experiences that develop the skills and
competencies needed to achieve post-school goals
 Actively involve the student and his/her family in
transition IEP development
 Encourage self-advocacy
 Identify accommodations and modifications needed to
achieve post-school goals
 The transition plan should include strengths of the
student that will help them achieve their goal.
Transition Planning

 Partner with local agencies such as Michigan
Rehabilitation Services (MRS) and the Centers for
Independent Living.
 For students planning to enroll in post-secondary
education:
 Early planning for ACT/SAT including extended time and
small group administration
 Facilitate contacting potential schools to link students with
the student disability centers
 Increase student understanding about available resources in
the collegiate environment
 For immediate job placement include practice for resume
preparation, interviewing and practicing requesting
accommodations from employers; this is not learned by
osmosis.
Transition Planning

 Discuss money management and
guardianship/conservatorship issues at IEPs – this is a
component of independent living and critical to organize
before the student turns 18. Similar to school, target a least
restrictive environment.
 Consider vocational/technical schooling options for
students with severe academic delays.
 Conduct a vocational assessment with students to aid in
identifying strengths/weaknesses/interests.
 Consider using MRS options for job “try-outs” to explore
interests and skill-sets in a sheltered work environment.
 For students with severe disability who seek a college
experience, it is possible to work with many universities
to enroll in classes for this purpose.
Transition keys

 Involve the student early and often.
 If comprehension is limited, or if sensory or speech
limitations are barriers to participation be sure to include
the student maximally to the degree they are able.
 Discuss transition planning as “door opening” rather than
pigeon holing students into a path they can’t change.
 Begin discussions early about the many pathways for
completion of school including diploma and certificate
completion, highlighting benefits of both.
 Work hard to not overlook transition planning needs of
high functioning special education students who will
need more help when attending college or jobs; maintain
IEPs even for this purpose when possible.
You’re an expert!

 Remember – you’re the expert of your school, and
your community and the kids you work with.
 Partner with parents to develop plans that meet each
individual child’s needs and don’t be afraid to use
community resources.
 Bring in outside voices by school visits or phone
conference to aid in problem solving.
 Be honest and realistic with families about resources;
if you can’t provide them do you know of a school
resource that can?
Take home points

 School psychologists conduct essential intellectual and academic
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testing to aid in proper placement in school and to identify
necessary supports for children with disabilities.
Neuropsychologists are often beneficial or needed to help tease
out performance when basic IQ and academic testing are
insufficient to inform a child’s needs.
Children who are D/HOH carry particular risks for
underestimation of skill and intellect and care must be taken to
ensure that testing is accessible and appropriately interpreted.
Children with complex medical factors are at particular risk and
should be monitored closely for progress.
When in doubt, ask if neuropsych testing is appropriate! Clinics
in academic medical centers or other specialty clinics are there to
help you decide when it is unclear how to proceed.
THANK YOU!

Questions??