Psychoeducational Testing,
Learning Disabilities, and
School Consultation
Courtenay Rourke Ainsworth, Ph.D.
Pediatric Neuropsychologist
Licensed Clinical Psychologist
courtenayainsworth@gmail.com
Pediatric Evaluations
 School Case Study- team approach including
assessment of vision, hearing, social & emotional
status, intelligence, academic skills, communication
skills, motor abilities
 Psychoeducational- IQ, achievement, parent &
teacher behavioral checklists, observation
 Neuropsychological- cognitive profile in the
context of brain/behavior relationship
 Neurodevelopmental- assessment of milestone
acquisition & trajectories; not predictive of later IQ
Conditions & Issues Commonly Referred for
Neurodevelopmental/Neuropsychological Assessment
 Neurological conditions such as stroke,
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epilepsy, brain tumors, disorders of
movement (e.g., cerebral palsy)
Head trauma
Attention-Deficit/Hyperactivity Disorder
Behavioral problems
Learning disorders
Developmental delay
Socialization difficulties
Other Conditions/Issues (continued)
 Chromosomal/Genetic disorders
 Toxic exposure (in utero & environmental)
 Medical conditions such as metabolic disorders,
HIV infection, liver disease, renal disease, sickle
cell anemia
 Perinatal trauma
Uses of Neuropsychological Assessment
 Differential diagnosis
 School-based psychoeducational evaluation will not provide
diagnosis
 Baseline status secondary to neurological disease,
injury, or abnormality affecting cerebral function
 Progression of disease/recovery of function over
time; measurement of treatment response
 Determining cognitive strengths & weaknesses for
educational placement
 Clarify significance of pathology on “real life”
functioning (e.g., academics, social)
Uses of Neuropsychological Assessment
 Provide information relevant to management,
rehabilitation, and treatment planning (e.g.,
strategies to help compensate for deficits; need for
modified school program)
 Capacity for functional independence such as
driving, decision-making, & independent living
 Legal/forensic issues- Litigation around a patient’s
cognitive status
Neurodevelopmental Testing
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Used to assess infants and young
children in order to examine early
development to see if it is on track
NEPSY-II
Pediatric Neuropsychological Evaluation
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Intellectual Functioning
Academic Achievement
Attention and Concentration
Verbal and Visual Memory
Problem Solving Skills
Receptive and Expressive Language
Visual-Perceptual Abilities
Sensorimotor Skills
Personality and Emotional Status
Behavioral Functioning
The Neuropsychological Evaluation
 Portable: 4-7 hours
 Individually tailored; hypothesis testing
 Objectively scored
 Standardized, valid, and reliable
 Can be modified
 Quantitative and qualitative interpretation
 Task performance is analyzed to determine
component processes
Intelligence Testing
 Wechsler Intelligence Scale for Children-IV
 Verbal Comprehension Index
 Perceptual Reasoning Index
 Working Memory Index
 Processing Speed Index
120+ Superior
110-119 High Average
90-109 Average
80-89 Low Average
70-79 Borderline
69 Mental Retardation
WISC-IV Verbal Questions
 Vocabulary
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What is a clock?
What does garrulous mean?
 Similarities
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In what way are an apple and a banana alike?
In what way are reality and a dream alike?
 Information
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At what temperature does water boil?
What is the capital of France?
 Comprehension
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Why do people wear seatbelts?
Why do we put stamps on letters?
WISC-IV Matrix Reasoning
WISC-IV Matrix Reasoning
WISC-IV Coding
Academic Achievement
 Reading- word identification, comprehension,
non-word decoding
 Math- calculation & application
 Spelling words to dictation
 Written expression
 Academic fluency- timed reading, math, & writing
WJ – Reading Fluency
WJ – Math Fluency
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3
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Memory Functions
 Immediate verbal/auditory retention
span
 Learning over trials
 Efficacy of retrieval- spont. & cued
 Long-term memory
 Remote memory
*Not assessed in a psychoeducational
evaluation
Memory Evaluation
 Children’s Memory Scale
 California Verbal Learning Test/CVLT-C
 Rey-Osterreith Complex Figure Test
Encoding
Storage
Retrieval
Verbal Memory Tests
 Associated with left temporal-limbic function
 Narrative Memory (Children’s Memory Scale)
 Structure and semantic context
 Immediate & Delayed Memory
 Recognition
 Serial Learning Tests (California Verbal Learning Test)
 Attention
 Learning- benefit from repeated trials
 Chunking/clustering
 Immediate, Cued, Delayed Memory
 Recognition
“Frontal” Errors on
Memory Testing
 Impoverished learning strategies
 Intrusions and perseverations
 Poor retrieval strategies
 Difficulty with temporal tagging (proactive &
retroactive interference)
California Verbal Learning Test particularly helpful
Visual Memory Tasks
 Associated with right temporal-limbic function
 Brief Visuospatial Memory Test
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Learning trials
Delayed Memory (30 minutes)
Recognition
 Rey Complex Figure
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Copy
Immediate (3 minutes)
Delayed (30 minutes)
Recognition
Rey Complex Figure
Evaluation of Attention/Concentration
 Test of Everyday Attention for Children
 Conner’s Continuous Performance Test
 Trail Making Test
*Not assessed in a psychoeducational evaluation
Trail Making Test- A
Trail Making Test (Part B)
Trail Making Test: B
Executive Functioning
*Associated with frontal-subcortical circuitry
 Goal formulation
 Initiate, maintain, switch, & inhibit
 Mental flexibility
 Planning & organization
 Decision making
 Self-monitor, self-correct, & persist
 Nonverbal problem-solving
*Not assessed in a psychoeducational evaluation
Executive Function
 Tests of Executive Function
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Wisconsin Card Sorting Test
Similarities, Interpretation of Proverbs
Children’s Category Test
Tower of London
 Critical for adaptive, independent living
Wisconsin Card Sorting Test (WCST)
Language Functions
 Auditory & verbal comprehension
 Vocabulary
 Verbal fluency, volume, rate
 Articulation
 Naming
 Pragmatic skills, prosody, gestures
Evaluation of Language Function
 Verbal/Semantic Fluency
 Peabody Picture Vocabulary Test
 Expressive One Word Picture Vocabulary Test
 Boston Naming Test
 Sentence Repetition
 Clinical Observation
Visual Perceptual Skills
 Visuoconstruction
 Patterns/sequences
 Location in space
 Facial recognition/Facial expressions
 Visual abstract reasoning
 Personal space
 Integration/organization
 Attention to visual details
Visual-Spatial Tasks
 Judgment of Line Orientation
 Visual Motor Integration
 Test of Visual Perceptual Skills-Revised
 Test of Facial Recognition
Judgment of Line Orientation
Visual Motor Integration
Visual Motor Integration
Facial Recognition
Motor
 Grip Strength
 Dynamometer
 Fine Motor
 Tapping Speed
 Coordination/Dexterity (Grooved Pegboard)
 Gross Motor
 Running, skipping, jumping, balance, throwing, catching,
up/down stairs
Psychosocial Functioning
 Personality
 Emotions
 Behavior
 Family dynamics
 Social network
 Situational influences
Behavioral Assessment
 Behavioral Assessment
 Behavior
Observation
 School
 Testing
 Behavior
Rating Scale/Checklist
 Presence
or absence of behaviors
 Intensity and frequency of behaviors
 Child Behavior Checklist (CBCL)
 Behavioral
 Vineland
Interview
Adaptive Behavior Scales
Child Behavior Checklist
Neuropsychological Report
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Content:
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Background, presenting concerns
Previous testing
Behavioral observations; validity of results
Performance on each neuropsychological
domain via the assessment tools utilized
Summary- profile of strengths/weaknesses
Diagnoses
Neuropsychological Report
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Recommendations
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IEP or Section 504 Plan
Classroom accommodations
Outside of school
 Psychotherapy
 Medication referral
Resources such as books and websites
Feedback- family, child, school, referral
Learning Disability
 Definition: LD is a neurological disorder that
affects the brain's ability to receive, process,
store, and respond to information
Learning Disorder: Subtypes
 Specific Learning Disabilities (Area of Reading,
Mathematics, and/or Writing)
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DSM-IV: Reading Disorder, Mathematics Disorder,
Disorder of Written Expression, Learning Disorder-NOS
 Verbal Learning Disability
 Dyslexia
 Dysgraphia
 Nonverbal Learning Disability
 DSM-IV: Learning Disorder- NOS
Ability-Achievement Discrepancy Model
 1968-SLD federally designated category
 1976-Discrepancy model primary criterion in LD
 Diagnosis of exclusion
 Wide variability to what constitutes a discrepancy
 Limited capacity to correctly evaluate ability
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achievement difference scores
Variability in measures used to define differences
Instability in discrepancy scores over time
IQ-Achievement discrepancy can occur for reasons
other than LD; no specific test to rule out other causes
Differentiating LD from low achievement
Recent Efforts to Change LD Identification
Process
 1999 - USDE began evidence-gathering for change in
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procedures for evaluating LD
2001 - Working group white papers & LD Summit in D.C.
H.R. 1350 - no requirement for assessment; SLD assigned
for failure following Response-to-Intervention (RtI)
Tier 1, 2, 3
However, little evidence on effectiveness of “researchbased” intervention
Not all teachers created equally to implement interventions
and monitor progress
Earlier intervention has better neurodevelopmental
outcome (vs. waiting for RtI tiers)
RtI Tiers
Dyslexia terminology
 Phoneme: fundamental/smallest unit of sound in a language (e.g., /t/, /d/)
 Grapheme: fundamental unit of written language (e.g., ‘ph’ of phoneme vs
/f/)
 Morpheme: smallest linguist unit with meaning (comprised of phonemes)
 Free: ‘dog’
 Bound: ‘un’ (occurs with other morphemes e.g., ‘undone’)
 Derivational: add semantic information (‘ness’ -> ‘happiness’)
 Inflectional: modifies word’s tense, number, or other aspects (‘s’ cat->
‘cats’)
 Lexicon: “mental vocabulary” with syntactical rules
 Shared properties (e.g., action verbs)
 Generate “new” words (‘able’ -> actionable vs cryable)
 Language
 Imageability: concrete versus abstract
 Dog- living, 4 legs, domesticated, dachsund, had a dog, furry, barks
Developmental Dyslexia
 Type of Reading Disorder (DSM-IV classification)
 Type of Verbal Learning Disability (educational terminology)
 Presumed genetic origin with neurologic findings
Genetics: 9 chromosomes found linked to susceptibility of disorder
Average or above average intelligence
Verbal IQ lower than Performance IQ
Verbal Memory lower than Visual Memory
Dysfluent or inaccurate word recognition
Phonetic decoding difficulties
Poor spelling/written language
Sometimes reversal of letters (single & within words) when reading and
writing
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Developmental Dyslexia
 Prevalence of dyslexia ranges from five to nine percent
of school-aged children
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high as 17 percent
 Main manifestation is a difficulty in developing word-
level reading skills in elementary school children
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Reduced ability to associate visual symbols with verbal sounds
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Grapheme-> Phoneme Correspondence
Dyslexia
 Deep dyslexia (large perisylvian lesions extending to frontal lobe)
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production of semantic errors (e.g., knight when shown castle)
better able to read words of high imageability
nouns better than modifiers & functors
can’t read nonwords
 Phonological dyslexia (superior temporal/angular gyrus/supramarginal
gyrus)
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translation from print to sound (e.g., read ‘pat’ as ‘bat’)
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can’t read nonword letter strings
few semantic errors
 Surface dyslexia (widespread/poorly localized L hemisphere lesions)
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inability to read words with irregular correspondence (e.g., /c/ in cat vs /c/
in ice)
Some Related Features…
 Visual errors: skate -> ‘scale’
 Morphological errors: scolded-> ‘scolds’ or governor -> ‘government’
 Imageability
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Many do better at reading words with high imageability (e.g., chair, table) vs
low/abstract concepts (e.g., destiny, wish)
 Deficits at reading functor words (pronouns, prepositions, conjunctions,
interrogatives)
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Especially switches of ‘that’ read as ‘which’
 Reading non-words (e.g. flig ->’flag’) cannot employ print to sound
correspondences
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Over-reliance on lexical reading?
 Possibly a deficit at the level print to sound conversion (phonological
dyslexia) AND at the level of semantics
Coslett, 2003
Reading and Spelling
 Spelling errors
due to deficit with learning letter-sound correspondences, tend to
misspell words, or leave vowels out of words
Letter order
 reverse the order of two letters especially when the final, incorrect,
word looks similar to the intended word (e.g., spelling "dose"
instead of "does")
Highly phoneticized spelling
 "shud" for "should"
Difficulty distinguishing among homophone (e.g., "their" and "there“;
“passed” and “past”)
Vocabulary
 small written vocabulary on context of a large spoken vocabulary
Handwriting
 slower writing speed
 poor handwriting; irregularly formed letters
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Mathematics
 Difficulty with word problems (i.e., descriptive
mathematics, engineering, or physics problems that
rely on written text rather than numbers or formulas).
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also have difficulty:
 remembering mathematical facts (e.g., multiplication tables)
 learning the sequence of steps when performing calculations
(e.g., long division)
Compensation
 Many dyslexics possess excellent long-term memory
 Some research suggests that particularly young girls, tend to
memorize beginning readers
May be unable to read individual words or phrases
 However, may learn to memorize all words versus just the
irregular words
 “isle” (as in island)
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Testing for Dyslexia
 Sight word reading
 Nonsense words
 Language tests (receptive & expressive)
 Reading fluency
 Pattern of spelling errors
 Oral reading sample
 Spontaneous writing sample
Mathematics Disorder
 Mathematical ability is substantially below the level
normally expected based on age, intelligence, life
experiences, and educational background
 Affects the ability to do calculations as well as the ability
to understand word problems and mathematical
concepts
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Description
difficulty reading and writing numbers
difficulty aligning numbers in order to do calculations
inability to perform calculations
inability to comprehend word problems
Mathematics Disorder
 Signs of mathematics disorder in a child's schoolwork:
 problems counting
 difficulty memorizing multiplication tables
 inability to grasp the difference between such operations as addition and
subtraction
 poor computational skills; many errors in simple arithmetic
 slowness in performing calculations
 difficulty arranging numbers in order (from smallest to largest, for
example)
 inability to grasp information on graphs
 difficulty copying numbers or problems
 inability to grasp the concept of place value
 inability to align two or three digit numbers to do calculations
 difficulty understanding word problems
 inability to understand mathematical symbols
Disorder of Written Expression
 Learning disability in which a person’s writing ability
falls substantially below normally expected range
based on the individual’s age, educational
background, and measured intelligence
 Poor writing skills must interfere significantly with
academic progress or daily activities that involves
written expression (spelling, grammar, handwriting,
punctuation, word usage, etc.)
Dysgraphia
 A neurological disorder characterized by writing disabilities-
inappropriately sized and spaced letters, and wrong or misspelled
words, despite thorough instruction
 Causes difficulty with processing information, organizing thoughts, and
going through the process of putting the words down onto paper
 Often children with dysgraphia hate writing, show variable letter size
and spacing, and sometimes orient letters incorrectly
 Often able to express themselves well verbally, however seem unable to
write at a level that reflects the complexity of their thoughts (e.g., will
verbalize, "The apatosaurus was gigantic, but was primarily a
herbivore" but writes, "The dino was big“)
Nonverbal Learning Disability (NLD)
 Cluster of neuropsychological, academic, and social-
emotional characteristics that reflect primary
deficiencies in non-verbal reasoning
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A signature neurocognitive pattern on testing
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Byron Rourke
 Hallmark: Difficulty learning from visual
environment
 Clinically, this LD classification resembles an adult
patient with a head injury to the right hemisphere,
both symptomatically and behaviorally
Nonverbal Learning Disability
 Neuropsychological Deficits
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VCI > PRI on WISC-IV
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Nonverbal memory, executive functions, pragmatic
language, tactile/visual perception
 Academic Deficits
 Math calculation/reasoning, abstract reading
comprehension, handwriting, specific aspects of written
language
 Social/Emotional/Adaptational Deficits
 Social perception & interaction
 Increased risk of depression & anxiety
NLD Continued
 “Reverse syndrome” of dyslexia
 Difficulty producing in situations that require
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speed and adaptability
Involves performance processing
Mild abnormalities in right hemisphere
Between .1% and 1% of population
Poor coordination
Exceptional rote memory
NLD: Proposed Etiology
Dysmyelination of the white matter fibers,
primarily in the right hemisphere
 “Developmental” manifestation
 Observed in cases of closed head injury,
hydrocephalus, congenital absence of corpus
callosum
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Right hemisphere more susceptible to early
neurologic insult
Intervention Strategies
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Use verbal strengths to compensate
Hands on/experiential learning
Encourage kinesthetic sports
Social skills training
Preferential seating
Previewing/outlining instructions
Model/reinforce on-task behavior
Instructions presented in single steps/slower pace
Guided practice
Reduce visual stimuli on page
Present classroom rules in positive form
Cue before transitions
School Consultation (Mike Kiser, Ed.D., J.D.)
 Criteria and process for obtaining school services
under the Individuals with Disabilities Education
Act (IDEA)
Eligibility requires a qualifying disability that adversely
affects a child’s educational performance
 Free and Appropriate Public Education (FAPE) must:
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Meet child’s unique needs
 Prepare child for further education, employment and independent
living
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IEP Process
Request case study evaluation in writing
 Evaluation domains established and evaluations conducted:
health; vision; hearing; social/emotional; general intelligence;
academic performance; communication; and motor abilities
 Team meets to review evaluations and determine eligibility
 Must have a qualifying disability
 The disability must affect the ability to benefit from educational
program
 School not required to address medical issues that do not affect
education
 School may have to provide a medical service if necessary to
benefit from education
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IEP Process
If eligible, develop an Individualized Education Program (IEP),
which includes:
 Educational needs
 Goals, including objectives/benchmarks
 Any accommodations needed
 Any related services needed (e.g., social work, speech,
occupational therapy, and physical therapy)
 The least restrictive environment (LRE) in which child can
benefit from educational services (placement)
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 Placements
include general education with support, general
education with resource classes, self-contained classroom in
public school, public or private day program, and residential
IEP Eligibility Categories
 Disabilities that make the child eligible for services if affect education:
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Autism (including Asperger’s Syndrome and Pervasive Developmental
Disorder-NOS)
Deaf-Blindness
Deafness
Emotional Disturbance (including psychiatric disorders):
 Attachment disorder, Obsessive Compulsive Disorder, Depression,
Bipolar Disorder, Oppositional Defiant Disorder, Anxiety Disorder
Hearing Impairment
Intellectual Disability (Mental Retardation)
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment (e.g., ADHD, epilepsy, sickle cell anemia, and
Tourette's syndrome)
Specific Learning Disability
Speech/Language Impairment
Traumatic Brain Injury
Visual Impairment
School Consultation
 Services available to students with disabilities
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IEP provides special education services
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Goals/objectives
Support services
 Special Education Resource
 Social work/counseling
 Speech and language
 Occupational therapy
 Physical therapy
 Transportation
Accommodations
 Addressing unique learning styles and needs
 Addressing behaviors
Functional Behavioral Analysis (FBA)/Behavior Intervention Plan (BIP)
Placement in LRE
Accountability
 Section 504 Accommodations Plan provide accommodations only
School Consultation
 Possible accommodations under a 504 Plan could be:
 Structured learning environment (e.g., preferential seating)
 Repeated or simplified instructions
 Behavior management or intervention strategies
 Modified testing procedures- small group; oral testing;
extended time; test read to student
 Tape recorders, spell checkers, calculators, computers, word
processor, etc.
 Modified or adjusted homework, workbooks, second set of
textbooks
 Textbooks on tape
School Consultation
 Strategies for obtaining services
 RtI followed by Case Study; OR obtain outside, private
evaluation
 Include evaluator in school meetings, particularly if:
School staff members not supportive of providing services
 Evaluators can make recommendations for classroom
accommodations and school services
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 Disputes (e.g., Conducting case study evaluation,
eligibility, IEP content, and complying with the IEP)
are adjudicated in a Due Process hearing
School Consultation
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Some educators do not understand emotional and sensory issues
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Do not recognize disability when appearance is that of a typical
student
Assume volitional conduct when student is bright
Verbally and physically aggressive students least likely to receive
services
Withdrawn and disengaged students are commonly ignored
Soft strategies for obtaining services
Evaluations
 Education
 Participation of experts
 Compromising
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Hard strategies for obtaining services
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Due process hearing, including mediation
School Consultation
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Working with parents and schools
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Address the fears of many parents of retaliation
Give the parents a constructive place to vent
Remind school staff members and parents that the focus is the child, not a
position or “principle”
Don’t intimidate school staff members, which takes the focus off the child
Rehashing the past is not helpful to the child and should be left for litigation
Burned bridges must be repaired
Some school cultures are focused on finances
Some school staff members are much more child-centered than others
Educators often need educating about disabilities
Higher grade levels mean less flexibility
Higher grade levels mean more punitive approaches to problem behaviors,
absences and failure to complete work
Non-school etiology (e.g., dysfunctional family) does not mean that the child
does not have a right to services
Be respectful, but firm