Why a Comprehensive Assessment is Essential for Identifying Neurodevelopmental Disorders and Improving Outcomes in Children with Learning and Social-Emotional Challenges
Karen I. Wilson, PhD, Clinical Neuropsychologist and Professor, Department of Psychology, California State University, Dominguez Hills
When a child is struggling in school, parents often ask: how can I support my child so that he can demonstrate his full potential? This question highlights a desire to understand the source of the difficulty so that it can be addressed. Areas of struggle may not be easily identified, however. In addition, there are barriers to uncovering difficulties, barriers that include fear of a child being labeled, rationalizations regarding the struggles children face, and the belief that a child’s problem can be solved with tutoring, repetition of information, or by simply increasing grit.
In order to effectively address weaknesses or areas of difficulty and build on a child’s existing skills, parents and educators must first fully understand why a child is struggling. Unfortunately, when struggles, disengagement, frustration and underachievement are observed, there is sometimes a tendency to rationalize the difficulty a child is experiencing with statements such as: “He’ll grow out of it,” “He’s just a boy,” “She’s just shy,” “She’s just lazy,” “He just needs to work harder.” These rationalizations can delay the identification and treatment of neurodevelopmental disorders. Moreover, misunderstanding of a child’s struggles can lead to mislabeling, which can cause anxiety, decrease motivation, increase feelings of inferiority and lead to social isolation.
We know that not all brains develop in the same way; there are differences in the way our brains are wired. In some cases, the asynchronous development and organization of brain networks result in inefficient communication between areas of the brain that affect a child’s ability to learn, process information and regulate social and emotional experiences.
In the United States, approximately 5% of school-aged children have a learning disability and about 13% of all public school students receive special education services. In addition, it is estimated that 15% or more of students struggle due to unidentified and unaddressed learning and attention issues, and of the 20% of children expected to have some type of diagnosable mental health problem within the first 18 years of their lives, most never receive services.
An assessment of a child’s functioning can help identify learning, neurodevelopmental and social-emotional challenges. While a brief psychoeducational or psychological assessment can identify whether a specific disorder exists (e.g., Attention-Deficit/Hyperactivity Disorder (ADHD), Specific Learning Disorder in Reading), a more comprehensive assessment is needed when parents and educators do not know the source of a child’s struggle or suspect multiple areas of difficulty. For example, a child’s difficulties with reading comprehension could be due to poor receptive language, problems encoding of verbal information into long-term memory, poor working memory, difficulties with phonological processing, inattention, high distractibility, or slow processing speed. A comprehensive evaluation can identify the factors contributing to the comprehension difficulty and therefore, inform the type of intervention needed (e.g., speech/language therapy, educational therapy, a multimodal phonological processing program, classroom accommodations and/or modifications, behavioral support, medication management).
It is important to note that comprehensive assessments and neuropsychological evaluations involve more than just “testing,” they involve a thorough review of family history, developmental milestones, and medical and educational history. Adults in the child’s life complete rating forms that provide information about behaviors observed at home and at school, and parents and educators are interviewed about the nature of a child’s struggles. An evaluation may also involve an observation of a child in his school environment.
As part of an assessment, the child completes standardized tests that allow the clinician to determine how that child is performing in the areas of reading, writing, math, and other cognitive domains, compared to others the child’s age. A more comprehensive evaluation (e.g., a neuropsychological assessment) will typically include an assessment of intellectual and adaptive functioning, academic achievement, speech and language testing, an evaluation of attention, executive functioning, learning and memory, fine motor skill, visual-spatial and visual-perceptual abilities, and social and emotional functioning. During the testing sessions, the clinician also observes a child’s motivation, approach to tasks and response to difficulties.
The assessment process helps to identify the kinds of struggles a child is experiencing (e.g. problems with following directions, forgetfulness, difficulty working independently), when and where the struggles occur, and behaviors that seem to be related to school difficulties (e.g., sadness, avoidance of homework, lying about having homework, procrastination, stomachaches before school). In the case of a neuropsychological evaluation, an aim of the assessment is to identify brain-behavior relationships that contribute to difficulties observed.
An evaluation can also reveal issues that exacerbate learning struggles. For example, a comprehensive assessment could reveal that sleep deprivation is contributing to emotional dysregulation, inattention, slowed thinking, or problems with memory and executive functioning. Alternatively, an assessment could reveal that lack of sleep, which can result in ADHD symptoms, is the primary issue. Similarly, emotional difficulties might be the main issue interfering with classroom adjustment. If a child is experiencing childhood depression, he will often have trouble managing academic demands and may experience problems with learning and memory. It follows that the intervention for this child would not focus on increasing educational support; rather, the educational plan would primarily involve psychological or psychiatric treatment.
In children with psychological or neurodevelopmental disorders, there is an increased risk for having one or more additional disorders. For example, approximately 44-59% of children with AD/HD have another psychiatric disorder (e.g., an anxiety disorder), and studies indicate that at least one in three children with one disorder will also meet criteria for one or more additional disorders. Furthermore, students with two or more disorders are more likely to experience school failure and functional impairment, and difficulties are more likely to persist into adulthood. Therefore, identifying co-occurring issues (e.g., anxiety, depression, family discord) is critical.
Early identification and intervention are the most effective strategies for improving outcomes for children with neurodevelopmental disorders and for improving the developmental trajectory of students at risk for academic difficulties. Early use of effective, evidence-based interventions can close achievement gaps and reduce the likelihood that students experience months or even years of academic failure. For example, research shows that when dyslexia, which is associated with disruption in brain pathways, is treated with an evidence-based intervention a reorganizing of brain pathways occurs and improvements in reading are seen.
Children and adolescents whose neurodevelopmental disorders go undiagnosed or untreated are at greater risk for academic and social-emotional difficulties. Delays in the identification of neurodevelopmental challenges lead to delays in appropriate intervention, which in turn delays the opportunity to take advantage of neuroplasticity, the brain’s ability to reorganize and rewire in response to environmental changes during critical periods of brain development (e.g., while brain white matter is still developing).
A comprehensive assessment or neuropsychological evaluation can identify delays in development, learning challenges, neurodevelopmental disorders, social-emotional difficulties and can be helpful in elucidating how aspects of cognitive functioning, like attention or executive functioning, are affecting social relationships and classroom learning. It can also serve as a baseline against which to measure responses to intervention.
It is important to not delay in evaluating children suspected of having learning or processing issues. Instead, we must ensure that those children receive appropriate treatment early on, including preventative interventions. We need to move from a “wait and see” approach to identifying the source of struggles early on and then using evidence-based interventions to address difficulties. Doing so, will result in children experiencing greater success, less academic failure and help with the development resilience, which will encourage those students to continue to work hard, despite challenges, to reach their full potential.
In the midst of a pandemic, as is the case with COVID-19, it is important that parents communicate often with educators and discuss academic progress, responses to distance learning and therapies and interventions that occur via videoconferencing. It is also essential that a child’s emotional needs are being met and addressed as returning to school could create an increase in anxiety that could have longstanding academic and social implications.
If difficulties have been observed, and a comprehensive assessment is not possible due to restrictions related to COVID-19, a brief evaluation that involves a clinical interview with parents, teachers and the child, a review of academic and medical records, and the administration of standardized rating forms may help to determine areas where support may be needed for the academic year.
This article first appeared in Los Angeles Psychologist, and is published with permission from the author.
Karen I. Wilson, PhD., is a Clinical Neuropsychologist, Director of West LA Neuropsychology, PC and an Assistant Clinical Professor (Voluntary) in the Medical Psychology Assessment Center at the Semel Institute for Neuroscience and Behavior at UCLA. She specializes in the assessment of neurodevelopmental disorders in children and adolescents, and she is passionate about helping students reach their full potential. Dr. Wilson is also the Founder of www.ChildNEXUS.com, a digital platform that connects parents whose children struggle with learning or social-emotional issues with professionals who provide psychological and educational support services. Dr. Wilson has shared her expertise in a broad range of media outlets. She is a sought after expert speaker and has been invited to address a multitude of audiences, including parenting groups, educators, and professionals attending national conferences. To learn more about Dr. Wilson’s work, visit www.westlaneuro.com.