NESCA’s Newton, MA location has immediate availability for neuropsychological evaluations. Our MA clinicians specialize in the following evaluations: Neuropsychological; Autism; and Emotional and Psychological, as well as Academic Achievement and Learning Disability Testing.

Visit www.nesca-newton.com/intake for more information or to book an evaluation.

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NESCA Notes 2022

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11

Private Neuropsychological Evaluation vs. School Evaluation

By | NESCA Notes 2022

By: Cynthia Hess, PsyD
Pediatric Neuropsychologist

While both a school evaluation and a private neuropsychological evaluation often provide valuable information, there are some considerable differences. The primary purpose of a school evaluation is to determine whether or not a student presents with a disability that impairs their ability to access the curriculum and fully participate in the academic and social life of the school. Once a student has been referred for special education, the special education team convenes to determine if, when, and how the student should be evaluated. They decide which instruments will be used for the assessment and who will be responsible for administering them. For example, if a student is referred for a suspected disability, a school psychologist conducts a cognitive evaluation, and a special education teacher will administer an academic assessment. A speech and language, physical therapy, functional behavior, or occupational therapy evaluation may be requested as well. After testing, each specialist writes their report and presents their results individually.

When a student participates in a private neuropsychological evaluation, the parents and student work closely with the evaluator through the entire process, from the intake to feedback and beyond. While there are certainly very comprehensive school evaluations, the information obtained by the evaluators is rarely integrated and instead presented as separate evaluations. This does not allow for a complete understanding of how deficits (or strengths) impact functioning across domains, especially when the child has complex challenges. A comprehensive neuropsychological evaluation is comprised of many elements. Most evaluations consist of a detailed developmental and family history, cognitive, academic, learning and memory (auditory and visual) assessment, visual-spatial and graphical motor skills, and attention and executive function. Depending on the referral question, the evaluation may include reviews of social skills and adaptive functioning or specific measures to assist with making a differential diagnosis. Generally, the assessment is conducted by a single evaluator. The data, including data from prior testing, is synthesized into a detailed report with specific recommendations for school, home, and community life when appropriate.

There are undeniably circumstances when a thorough school evaluation is beneficial. School evaluators have opportunities to observe students at school and consult with their teachers, which can be advantageous (although observations may be requested or necessary to complete a thorough private evaluation, too). School team members also have many opportunities to collaborate when evaluating and working with students. However, school personnel are limited in their ability to integrate data across disciplines, provide diagnoses, and directly assess medical conditions, such as attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and complex challenges, such as dyslexia and nonverbal learning disability (NLD). Additionally, while some parents establish a good working relationship with members of the special education team, they do not have the opportunity to develop a long-term, collaborative relationship with the evaluator as they would when a private evaluation is obtained.

 

About the Author

Dr. Cynthia Hess recently graduated from Rivier University with a PsyD in Counseling and School Psychology. Previously, she earned an M.A. from Antioch New England in Applied Psychology. She also worked as an elementary school counselor and school psychologist for 15 years before embarking on her doctorate. During her doctorate, she did her pre-doctoral internship with RIT in Rochester, N.Y. where she worked with youth ages 5-17 who had experienced complex developmental trauma. Dr. Hess’s first post-doctoral fellowship was with The Counseling Center of New England where she provided psychotherapy and family therapy to children ages 5-18, their families and young adults. She also trained part-time with a pediatric neuropsychologist conducting neuropsychological evaluations.

 

To schedule an appointment with one of NESCA’s expert neuropsychologists, please complete our online intake form. 

 

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton and Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.

 

1

Why Delay a Diagnosis?

By | NESCA Notes 2022

By Angela Currie, Ph.D.
Pediatric Neuropsychologist, NESCA
Director of Training and New Hampshire Operations

As part of NESCA’s ongoing blog series addressing some of the most frequently asked questions about neuropsychological testing, today we are addressing why neuropsychologists may choose to delay a diagnosis.

At NESCA, I often supervise neuropsychology trainees, and one of the first questions I asked them is: “What is the goal of a neuropsychological evaluation?” I often hear answers, such as “to identify strengths and weaknesses” or “to determine appropriate diagnosis.” These answers are not wrong, per se – they are what we are taught in graduate school. However, I often explain that while these may be part of our goal, the primary goal is to tell a client’s story and help them understand a path for moving forward. While this may sound a bit aspirational, it is the approach that best appreciates developmental, systemic, and individual factors that may come into play. As addressed by Dr. Moira Creedon in the first blog within this series, this is also one of the reasons why neuropsychologists want to review all prior evaluations and documentation, as this helps to elucidate the developmental timeline.

When a neuropsychologist is approaching an evaluation through the above developmental lens, it is not always possible to land on a specific diagnosis. This may sometimes be referenced as a “deferred diagnosis” or “differential diagnosis,” meaning there is evidence to possibly support the diagnosis, but not enough evidence at this time to decide for certain. Another term that may be used is “provisional diagnosis.” This indicates that there is enough evidence to support the diagnosis at this time, and there is clinical utility to diagnosing (e.g., informs intervention, qualifies for services, etc.); however, more information or monitoring may be needed to be completely confident, so future reassessment is warranted.

There are several reasons why a diagnosis may be deferred or deemed provisional. First, children are constantly developing, and sometimes the challenges they are demonstrating may be developmental in nature. This may be particularly so when evaluating young children. For example, if a young child has significant language delays, it may be difficult to assess whether they are also on the autism spectrum or have early signs of a learning disability, as their observed weaknesses in these areas may be accounted for by their language. Often times these are children who may “catch up” in skills once provided intervention, meaning their difficulties were related to delayed acquisition, rather than an being an issue of innate impairment.

Similarly, another reason diagnosis may be deferred is if a child’s self-regulation challenges interfere with their ability to engage in typical daily demands. For example, for a child who has significant anxiety or behavioral dysregulation that interferes with their ability to engage in school, it may be difficult to determine if academic delays are related to a learning disability or are a secondary consequence to their dysregulation. While provision of targeted instruction may still be necessary in order to help the child regulate and close gaps in skills, a full understanding of their innate learning profile may not be possible until such supports are in place.

Deferred diagnosis is quite common when more significant psychiatric diagnoses are in question, such as whether a child or adolescent is presenting with a mood or thought disorder, such as bipolar or emerging psychosis. There are many other conditions that may “look like” these disorders, including trauma or co-occurring anxiety and ADHD. When diagnosing more significant, often life-course disorders, it is important to ensure that all other potential explanations are identified and addressed. This is important for informing the appropriate treatments while also allowing the evaluator to outline some of the “red flags” that should be monitored by the client, their parents, and their care team over time.

Another reason why a diagnosis may be deferred is that there may be systemic factors at play. In other words, there may be things going on within the child’s home, peer setting, school, or other surroundings that interfere with the evaluator’s ability to understand the child in isolation. This is a particular issue when evaluating a client with a trauma history. Developmental trauma can often “mimic” other symptom profiles, and so it may be important to first address issues within the system before providing a diagnosis for the individual.

There are other less common situations in which diagnosis may be deferred, but they warrant mention. One is when the neuropsychologist is concerned about possible malingering, which is when certain symptoms are being falsified or exaggerated for personal gain (e.g., a child with learning disability exaggerating mood symptoms to avoid school). Another less common situation is when prescribed medication or recreational drugs may be inadvertently causing the symptoms of concern (e.g., depression occurring as a side effect).

A final reason why a diagnosis may be deferred is simply that things can sometimes be messy. We often evaluate children and teens who have several presenting concerns, and sometimes it takes time to peel away the layers of the onion. In any of the above scenarios, we start with “what we know” and then describe “what is possible.” Regardless of whether or not a diagnosis is certain, as neuropsychologists, we are still able to tell the client’s story, describing how they “got here” and how to move forward. This developmentally-sensitive approach allows us to make recommendations based on their need, not just their diagnostic label. We are then able to assess how their profile and symptoms change as they access intervention. It is for this reason that we enjoy the opportunity to develop long-term relationships with our clients, helping to monitor growth over time. Children do not develop in one finite time point, and the neuropsychological evaluation process sometimes has to be patient and continue to develop alongside them.

 

About the Author

Dr. Angela Currie is a pediatric neuropsychologist at NESCA. She conducts neuropsychological and psychological evaluations out of our Londonderry, NH office. She specializes in the evaluation of anxious children and teens, working to tease apart the various factors lending to their stress, such as underlying learning, attentional, or emotional challenges. She particularly enjoys working with the seemingly “unmotivated” child, as well as children who have “flown under the radar” for years due to their desire to succeed.

 

To book an evaluation with Dr. Currie or one of our many other expert neuropsychologists, complete NESCA’s online intake form. Indicate whether you are seeking an “evaluation” or “consultation” and your preferred clinician in the referral line.

 

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Londonderry, NH, Plainville, MA, and Newton, MA serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call (603) 818-8526.

10

Are We Working With a Full Deck of Cards? Why Neuropsychologists Want Results from Previous Evaluations

By | NESCA Notes 2022

By: Moira Creedon, Ph.D. 
Pediatric Neuropsychologist, NESCA

Neuropsychological testing is a tremendous undertaking in time and effort for a family. It involves intake documents, questionnaires, financial paperwork, insurance information, teacher forms, and the list goes on. I promise this paperwork is meaningful and helpful, a way to get the most out of the time and investment in a neuropsychological evaluation. Over the next few weeks, several of NESCA’s neuropsychologists will tackle a few common questions that we face that will help you prepare for neuropsychological testing.

The first topic to tackle relates to the need for previous records. It can feel time consuming to track down documents from years ago, particularly if your child has grown and changed over time. There are many reasons why it is critical to provide these records so your provider has the full deck of cards as they build an individualized evaluation for your child. I’ll tackle the three most important reasons to me:

First, pediatric neuropsychologists want to understand the development of your child over time. For example, if we are evaluating learning problems, I want to know what it was like in kindergarten and early elementary school when your child learned to read. I want to know when the attention problems started or problems interacting with peers were first noticeable to those around them. As we build a developmental timeline, it can help to conceptualize where it all began to help us get at the magical “root cause” that parents often seek. Understanding development over time also helps us to build a better treatment plan. For example, if I can see that a child struggled to develop early reading skills and then years later is extremely anxious about attending school, it helps guide recommendations in both domains.

Secondly, records are critical so we do not risk “practice effects.” “Practice effects” refer to the improvement in scores that happens simply from being exposed to the task before. While guidelines are not as set in stone as some may think, it is generally advised not to repeat many neuropsychological measures within a year of testing. There may be reasons to speed up this timeline that are client-specific, but we cannot make that determination unless we see the documents. Research says practice effects diminish over a few months to a year. We want to eliminate any interfering factors that would make it harder to draw conclusions about the data in the current evaluation. With the time and investment you make in testing as a parent, I can only imagine how frustrating it would feel to hear that something we can manage interfered with the process. Access to records helps us to choose the right measures for the right moment.

Thirdly, providing previous records also allows us to track skill development over time. This is particularly important if we want to see if an intervention (e.g., reading instruction, therapy, attending social skill groups) is working to build the skills. Put simply, it tells us if a problem is getting better or getting worse. Even if you do not agree with the final conclusions drawn by the previous professional, the scores still provide critical data points in development. For more information on seeking a second opinion when you disagree with results, sit tight – that blog post is coming!

I often use the metaphor with kids and families that neuropsychological testing can help us to develop a type of “instructional manual” for how their brain works. With younger kids, I tell them that I am writing the LEGO instructional manual for which steps to take in what order and with what pieces. Without the prior records, I’m missing a bag of pieces. That is almost as frustrating as stepping on the actual LEGOs!

Please come back over the next several weeks to hear more from my colleagues about how to make the most of your child’s neuropsychological evaluation!

 

About the Author

Dr. Creedon has expertise in evaluating children and teens with a variety of presenting issues. She is interested in uncovering an individual’s unique pattern of strengths and weaknesses to best formulate a plan for intervention and success. With experiences providing therapy and assessments, Dr. Creedon bridges the gap between testing data and therapeutic services to develop a clear roadmap for change and deeper of understanding of individual needs.

 

If you are interested in booking an evaluation with Dr. Creedon or another NESCA neuropsychologist, please fill out and submit our online intake form. 

 

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton and Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.

15

Parenting is a Hard Job – Remember You are Good Enough!

By | NESCA Notes 2022

By Dot Lucci, M.Ed., CAGS
Director of Consultation and Psychoeducational Counseling Services, NESCA

Much has been published about parenting and parenting styles, whether in YouTube clips, books, podcasts, scholarly articles, newspaper articles, and so much more. But basically, if you are a parent, you are just doing your job – you are parenting, trying to guide your children, teens, and young adults on their own paths so they grow up to be “good humans and lead happy, successful lives.”

My guess is you probably haven’t given your parenting style too much thought. You just go about whatever the day brings you with whatever you’ve got in your tank that day. You’ve probably heard the terms Helicopter Parents, Tiger Moms, Free-range Parenting, etc., to describe different parenting styles. Usually, our parenting styles emerge from our own histories, role models, experiences, and personalities. You may be parenting how you were parented because it worked for you or because you disliked the way you were parented so you moved to the complete opposite way of parenting.

Remember the book, “Battle Hymn of The Tiger Mother,” by Amy Chua from 2011? She wrote this book as a memoir – not as a parenting guide – but what a controversy it stirred regarding parenting styles! Alan Paul, a journalist for The Wall Street Journal then wrote, “Tiger Mom…Meet Panda Dad,” as a commentary against the Tiger Mom mentality and to bring dads into the parenting discussion. During this time period, there was much written about parenting styles, often characterized into four styles: Authoritative, Authoritarian/Disciplinarian, Permissive/Indulgent, and Uninvolved/Neglectful. As you can imagine, each style has its driving principles. In case you are interested in what the research says about the four parenting styles, the Authoritative parenting style wins out over the others in helping children develop into well-functioning adults.

No matter what style you are, you are giving it your best shot. Each of the styles has much written about them and their impact on child development – some good some not so good. Parents may change their style(s) depending upon a variety of factors and adopt new ways. Try to be aware of your style and its impact on your kids – this realization may happen as you go. That’s okay. You are learning this job as you go, and we all know there is no manual. You are just doing it, living each and every day with what it brings to you. Most parents do not think about what parenting style they are going to use in the moment. Sometimes you may “catch yourself,“ see your child’s reaction, and adjust your style. Perhaps you are the “softie” most of the time, but then turn on the “tough love” style when needed.

As a parent consultant, I often hear, “I must be the worst parent you’ve ever seen. You must think I’m a fool. Do all kids do this? Am I the only one who struggles getting their kids to follow directions?”…and so much more. Sure, I give them specific suggestions for parenting their child who has ADHD or is autistic; however, I match my recommendations to their parenting styles and personalities.

As a consultant, I often find myself saying these mantras in parent sessions:

You are good enough.
Show and tell your kids you love them.
You are giving it your best shot in this moment.
Be kind and gentle with yourself and your kids.
Have compassion and empathy for yourself and your kids.
Stay calm in the eye of the storm. ___ Happens!
You are human, and humans make mistakes – own them.
Don’t expect perfection. It is overrated. Cut yourself some slack.
Point out the positives. Catch ‘em being good!
Tell them what to do not what not to do.
Develop honest, authentic relationships with your kids.
Lead with your heart.

And as the saying goes….

If you are interested in learning more about NESCA’s Consultation Services, please complete our online Intake Form.

References

Alan Paul http://alanpaul.net/panda-dad/

4 Research-Backed Parenting Styles and How they affect your kids by Caroline Bologna https://www.huffpost.com/entry/four-parenting-styles-affect-kids_l_6270493fe4b0bc48f57e705f

4 Types of Parenting Styles and their effects on the child https://www.parentingforbrain.com/4-baumrind-parenting-styles/

Here’s what makes ‘authoritative parents’ different from the rest—and why psychologists say it’s the best parenting style by Francyne Zelster
https://www.cnbc.com/2021/10/05/child-psychologist-explains-why-authoritative-parenting-is-the-best-style-for-raising-smart-confident-kids.html

 

About the Author

NESCA’s Director of Consultation and Psychoeducational Services Dot Lucci has been active in the fields of education, psychology, research and academia for over 30 years. She is a national consultant and speaker on program design and the inclusion of children and adolescents with special needs, especially those diagnosed with Autism Spectrum Disorder (ASD). Prior to joining NESCA, Ms. Lucci was the Principal of the Partners Program/EDCO Collaborative and previously the Program Director and Director of Consultation at MGH/Aspire for 13 years, where she built child, teen and young adult programs and established the 3-Ss (self-awareness, social competency and stress management) as the programming backbone. She also served as director of the Autism Support Center. Ms. Lucci was previously an elementary classroom teacher, special educator, researcher, school psychologist, college professor and director of public schools, a private special education school and an education collaborative.

Ms. Lucci directs NESCA’s consultation services to public and private schools, colleges and universities, businesses and community agencies. She also provides psychoeducational counseling directly to students and parents. Ms. Lucci’s clinical interests include mind-body practices, positive psychology, and the use of technology and biofeedback devices in the instruction of social and emotional learning, especially as they apply to neurodiverse individuals.

 

To book a consultation with Ms. Lucci or one of our many expert neuropsychologists, complete NESCA’s online intake form. Indicate whether you are seeking an “evaluation” or “consultation” and your preferred clinician/consultant in the referral line.

 

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.

 

39

Making the Most of Summer – Setting a Few Life Skill Goals (for College and Life in General after High School)

By | NESCA Notes 2022

By: Kelley Challen, Ed.M., CAS
Director of Transition Services; Transition Specialist, NESCA

Summer in the United States is in full swing. If you have teenagers, they may be working, completing driver’s education, visiting colleges, travelling, or even getting started with their college application this summer. No matter what your teenager is doing, this is great time to sit down and set a few “simple” life skill goals for the summer.

In 2020, I wrote a two-part blog series focused on eight life skills that are critical to build before college:

  1. Getting up “on time” each morning
  2. Washing, drying, and putting away laundry—including sheets
  3. Basic kitchen skills
  4. Using basic tools (e.g., screwdriver, hammer, measuring tape, etc.)
  5. Medication management
  6. Money management
  7. Routine exercise
  8. Using a calendar for scheduling

For teenagers in high school or heading off to college, these are great skills to begin tackling over the summer months. For example, getting up by a certain time is something that can be especially important to work on when consequences are low. For instance, it is hard to let a teen sleep in when they are going to miss an AP exam, but it can be easier to let them practice using an alarm (and possibly oversleeping) when they are going to a movie with a friend or attending a camp. Summer is a great time for teens to be able to experience natural consequences as they practice taking on new risks and responsibilities associated with some of the life skills above.

A challenge when working with, or parenting, teenagers who have a lot of skills to develop is figuring out where to start or how to gain “buy-in.” One of the ways that I like to work with students to set life skill goals is to have the student take a basic life skills inventory, such as the Casey Life Skills Toolkit, Life Skills Inventory, or Adolescent Autonomy Checklist. After a student rates their own skill levels, I ask them to review skills that they cannot already do and identify how important those skills are on a scale of 1 to 10. Then, we go through the list again, and I ask which skills they would like to learn in the next 2 months, 6 months, and year. Once the teenager has identified the importance of a skill and the desire to work on the skill in the near future, it is much easier to set short-term goals. We can work out a skill-building plan for the summer. including how much time to dedicate on a daily or weekly basis. We can also talk about the types of barriers or challenges that might get in the way of the teenager practicing these skills. Additionally, we can set expectations for how often the teen is going to report back to me on the skill so that there is built-in accountability, and the teen knows to expect the check-ins rather than feeling like someone is checking up on them.

Every teenager is different. If you are a parent wanting to help your child make the most of summer, you may find that you can go through the same process that I do to help your child set a few short-term goals. Other teenagers will be able to work on goals themselves—once they have gone through the exercise of setting them. And others, may benefit from having a coach who can build a relationship, support development of executive function and coping skills, and partner with the teen in making the most of summer. If you think your child would benefit from some coaching or an “expert” to work with them, we have a great team of professionals here at NESCA who are ready to help.

If you are interested in working with a transition specialist, executive function coach or real-life skills coach at NESCA for consultation, coaching, planning or evaluation, please complete our online intake form: https://nesca-newton.com/intake-form/.

About the Author
Kelley Challen, Ed.M., CAS, is NESCA’s Director of Transition Services, overseeing planning, consultation, evaluation, coaching, case management, training and program development services. Ms. Challen also provides expert witness testimony in legal proceedings related to special education. She is also the Assistant Director of NESCA, working under Dr. Ann Helmus to support day-to-day operations of the practice. Ms. Challen began facilitating programs for children and adolescents with special needs in 2004. After receiving her Master’s Degree and Certificate of Advanced Study in Risk and Prevention Counseling from Harvard Graduate School of Education, Ms. Challen spent several years at the MGH Aspire Program where she founded an array of social, life and career skill development programs for teens and young adults with Asperger’s Syndrome and related profiles. She additionally worked at the Northeast Arc as Program Director for the Spotlight Program, a drama-based social pragmatics program, serving youth with a wide range of diagnoses and collaborating with several school districts to design in-house social skills and transition programs. Ms. Challen is co-author of the chapter “Technologies to Support Interventions for Social- Emotional Intelligence, Self-Awareness, Personality Style, and Self-Regulation” for the book Technology Tools for Students with Autism. She is also a proud mother of two energetic boys, ages six and three. While Ms. Challen has special expertise in supporting students with Autism Spectrum Disorders, she provides support to individuals with a wide range of developmental and learning abilities, including students with complex medical needs.

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com, call 617-658-9800 or complete our online Intake Form.

4

Coping Strategies for Anxiety and Panic

By | NESCA Notes 2022

By: Lyndsay Wood, OTD, OTR/L
NESCA Transition Specialist & Occupational Therapist

Do you, your child or your loved one deal with frequent anxiety? Stress? Panic? Sometimes it may feel like you are spinning out of control. With so much going on in the world, in our own lives, and in our own head, it can feel like an impossible task to quiet the mind and calm the body. However, there are things we can do to regulate the nervous system, thereby relaxing the body and reducing the effects of anxiety. Below is a list of these strategies, but they are not one-size-fits all. Try each of them and see what works best for you or your loved one.

  • 5, 4, 3, 2, 1 Grounding Technique: This technique is helpful to ground yourself in the present moment. Often, we can get stuck in our own head, and our worries and fears spiral out of control. This strategy is helpful to pull yourself out of those thoughts and into the present moment. The procedure is as follows:
    • Identify five things you can see. Feel free to describe them. What color are they? What are their shapes?
    • Identify four things you can touch. Get up and actually touch them! How do they feel? Are they soft? Hard? Squishy? Wet?
    • Identify three things you can hear. Is there a car driving by? Are the noises loud or soft?
    • Name two things you can smell. Are the smells pleasant? Neutral? Familiar?
    • Finally, name one thing you can taste. Can you taste the remnants of dinner on your tongue? Perhaps you have a piece of candy nearby you want to put in your mouth and describe.

Hopefully, completing this technique helps break the anxiety spiral. Feel free to repeat it as many times as you need. You can try to identify new items and sensations each time.

    • Weighted blanket or deep pressure: Deep pressure activates the parasympathetic nervous system, which is responsible for relaxing your body. Therefore, if you are feeling anxious, try sitting with a weighted blanket. Alternatively, if you have a pet, put them on your lap. Both the pressure of their body and the act of petting them is great for relaxing. You could also try giving yourself a hand massage or tight hug.
    • Box breathing: This is a breathing technique that also activates the parasympathetic nervous system and relaxes the body. The steps of this technique are as follows:
      • Take a slow breath in through your nose (if possible) for four seconds
      • Hold that breath for four seconds
      • Slowly breathe out for four seconds
      • Hold your breath again for four seconds
      • Repeat this cycle three or four times
    • Funny videos: Sometimes it can be helpful to distract the mind with a funny video. Animal videos can be great! Or perhaps you have a favorite comedian that will always make you laugh.
  • Progressive Muscle Relaxation: This technique involves tightening different muscle groups and then letting them go. It helps to relax the body and reduce tension. You can find a guided YouTube video to walk you through the process, or you can also try it on your own by moving from head to toe, tightening different muscle groups. You may start by tightening all of the muscles in your face for 5-to-10 seconds as you inhale and relaxing the face muscles as you exhale. Give yourself 10-to-20 seconds to relax before moving on to the next muscle group.

 

About the Author

Lyndsay Wood, OTD, OTR/L, is an occupational therapist who focuses on helping students and young adults with disabilities to build meaningful skills in order to reach their goals. She has spent the majority of her career working in a private school for students with ASD. She has also spent some time working in an inpatient mental health setting. Lyndsay uses occupation-based interventions and strategies to develop life skills, executive functioning, and emotional regulation. While completely her doctoral degree at MGH Institute of Health Professions, Lyndsay worked with the Boston Center for Independent Living to evaluate transition age services. She uses the results from her research to deliver services in a way that is most beneficial for clients. Specifically, she focuses on hands-on, occupation-based learning that is tailored the client’s goals and interests.

 

To book coaching and transition services at NESCA, complete NESCA’s online intake form. 

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton and Plainville, Massachusetts, as well as Londonderry, New Hampshire. NESCA serves clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.

7

Learning with Executive Dysfunction—How Graphic Organizers Can Help

By | NESCA Notes 2022

By Olivia Rogers, MA, CCC-SLP
Speech-Language Pathologist, NESCA

When it comes to executive dysfunction, we often see students struggle with the organization of language. This presents differently in each student, but may be seen as difficulty comprehending information, and getting ideas out of their heads and organized into words or on paper. They might recognize the words when listening or reading, but they hit a wall when it comes to making sense of the message or describing it. This often results in students feeling lost, confused, and overwhelmed.

When students struggle to organize language and grasp concepts independently in the classroom, we need to break it down and teach it differently. Graphic organizers help us to do so.

What is a graphic organizer?

Graphic organizers are tools that use visual symbols to express knowledge, concepts, thoughts, or ideas, and the relationships between them. The main purpose of a graphic organizer is to provide a visual aid to facilitate learning and instruction. They help students see visually what is expected of them, what they should focus on, and break complex tasks down for them.

What does the evidence show?

There is plenty of evidence demonstrating the benefits of using graphic organizers. The results of most studies have voiced the positive effects of graphic organizers in mainly comprehension and writing, in addition to remembering course content. One such study recommended the use of graphic organizers for teaching expository text structures with students to improve reading comprehension. A popular strategy to help students understand expository texts is to teach the various types of text structures: cause-and-effect, compare/contrast, problem/solution, etc. When students know the underlying organization of the information, it helps them create a working model of it in their minds, resulting in a better understanding and ability to recall. (Pyle et al., 2017). Another study sought to investigate how pre-writing activities based on graphic organizers, such as webs, and beginning, middle and end charts, affect the overall quality of student writing. The results of the study indicate that using appropriate pre-writing strategies based on graphic organizers and giving enough time for the students lead to better quality writing (Servati, 2012).

How are Graphic Organizers Used in Speech Language Therapy?

1. Graphic Organizers Help Students Focus

Many students exhibit disorganized thinking processes, poor initiation skills, word recall difficulties, poor attention, and decreased task endurance. These weaknesses can impact a student’s ability to get started on a project, organize a writing assignment, or even complete a math task. Graphic organizers help students access prior knowledge and get them actively engaged in learning.

2. Graphic Organizers Provide a Visual Map and Help Clarify Abstract Concepts

Have you ever had so much information that you couldn’t hold onto it all? Graphic organizers bring together large pieces of information and tie the relationships together. The concepts and linguistic relationships flow better and make sense to students.

3. Graphic Organizers Help Build Vocabulary

Students benefit from graphic organizers as they expand their word knowledge and make connections. Graphic organizers are great for teaching concepts like descriptive adjectives, antonyms/synonyms, items in a category, part/whole relationships, and definitions.

4. Graphic Organizers Improve Expressive Language

Graphic organizers support oral and written language in all areas of academic learning. Some students have difficulty creating pictures in their head, retrieving words to verbalize their ideas, and putting their thoughts in order. Utilizing a graphic organizer can help students when they need to present information orally or develop a draft for writing.

 

Resources:

Architects For Learning. (2022, May 18). Helping students manage what’s hard about school and thrive as life-long learners. Retrieved June 21, 2022, from https://www.architectsforlearning.com/students-parents/about-us/

Erwin, L. (2017, May 26). 5 reasons to use graphic organizers in speech therapy. My Speech Tools. Retrieved June 21, 2022, from https://myspeechtools.blogspot.com/2017/05/5-reasons-you-should-use-graphic-organizers-speech-therapy-sessions.html

Servati, Katrina, “Prewriting Strategies and their Effect on Student Writing” (2012). Education Masters. Paper 242. https://fisherpub.sjfc.edu/education_ETD_masters/242

Sherman, H. (2017, December 23). Using Graphic Organizers is Essential in Speech Therapy. Speech Time Fun Speech and Language Activities. Retrieved June 21, 2022, from https://speechtimefun.com/using-graphic-organizers-is-essential-in-speech-therapy/

Pyle, N., Vasquez, A. C., Lignugaris, K., & B., Gillam, S.L., Reutzel, D.R., Olszewski, A., Segura, H., Hartzheim, D., Laing, W., and Pyle, D. (2017). Effects of expository text structure interventions on comprehension: A meta-analysis. Reading Research Quarterly, 52(5), 1–33. https:// doi. org/ 10. 1002/ rrq. 179

 

About the Author

Olivia Rogers received her Master of Arts in Speech-Language Pathology from the University of Maine, after graduating with a Bachelor of Arts in Communication Sciences and Disorders and concentrations in Childhood Development and Disability Studies. She holds a Certificate of Clinical Competence in speech-language pathology from the American Speech-Language-Hearing Association, as well as a professional license in speech-language pathology from the Commonwealth of Massachusetts.

Ms. Rogers has experience working both in the pediatric clinic setting as well as in public schools, evaluating and treating children 2-18 years of age presenting with a wide range of diagnoses (e.g., language delays and disorders, speech sound disorders, childhood apraxia of speech, autism spectrum disorder, social communication disorder, and Down syndrome). Ms. Rogers enjoys making sure therapy is fun and tailored to each client’s interests.

In her free time, she enjoys listening to podcasts and spending times with friends and families.

 

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.

 

To book an appointment with Olivia Rogers, please complete our Intake Form today. For more information about NESCA, please email info@nesca-newton.com or call 617-658-9800.

 

39

Testing Outside the Box—Vocational Assessments for Nonverbal, Nonreading and/or Hard-to-Test Students

By | NESCA Notes 2022

By: Kelley Challen, Ed.M., CAS
Director of Transition Services; Transition Specialist, NESCA

My colleague Tabitha Monahan and I have dedicated several recent blog entries to vocational assessment—a vital tool for helping students to learn about career planning and employment and to set career goals for themselves. Previous blogs have included an overview of vocational assessment as well as an in depth look at career interest inventories, career aptitude testing, assessing work motivation and values and real-life experiences, such as informational interviews and job shadows.

However, many of the most “popular” or common tools for vocation assessment are intended for use with students who have functional reading abilities (i.e., basic reading skills at or above 5th grade levels). While there are many accommodations a skilled evaluator might use to help a wide range of students effectively access these tests, there are also students who receive special education services and cannot access these word-based and rating-based assessment tools. So, what tools can be used effectively with these students? How do we assess interests and aptitudes for students who are nonverbal, have reduced reading skills, or may provide unreliable responses to language-based testing methodologies? Below are a few of the methods that we find particularly useful at NESCA.

  • Picture-based Interest Inventories

Instead of using text-based items and rating scales, picture-based career interest inventories help individuals to express their occupational interests by selecting preferred pictures of people at work or people performing work-related tasks. Pictures are presented in sets of two, three, or more, and the student points to or circles the picture that seems most interesting. Based on the number and types of pictures selected, the test identifies work themes that are most appealing to the student. Evaluators can also look for themes among pictures selected, such as a student who selects a high number of pictures that have multiple people, computers, vehicles, outdoor activities, etc. Three popular picture-based assessments are the Picture Interest Career Survey (PICS) published by JIST, the Reading-Free Vocational Interest Inventory-Third Edition (RFVII-3) by Katherine Synatschk and Ralph Becker, and the Career Interest Inventory – Pictorial Version by Shasta Twenty-first Century Career Connections.

  • Video-based Interest Assessment

Video-based career interest assessments are more difficult to find but can be incredibly useful nonverbal tools for vocational evaluation and career planning. A tool that we use at NESCA is Your Employment Selections (YES), which is a CD-ROM-based reading-free job preference and career exploration program that has 120 videos of different jobs which are viewed and compared strategically in pairs. Through initial video-based trial, students indicate preferences, such as a desire to work indoors or outdoors, work alone or with coworkers, interact with the public or coworkers, and do light or heavy lifting work. These preferences are used to determine which subset of job videos the student will view. Traditional testing involves the student watching two videos and pointing to, or clicking on, the one they like more. However, the evaluator can work with a student who has limited verbal abilities to determine some of the features or tasks the student likes most, or dislikes most, within the specific job videos shown. While this video program is no longer available for retail, there are plenty of great career videos that can be used to carry out similar informal assessment on web sites, such as CareerOneStop, Dr. Kit, MassHire Career Information System, and even YouTube.

  • Functional Assessments and Observations

For all students, regardless of communication or self-determination skills, functional assessments and real-world observations play a vital role in career assessment and planning. For students who struggle with reading- and writing-based assessments, it can be important to have access to more hands-on standardized assessments of employment strengths and abilities. One such assessment tool is the Skills Assessment Module (SAM) published by Piney Mountain Press, which includes an auditory directions screen to determine how well a student can follow verbal directions and 12 work-related activities that simulate actual work aptitudes required in training and jobs (e.g., mail sort, ruler reading, assembling small parts, etc.). However, evaluators who do not have access to formal assessments can purchase or create pre-vocational and vocational kits for assessing and learning work skills and can carry out functional assessment of real or simulated work-related tasks in school, community, and work settings.

Observing students performing work-related behaviors and tasks is one of the most powerful evaluation tools that we have for determining strengths and needed areas for growth. If a student is performing vocational activities at school or has a volunteer or paid job during the week, that can be critical for an evaluator to observe. There are also protocols that can be used to formally assess students’ skills during observations, such as the Vocational Skills Assessment Protocol from The Assessment of Functional Living Skills (AFLS), and the Becker Work Adjustment Profile – Second Edition (BWAP-2).

  • Interviews and Parent/Educator Participation in Interest Inventories

While some transition-aged students may have trouble clearly expressing interests using words or inventories, all students have some way of communicating information to people who know them well. Transition and vocational assessments often require creativity and effort to gain informal, subjective, and anecdotal information from educators, parents, and other stakeholders who know the student well. It is useful to interview several people, asking questions about the student’s preferred leisure and school activities, areas of strength, preferences that need to be taken into account when planning for future employment, and specifically asking if there are any jobs that the interviewee is aware of that they think might be a good fit for the student in the future. Another technique is to use career interest inventories which are intended for self-report, such as the O*Net Interest Profiler (IP) or RIASEC, and ask parents or educators to fill out the inventory with what they believe the student’s preferences would be. Having a high level of correlation between parent report, educator report, and the student’s responses on picture-based or video-based testing can be extremely helpful in knowing where to focus career planning energy for the student.

Conducting vocational assessment, or any assessment, for this population of students—when tests are often not explicitly designed for them–is difficult. There are some tremendous tools specifically designed for testing students who are nonverbal or nonreaders, and there are many other assessment tools which can be made, modified, or used in nontraditional ways to gain a more complete picture of the student. The most important aspect of assessment is to choose the tools that are going to best suit the student.

For more information about vocational assessment and transition assessment at NESCA, visit our transition services page and our transition FAQs.

 

About the Author
Kelley Challen, Ed.M., CAS, is NESCA’s Director of Transition Services, overseeing planning, consultation, evaluation, coaching, case management, training and program development services. Ms. Challen also provides expert witness testimony in legal proceedings related to special education. She is also the Assistant Director of NESCA, working under Dr. Ann Helmus to support day-to-day operations of the practice. Ms. Challen began facilitating programs for children and adolescents with special needs in 2004. After receiving her Master’s Degree and Certificate of Advanced Study in Risk and Prevention Counseling from Harvard Graduate School of Education, Ms. Challen spent several years at the MGH Aspire Program where she founded an array of social, life and career skill development programs for teens and young adults with Asperger’s Syndrome and related profiles. She additionally worked at the Northeast Arc as Program Director for the Spotlight Program, a drama-based social pragmatics program, serving youth with a wide range of diagnoses and collaborating with several school districts to design in-house social skills and transition programs. Ms. Challen is co-author of the chapter “Technologies to Support Interventions for Social- Emotional Intelligence, Self-Awareness, Personality Style, and Self-Regulation” for the book Technology Tools for Students with Autism. She is also a proud mother of two energetic boys, ages six and three. While Ms. Challen has special expertise in supporting students with Autism Spectrum Disorders, she provides support to individuals with a wide range of developmental and learning abilities, including students with complex medical needs.

 

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com, call 617-658-9800 or complete our online Intake Form.

9

ADHD & Social Skills

By | NESCA Notes 2022

By: Maggie Rodriguez, Psy.D.
Pediatric Neuropsychologist, NESCA

When most of us hear the term “ADHD (attention deficit hyperactivity disorder),” we think of the little boy who can’t sit still at his desk or the girl gazing out the window lost in her own thoughts during class. While difficulties with hyperactivity and/or attention are core features of ADHD–embedded directly in the diagnostic label–there are often co-occurring features that are less obvious. Moreover, even the central aspects of ADHD can have far-reaching impacts beyond the classroom. One of the most frequently misunderstood and overlooked facets of ADHD is its potential impact on social functioning.

In clinical practice, parents of children with ADHD are often confused by the unexpected and indirect ways that attentional and executive functioning deficits can affect social functioning. They sometimes wonder if their children have an additional challenge, such as autism spectrum disorder. Most often, that’s not the case. Rather, it’s more likely that one or more of the following is at play:

  • Kids with ADHD can have difficulty selectively attending to relevant social cues
    • Imagine looking through a camera with a broken zoom lens. At first everything is in frame at once; it’s too much information. Then you try to zoom in, but when you do, sometimes the lens focuses on unimportant things (like the random details in the background), leaving out what’s most relevant (like the person you’re trying to capture in your photo). Children with ADHD have difficulty figuring out what details to focus on and struggle to effectively “zoom in” on those elements. In social settings, which are often unstructured, kids with ADHD are even more prone to “zoom in” on unimportant things and miss the more salient information. They can also become easily distracted and fail to register important information in the moment. To others, this can come across as lack of interest (for instance, the child who seems not to be listening or is distracted by sounds, sights, or other sensory information in the moment). It can also lead children with ADHD to overlook contextual cues about what’s expected in a given social setting, which can lead to inappropriate behavior.
  • Children with ADHD often struggle with nuance, making inferences, and reading between the lines
    • Social situations are much more complex than we often realize. Successfully navigating social interactions requires paying attention, not just to surface level information but to the often subtle, implied meaning embedded in things like figures of speech, tone of voice, and body language. For many with ADHD, it’s already a challenge to maintain focus at the surface level; the task of trying to simultaneously attend to and interpret subtext is too much. Individuals with ADHD may focus on what another person says (the content of their speech) but fail to notice the eye roll or sarcastic tone of voice that goes along with it.
  • Impulsivity can lead to social faux pas
    • Impulsivity is a central feature of ADHD in many cases. In social settings, difficulty inhibiting impulses can take many forms. For some, it may simply present as rapid-fire speech, leaving little room for others to respond in conversation. It can also look like interrupting, cutting others in line, or expressing ideas and opinions in a way that can be hurtful or seem rude. Especially in younger children, impulsive behavior can lead to difficulty sharing, physical aggression towards others, and trouble with turn taking. Children who have more difficulty slowing down and inhibiting impulses are more likely to inadvertently offend others or to engage in behavior that their peers may view as odd or inappropriate; in turn, this can lead to trouble developing and sustaining friendships and other positive relationships.
  • Hyperactivity makes participating appropriately in some social settings difficult
    • There are some social contexts in which an abundance of energy is a very good thing. For this reason, many ADHD kids can excel in activities like sports, into which they can channel their high energy. But other social situations demand a different set of skills. For kids with hyperactivity as part of their ADHD, sitting still and maintaining quiet can be a challenge. They may struggle with activities like going to the library, watching a movie in a theater, attending church or religious ceremonies, or sitting at the table in order to have family dinner.

The good news is that there are ways to manage these social challenges. If your child with ADHD has difficulty with any aspects of social functioning, it may help to seek out social skills training with a therapist or through a structured social skills training program. Interventions often include a combination of explicit instruction, modeling, role playing, and feedback. Parents can also help by implementing simple, consistent ground rules for behavior and providing gentle but clear reminders as needed. Additionally, parents can facilitate play dates with peers, during which the parents take an active role in helping children utilize social skills and engage with each other appropriately.

Finally, though ADHD can present challenges in the social domain, kids with ADHD often possess many strengths that can help actually them succeed socially. Children with ADHD can be highly engaging, curious, energetic, creative, and open-minded. When these strengths are reinforced, kids with ADHD can often utilize them to create fun, rewarding social interactions and to develop rich, dynamic relationships.

 

About the Author

Maggie Rodriguez, Psy.D., provides comprehensive evaluation services for children, adolescents, and young adults with often complex presentations. She particularly enjoys working with individuals who have concerns about attention and executive functioning, language-based learning disorders, and those with overlapping cognitive and social/emotional difficulties.

Prior to joining NESCA, Dr. Rodriguez worked in private practice, where she completed assessments with high-functioning students presenting with complex cognitive profiles whose areas of weakness may have gone previously undiagnosed. Dr. Rodriguez’s experience also includes pre- and post-doctoral training in the Learning Disability Clinic at Boston Children’s Hospital and the Neurodevelopmental Center at MassGeneral for Children/North Shore Medical Center. Dr. Rodriguez has spent significant time working with students in academic settings, including k-12 public and charter school systems and private academic programs, such as the Threshold Program at Lesley University.

Dr. Rodriguez earned her Psy.D. from William James College in 2012, where her coursework and practicum training focused on clinical work with children and adolescents and on assessment. Her doctoral thesis centered on cultural issues related to evaluation.

Dr. Rodriguez lives north of Boston with her husband and three young children.  She enjoys spending time outdoors hiking and bike riding with her family, practicing yoga, and reading.

To book a consultation with Dr. Rodriguez or one of our many other expert neuropsychologists, complete NESCA’s online intake form.

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.

158

Executive Function: Skill Building and Maintenance over the Summer

By | NESCA Notes 2022

By: Sophie Bellenis, OTD, OTR/L
Occupational Therapist; Real-life Skills Program Manager and Coach, NESCA

With summer right around the corner, many students are thinking of warm evenings outside, days at the beach, pool or park, summer camps, and summer jobs. For parents, summer can sometimes feel like both a time of fun and a time of struggling to keep up with skills mastered and learned throughout the past school year, all while acclimating to a completely new summer routine. While some students receive summer services to keep up with important academic and executive function skills, there are absolutely ways for us to help support children and adolescents at home. Consider these three ways to incorporate executive function skill building into your child’s summer.

  1. Plan and Complete a Project – Work with your child to brainstorm a project that they would like to complete this summer. Some examples include having a lemonade stand, building a tree fort, doing a full bedroom makeover, or raising money for a cause they care about. Help your child figure out how to put together a plan to complete their goal. This will likely include a timeline complete with a comprehensive “To Do List,” a list of materials or supplies, and a list of people they may need to ask for help. The more intentional the planning of these steps is, the more a child will internalize the level of planning and prioritization that goes into accomplishing such a goal. You may need to jump in to help, but take every opportunity to defer to them and let them actively think things through before making suggestions or solving problems for them. Planning and executing a personal summer project helps to build organization, planning and prioritizing, flexible thinking, working memory, and task initiation.
  2. Organize a Family Outing – Summer can absolutely be a whirlwind, but reserve a day in the calendar for your child to plan a family outing or activity. This could be as big as a full day at the beach or as simple as a trip to lunch at their favorite restaurant. Help them think through everything that will be needed. What time will we leave? How long will it take to get there? How can you find that information? Should we check Google Maps together? How will we pay for the meal? By guiding your child through all of the steps before these activities, you help them recognize the level of planning and forethought that is necessary. For older children or adolescents, consider giving them a budget and asking them to plan a family outing independently, taking into account each family member’s preferences and schedules.
  3. Add a Weekly Task – During the school year, parents often do not have time to add chores or anything new at all to their child’s calendar. Dinners are often prepared and eaten on the fly between rehearsals, appointments, practices, and homework, and laundry gets done when someone has a free moment. Summer can be a great time of the year to add in an expectation for students who have been a bit overloaded with homework or other distractions. Consider adding a weekly task that student both need to complete and figuring out a way to remember (often a digital reminder!). One of my favorite options is to have a student cook a meal for the family one night per week. Have them set an alarm for 12pm that day, or even the day before, that prompts them to “figure out the plan for dinner.” This may look drastically different at various ages. An eight-year-old may be very proud of themselves for serving boxed macaroni and cheese (made with supervision), while a high school student may be up for trying to recreate a family recipe. The goal is not a gourmet Tuesday night meal, but practice with prior planning, sequencing, following directions, and building time management skills.

Incorporating children and adolescents into the planning, hard work, and many executive function tasks that go in to making a summer run smoothly allows them to build skills naturally. By handing down responsibility and increasing expectations bit by bit, we can allow our students to build their skills slowly and confidently. It’s important that students realize all of these many steps before they are expected to do everything on their own. Often, allowing children to feel this level of control and responsibility leads them to feel quite accomplished and proud of themselves! If you feel that facilitating this may be tricky, consider reaching out about executive function coaching, as all of these strategies can be practiced one-on-one with a coach!

 

About the Author
Sophie Bellenis is a Licensed Occupational Therapist in Massachusetts, specializing in educational OT and functional life skills development. Bellenis joined NESCA in the fall of 2017 to offer community-based skills coaching services as a part of the Real-life Skills Program within NESCA’s Transition Services team. Bellenis graduated from the MGH Institute of Health Professions with a Doctorate in Occupational Therapy, with a focus on pediatrics and international program evaluation. She is a member of the American Occupational Therapy Association, as well as the World Federation of Occupational Therapists. Having spent years delivering direct services at the elementary, middle school and high school levels, Bellenis has extensive background with school-based occupational therapy services.  She believes that individual sensory needs and visual skills must be taken into account to create comprehensive educational programming.

 

To book an appointment or to learn more about NESCA’s Executive Function Coaching Services, please fill out our online Intake Form, email info@nesca-newton.com or call 617-658-9800.

 

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.

 

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