Exciting announcement! NESCA is accepting clients for home- and/or community-based Real-life Skills and Executive Function Coaching with Leah Bridge, MSOT, OTR. Leah is available for in-person occupational therapy (OT) and coaching services in the Newton, MA and Central MA areas. NESCA’s team of coaches offer Real-life Skills, Executive Function, Functional OT and Parent/Caregiver Coaching remotely for those outside of the Newton area. To learn more or book coaching services, complete our Intake Form.

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emotional functioning

school student frustrated over the work

Navigating the Post-Honeymoon Phase: Signs Your Child May Need Support This School Year

By | NESCA Notes 2024

school student frustrated over the workBy Miranda Milana, Psy.D.
Pediatric Neuropsychologist

With the start of the school year well underway, we are beginning to see students and teachers settling into their classroom routines. Along with this increase in familiarity and comfortability, parents often start to see bits and pieces of challenges arise around this time of year that may have gone unnoticed during the initial “honeymoon period.” You may be wondering what challenges you should be looking out for and when those challenges warrant an evaluation to determine further supports and services. Let’s take some time to explore what to keep an eye on, and when it might be time to reach out to schedule an evaluation to dive a bit deeper into what is going on. 

Academics

No matter their age, if you ever feel your child is inundated and overwhelmed with schoolwork, it is a great idea to reach out to their teachers; ask how long homework should be taking and whether it should feel like review vs. new material. If homework starts to consistently become a battle, it might be worth taking a closer look into why. It could be because it’s a new and appropriately challenging course. It could also be because there are underlying language-based learning disabilities, a nonverbal learning disability, executive function challenges, or increasing symptoms of anxiety or depression. Some specific things to watch for:

  • Frequent tears during homework that appear to get worse instead of better
  • Not appearing to “get it” even after review and repetition
  • Difficulty studying/holding information in memory
  • Dysfluent reading or not understand what they’ve read
  • Challenges understanding math concepts or memorizing math facts
  • Difficulty applying and generalizing concepts
  • Opposition to handwriting tasks or when asked to compose a writing assignment
  • Poor penmanship that is illegible and/or immature for age
  • Not meeting benchmarks on assessments

Social Skills

At this point in the school year, children are typically starting to be interested in other peers within their classrooms. For younger kids, they are likely to feel more comfortable interacting with other children in their play. Common social concerns can include:

  • Not remembering any names or faces of kids in their class
  • Preferring to play alone, hesitant to join in with a group
  • Appearing unaware of social cues or how to initiate conversation with others
  • Rigidity in play—always wanting to play their own game by their own specific rules
  • Frequent peer conflicts and feeling rejected or left out

Emotional Functioning

A new school year often elicits feelings of anxiety in kids no matter how outgoing and social they may be! When might it be a sign that there is something more?

  • Continued and persistent resistance to going to school
  • Frequent somatic complaints with no apparent cause (e.g., headaches, stomachaches)
  • Change in sleeping patterns – not being able to fall asleep at night or waking up frequently
  • Difficulty with regulating their emotions/frequent tantrums
  • Changes in appetite
  • Negative statements about themselves
  • Increase in irritability
  • Withdrawal from others or previously preferred activities
  • Always wanting to know what is happening next and struggling with changes in routine (i.e., Does a substitute teacher derail their whole day? If a friend is out sick, is there a perseveration on where they are? Do you wait to tell them about changes in plans so they don’t worry in advance?)

Attention/Focus

Have you ever found yourself feeling restless and distracted when sitting through a work meeting? Kids are no different! Sitting still and paying attention for extended periods of time can be really tough – especially after being on summer break! Here are a few things to keep an eye on:

  • Frequently fidgeting in their seat or needing a fidget item to increase concentration
  • Difficulty with multi-step directions
  • Not remembering information presented during lectures
  • Acting impulsively
  • Easily distracted/daydreaming
  • Acting as if run by a motor
  • Blurting out thoughts, interrupting conversations
  • Teacher feedback that they are interrupting other students or not able to sit quietly and attend to class discussions

As always, you know your child best! If you feel like this year is off to a rocky start, or you’re starting to have questions regarding their functioning, do not hesitate to reach out and schedule an evaluation. A comprehensive neuropsychological evaluation is designed to look at ALL aspects of a child to determine what is getting in their way of reaching their potential. We are always here to help!

 

About the Author

Dr. Miranda Milana provides comprehensive evaluation services for children and adolescents with a wide range of concerns, includingMiranda Milana Headshot attention deficit disorders, communication disorders, intellectual disabilities, and learning disabilities. She particularly enjoys working with children and their families who have concerns regarding an autism spectrum disorder. Dr. Milana has received specialized training on the administration of the Autism Diagnostic Observation Schedule (ADOS).

Dr. Milana places great emphasis on adapting her approach to a child’s developmental level and providing a testing environment that is approachable and comfortable for them. She also values collaboration with families and outside providers to facilitate supports and services that are tailored to a child’s specific needs.

Before joining NESCA, Dr. Milana completed a two-year postdoctoral fellowship at Boston Children’s Hospital in the Developmental Medicine department, where she received extensive training in the administration of psychological and neuropsychological testing. She has also received assessment training from Beacon Assessment Center and The Brenner Center. Dr. Milana graduated with her B.A. from the University of New England and went on to receive her doctorate from William James College (WJC). She was a part of the Children and Families of Adversity and Resilience (CFAR) program while at WJC. Her doctoral training also included therapeutic services across a variety of settings, including an elementary school, the Family Health Center of Worcester and at Roger Williams University.

Dr. Milana grew up in Maine and enjoys trips back home to see her family throughout the year. She currently resides in Wrentham, Massachusetts, with her husband and two golden retrievers. She also enjoys spending time with family and friends, reading, and cheering on the Patriots, Bruins, Red Sox, and Celtics.​

To book an appointment with Dr. Miranda Milana or another expert NESCA neuropsychologist, please complete our Intake Form today. 

NESCA is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Plainville, and Hingham, Massachusetts; Londonderry, New Hampshire; the greater Burlington, Vermont region; and Brooklyn, New York (coaching services only) serving clients from infancy through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.

 

Why does my neuropsychologist need that? What do the tests measure and why is previous testing important?

By | NESCA Notes 2019

 

By:  Stephanie Monaghan-Blout, Psy.D.
Pediatric Neuropsychologist

When a family books an intake for neuropsychological evaluation, they are typically asked to complete a few pieces of paperwork and to bring previous testing and other educational documents such as an Individualized Education Program (IEP) for their intake appointment. Despite this request, many parents will come to the intake session with empty hands. Understanding that parents have an enormous number of tasks on their plate, one could expect that paperwork was left at home due to timing or organization difficulties. However, when I ask parents about the missing paperwork decision, the reasons for leaving it behind generally fall into two groups: (1) lack of knowledge about the purpose of testing; and (2) concerns about creating some form of bias in the examiner’s mind. Some parents don’t share prior testing with me because they don’t have a clear idea of what the testing is and how it is going to be used for my evaluation. This is very common with families who are new to the special education or mental health process. Some parents are reluctant to share past testing because they want a “fresh view” and are concerned that looking at someone else’s work may create a bias. This often comes up when there is disagreement between parents and their school or past provider as to the nature of the child’s difficulties. Sometimes the parents and child have had a bad previous experience with testing and/or with the examiner, and they do not feel that the test results accurately (or at least empathetically) describe their child. In any of these situations, I find that parents feel more comfortable if they know more about how the tests we use are developed and why we find it helpful to view previous testing.

Purpose of Testing: The purpose of neuropsychological testing is to find out if a child (or adolescent or adult) is developing skills at a rate and capacity commensurate with their age and ability level. In order to do this in an efficient, equitable, and consistent manner, test developers identify skills they think are important in learning, devise a task that appears to quantifiably measure that skill, give that task to children in different age groups and then transform the raw scores attained by the children into a common scale. This allows them to compare different children within an age group, and this also allows them to compare the same child at different ages. Some common measurement scales are standard scores, scaled scores, Z scores, T-scores and percentiles. All of these formats are based on a normal distribution (remember the bell curve?) in which the majority of scores fall within a certain area with increasingly fewer scores falling at either end. The “bump” where most scores fall is described as average (between 25th and 75th%ile) with the tails receiving an above or below average description. While these descriptions do not begin to capture the whole child, they do convey information about how a child is performing relative to developmental expectations based on what we know about children of the same age. They can also tell us if the child is making age expected progress according to their unique learning curve. Furthermore, most people are good at some things and not so good at others, and the pattern of their scores can often give us valuable information about their learning profile.

Question of Bias: The concern about bias is important, given that neuropsychological tests are often used to classify people and make decisions about providing or denying services. There are a number of ways in which we try to control for bias, starting with trying to make sure that the group of people that are used as test subjects when developing norms are representative of the population at large. Test makers are getting better at this, but we have a long way to go, which means that it is important that evaluators know how each test has been developed and normed. Test selection is also extremely important; some tests are not appropriate for some groups. Think about giving a Calculus test to someone who has not completed Algebra 1; this kind of mismatch is going to result in a spuriously low score on math ability.

The main way that neuropsychologists and psychologists try to control for bias is through what is referred to as standardized administration—giving the test in the same way to each child. A good deal of the training of graduate students, interns, and post-doctoral fellows involves learning and practicing these skills so that the test is given to every child in the same way, regardless of who gives it. At the same time, children are children, and sometimes they need something different. It is up to the evaluator to decide when to engage in “non-standardized administrative procedures.” One example of non-standard administration could be starting a child who has trouble catching on to novel tasks at a lower age starting point in order to help them master the task demands. Another example would be stopping a task before a ceiling of errors is reached because the child is very anxious and is having a hard time staying with the activity. It is important to make note of that break in protocol in the report; while it may somewhat reduce the validity of the scores, it also tells us something very valuable about the child’s learning style and tolerance.

Value of Having Previous Testing: Having the opportunity to review all previous testing is extremely valuable to neuropsychologists because it gives up some insight as to a child’s developmental trajectory. Scores that are higher than in previous testing may suggest improvement in a skill set. Scores that are consistent with previous testing indicate that a child is making age-expected progress along their unique learning curve. However, they may be falling farther and farther behind their same-age peers or progressing more quickly. Scores that are significantly weaker than in previous testing need to be closely examined. This could be a result of an imbalance between the environmental demands and the child’s internal resources. For instance, smart kids with executive function deficits are often not prepared for the organizational challenges of middle and high school. Significantly lower scores could also indicate stalled development due to ineffective educational interventions. It could also be a sign of emotional distress that is interfering with a child’s functioning. Rarely, it could be a sign of a medical or neurological problem. There are also some times when a change in average scores reflects a change in the exact tests or subtests used for the child. For example, when a teenager turns 16, it is common to begin administering adult intelligence scales and these tests may place higher value on slightly different skills (e.g., mental math). Without reviewing previous testing, a current evaluator may be able to provide a snapshot of a child’s current functioning, but might miss a critical developmental pattern important for understanding if/how the child is learning, what is needed to enhance their performance, and what can reasonably be expected over time for the child.

 

About the Author:

Formerly an adolescent and family therapist, Dr. Stephanie Monaghan-Blout is a senior clinician who joined NESCA at its inception in 2007. Dr. Monaghan-Blout specializes in the assessment of clients with complex learning and emotional issues. She is proficient in the administration of psychological (projective) tests, as well as in neuropsychological testing. Her responsibilities at NESCA also include acting as Clinical Coordinator, overseeing psycho-educational and therapeutic services. She has a particular interest in working with adopted children and their families, as well as those impacted by traumatic experiences. he is a member of the Trauma and Learning Policy Initiative (TLPI) associated with Massachusetts Advocates for Children and the Harvard Law Clinic, and is working with that group on an interdisciplinary guide to trauma sensitive evaluations.

 

 

To book an evaluation with Dr. Monaghan-Blout or one of our many other expert neuropsychologists and transition specialists, 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.

 

Emerging Psychosis: When to worry about your teen’s thinking

By | NESCA Notes 2017

 

By:  Stephanie Monaghan-Blout, Psy.D.
Pediatric Neuropsychologist

Emerging Psychosis: When to Worry about Your Teen’s Thinking

Teenagers are famous for incidents of bad judgment and poorly considered decisions; it is one of the rites of passage for parents and children to have had at least one “What were you thinking?” discussion before the teen leaves the family nest for college or employment. These events are often memorable, however, because they tend to be outliers, occurring simultaneously with instances of relatively accurate appraisals of situations and relatively adequate problem-solving as they navigate the expectations of school, family, friends, and community.

Some parents must confront a separate set of ongoing concerns about their child’s thinking that effect their assessment of the world and themselves. In this article, I will talk about the nature of psychosis, describe the changes leading up to an episode of psychosis and outline emerging models of treatment which aim to prevent the first acute episode or at least delay onset of the episode as much as possible. These findings emphasize the critical importance of early identification and treatment of symptoms to prevent or reduce future impairment.

The Nature of Psychosis
Psychosis refers to a condition in which a person has lost contact with reality and is unable to distinguish what is real and what is not. Psychotic symptoms include what are called “positive” (what is present) and “negative” (what is absent) symptoms.

  • Positive symptoms include: abnormalities of thinking in both content as well as form; the former refers to distortions of reality such as hallucinations or delusions, and the latter refers to disorganization of thinking and bizarre behavior.
  • Negative symptoms refer to the reduction of emotional response (“blunted” or incongruous affect), apathy and loss of motivation, social withdrawal, impaired attention, reduced speech and movement, loss of enjoyment in life (“anhedonia”).

Researchers have also identified subtle cognitive impairments that include:

  • Deficits in processing speed
  • Executive function
  • Sustained attention/vigilance
  • Working memory
  • Verbal learning and memory
  • Reasoning and problem solving
  • Verbal comprehension
  • Social cognition

The impact of these issues can result in severe functional deficits across a range of domains such as work, school, and relationships.

Psychosis is now thought to be a neurodevelopmental disorder, meaning that it is thought to be related to abnormalities in brain development that become apparent as the brain matures in adolescence. Psychosis is thus a condition that emerges gradually as the underlying dysfunction comes to the fore. It is also thought to be a neurodegenerative disorder, meaning that the disease causes physical changes to the brain that results in impaired functioning. These changes include, on average, slightly larger lateral ventricle and slightly less cerebral gray matter for people at the first psychotic break compared to controls. From a behavioral perspective, researchers have found that the longer people live with an untreated psychosis, the more likely they are to experience functional impairments, have a poor response to psychiatric medications, and experience a poor quality of life. These alarming findings have prompted researchers and clinicians to research the period of time before the first psychotic break, referred to as the prodromal period, where symptoms start to emerge, in an effort to discover a way to divert or slow this process.

The Prodromal Period

The prodromal period is a time when “subclinical”, or milder symptoms of psychosis begin to appear. This period can vary in length from a few weeks to a few years. During this period, the adolescent or young adult may experience mild disturbances in perception, cognition, language, motor function, willpower, initiative, level of energy, and stress tolerance. These are differentiated from frank psychosis by lower levels of intensity, frequency or duration. The teen may complain of nonspecific clinical symptoms such as depression, anxiety, social isolation, and/or difficulties with school. They then may start to occasionally experience positive symptoms that are brief in duration and moderate in intensity. These events may become more serious over time, although they don’t happen often, last for only a few minutes to hours, and the person still retains some insight as to the unusual nature of the phenomena. However, this situation changes as the person comes closer to the initial psychotic break, signaled by the emergence of unusual thoughts, perceptual abnormalities, and disordered speech.

Risk and Resource

Who is most likely to move from the prodromal period to frank psychosis? Factors most predictive of this transition include people with a family history of psychosis and a recent deterioration of functioning, a history of substance abuse, and higher levels of unusual thoughts and social impairments. Other mediating factors include poor functioning, lengthy time period of symptoms, elevated levels of depression or other comorbid conditions, and reduced attention.

What factors appear to ameliorate risk of descending into psychosis? Risk/protective factors include higher premorbid cognitive skills and social skills and lack of a history of substance abuse.

How and When to Intervene

The information provided here about emerging psychosis underlines the critical importance of early intervention to address the serious and pervasive impact on functioning. Professionals who treat people at risk of psychosis are now beginning to use a clinical staging of treatment, meaning treatments should be tailored to the client’s needs, starting with safer and simpler interventions for the prodromal stages and increasingly intensive and aggressive treatment for people who are already contending with psychosis. This requires starting with what appears to be most problematic at the time for the person. For some people, this means treating the comorbid psychiatric conditions. For those who are experiencing difficulties with attention/executive function or reporting elevated levels of unusual symptoms, it may mean starting the person on an atypical antipsychotic. The use of targeted psychosocial interventions such as cognitive behavioral therapy, social skills training, and family therapy have all been found to be associated with reduced or delayed transition to first episode psychosis.

Where to Go for Help

Living in the Boston area, we are fortunate to have a wealth of resources in our hospitals and training sites that are engaged in cutting edge research and intervention to address the needs of young people who are contending with emerging psychosis. These include Beth Israel-Deaconess Hospital’s Center for Early Detection and Response to Risk (CEDAR) and the Prevention and Recovery in Early Psychosis (PREP) jointly run by the Beth Israel-Deaconess and Massachusetts Mental Health Center. Also, Cambridge Health Alliance offers the Recovery in Shared Experiences (RISE) program for the treatment of first episodes of psychosis.

Neuropsychological testing, augmented by psychological testing can be a useful tool to learn more about cognitive and emotional functioning. However, this is best undertaken as part of a comprehensive program of intervention.

 

Articles used for this blog:

  • Larson, M, Walker, E, and Compton, M (2010) Early Signs, diagnosis, and therapeutics of the prodromal phase of schizophrenia and related psychotic disorders, Expert Review of Neurotherapy. Aug. 10 (8), 1347-1359. https://www.nimh.nih.gov/health/topics/schizophrenia/raise/what-is-psychosis.shtml
  • NPR Your Health Podcast (2014) Halting Schizophrenia Before It Starts
  • Miller, Brian Negative Symptoms in Schizophrenia; The Importance of Identification and Treatment, Psychiatric Times, March 2017

 

 

About the Author:

Monaghan-BloutFormerly an adolescent and family therapist, Dr. Stephanie Monaghan-Blout is a senior clinician who joined NESCA at its inception in 2007. Dr. Monaghan-Blout specializes in the assessment of clients with complex learning and emotional issues. She is proficient in the administration of psychological (projective) tests, as well as in neuropsychological testing. Her responsibilities at NESCA also include acting as Clinical Coordinator, overseeing psycho-educational and therapeutic services. She has a particular interest in working with adopted children and their families, as well as those impacted by traumatic experiences.

 

 

To book a consultation with Dr. Monaghan-Blout 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.

 

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