While school may be wrapping up, Summer is an ideal time to embark on transition assessment and services to ensure that your child’s IEP process is preparing them for learning, living, and working after their public education. The ultimate goal of transition assessment is to identify the necessary skills and services to ready a student age 13-21 for transitioning from high school to the next phase of life. To book an intake and consultation appointment, visit: www.nesca-newton.com/intake. Not sure if you need an assessment? You can schedule a one-hour parent/caregiver intake and consultation.

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rating scales

Understanding the Neuropsychological Evaluation Process When an Autism Spectrum Disorder is Suspected

By | NESCA Notes 2024

By Miranda Milana, Psy.D.
Pediatric Neuropsychologist

In January, Dr. Folsom published a blog post detailing the reasons why so many females on the autism spectrum are misdiagnosed in childhood. Here at NESCA, we are continuously working to improve our testing practices and administration protocols to ensure that we accurately capture one’s diagnostic picture when they come in for a comprehensive neuropsychological evaluation regardless of gender identity, age, or diagnostic presentation. As clinicians, tailoring an appropriate testing protocol is only one piece of the puzzle when working with our clients. From the moment we review your intake paperwork and questions/concerns, we work diligently to make sure we are teasing apart each component of a child’s neuropsychological profile to ensure clarity and accuracy for diagnoses and tailored recommendations. Here is a look into some of what that process looks like:

Initial Paperwork: Before your first intake appointment, your clinician will thoroughly review all of the intake paperwork and supporting documents you have submitted to us. We make sure to read all of your questions and concerns, while also making our own notes of questions that we will have for you during the intake appointment. All neuropsychologists here at NESCA are trained to identify “red flags” or areas of potential concern that we want to know more about through our interviews with you, your child, teachers, and our testing protocols.

Intake Appointment: During this appointment, we will ask you more in-depth questions about your responses and questions from the intake paperwork you provided. This is an opportunity for us to explore any concerns we may have. For many diagnoses, there are overlapping diagnostic features that are important to tease apart. For example, inflexibility and rigidity (not handling transitions well, struggling with changes in routine) may be related to an anxiety diagnosis, a mood disorder, an autism spectrum diagnosis, and/or executive functioning weaknesses.

Speaking with Collaterals: Oftentimes, clinicians will ask for permission to speak to other caregivers who have knowledge of your child, such as teachers, therapists, and pediatricians. Because we only see your child for a “snapshot” in time, it is important for us to also consider the perspectives of those who have longstanding relationships with them in a variety of contexts and environments.

Developing a Testing Battery: After the intake appointment, clinicians put together a tentative list of assessment measures that we may want to utilize. Tentative is the key word because oftentimes testing batteries change throughout the course of the assessment as a diagnostic picture becomes clearer or when specific areas of deficit become more apparent.

At NESCA, we have access to multiple testing tools that allow us to tailor our testing battery to capture any nuanced constellation of symptoms or diagnostic profile. For example, when thinking about how to accurately diagnose someone who is “high functioning” or “masking” areas of vulnerability related to an autism spectrum diagnosis, clinicians have access to the following batteries:

  • Autism Diagnostic Observation Schedule—2nd (ADOS-2): The ADOS-2 is one of the most well-known assessments for autism as it utilizes a semi-structured format to assess social communication skills as well as restricted interests, repetitive behaviors, sensory sensitivities, and rigidity. The ADOS-2 relies on standardized observations to capture any difficulties in the aforementioned categories.
  • Childhood Autism Rating Scale—2nd (CARS-2): The CARS-2 is another measure that involves a standardized rating scale based on direct observations of the child. While playing and interacting with your child, the clinician is able to fill out this rating scale to assess symptoms associated with an Autism Spectrum Disorder. The CARS-2 also includes a parent questionnaire to allow for qualitative parent observations.
  • Monteiro Interview Guidelines for Diagnosing the Autism Spectrum—2nd (MIGDAS-2): The MIGDAS-2 assesses qualitative observations of language and communication skills, social relationships, emotional responses, as well as sensory interests and/or sensitivities. The MIGDAS-2 can be particularly helpful for children and adolescents who are “high-functioning,” or do not fit the presentation of the “male prototype” described in Dr. Folsom’s blog.
  • Social Language Development Test (SLDT): The SLDT measures social communication skills such as the ability to make inferences, interpret social situations, and navigate peer conflicts.

In addition to the above measures, clinicians may also choose to administer subtests related to social thinking, perspective taking, and/or emotion identification. Examples of these subtests include:

  • Affect Recognition and Theory of Mind from the NEPSY-II
  • Inferences, Meaning from Context, Idiomatic Language and Pragmatic Language on the CASL-2

For older children and adolescents, clinicians may ask them to fill out/answer questions about their own perceptions of their lived experiences. This can be done through an unstructured interview or by one of the following:

  • Camouflaging Autistic Traits Questionnaire (CAT-Q)
  • Ritvo Autism Asperger Diagnostic Scale—Revised (RAADS-R)
  • Autism Spectrum Quotient (ASQ)

Parent Questionnaires: Whenever there are any questions or concerns related to social communication and interpersonal relatedness, your clinician may ask you to fill out rating scales assessing your perception of your child’s ability to interact with others, engage in age-appropriate play, be flexible in their responses to change or new environments, and have a variety of interests. These questionnaires include:

  • Social Responsiveness Scale—2nd (SRS-2)
  • Social Communication Questionnaire (SCQ)
  • Autism Diagnostic Interview—Revised (ADI-R)
  • Gilliam Autism Rating Scale—3rd (GARS-3)
  • Gilliam Asperger’s Disorder Scale (GADS)
  • Autism Spectrum Rating Scales (ASRS)

As you can see, we have a wide variety of measures available at NESCA to look at symptoms of an Autism Spectrum Disorder. Based on the discretion of your clinician, one or more of these may be used to further assess social communication concerns. While you may have heard of some of these being referred to as “the gold standard,” your clinician will use their knowledge, experience, and training to tailor a testing battery for the individual needs of your child. There is never a one size fits all approach to neuropsychological testing!

 

About the Author

Dr. Miranda Milana provides comprehensive evaluation services for children and adolescents with a wide range of concerns, including 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.

 

Questionnaires, Rating Scales, and Checklists, Oh My!

By | Nesca Notes 2023

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

Before I had children, I knew parenting would bring with it new demands. If you’d asked me what tasks I imagined would take a lot of my time and energy as a parent, I would have listed things like feeding hungry little mouths, washing adorable clothes, driving kids to and from school and activities, dealing with bath time, and reading stories at bedtime. What I would never have guessed is how much time and mental effort I would spend filling out paperwork. From the moment a child enters a parent’s life—regardless of what process brings them together as a family—it seems like there are unending forms to complete. As a parent of three children, I cannot begin to calculate how many hours I’ve spent filling out forms for doctors, daycares, schools, camps, babysitters, and extracurriculars. It’s a lot.

Perhaps that’s why I sometimes notice a very relatable subtle sigh when I hand parents forms to complete as part of their children’s neuropsychological evaluation. I get it, and I never want to add to a parent’s already overwhelming list of tasks to complete. Nevertheless, carefully selected questionnaires are an important part of a thorough neuropsychological assessment. Here are a few of the reasons why.

  1. Simply put, parents are the experts on their children. No doubt about it, a parent (or primary caregiver) knows a child better than just about anyone else could. Parents are uniquely qualified to provide invaluable information about their children and are a tremendous resource.
  2. Parents have more data points. During an evaluation, I typically spend about five hours with a child over the course of two testing sessions. It’s a limited glimpse into mere hours out of years of a child’s life. Parents are typically positioned to observe their children much more frequently and on many more occasions. I may see a child at their best or on a particularly bad day, and I don’t want to rely on my observations alone. Having information from many points in time, and from different settings, is incredibly useful and helps capture a more complete picture of a child.
  3. I want and need to know what happens outside the testing office. By design, the testing environment is deliberately developed to be a quiet space as free of distractions as possible to maximize a child’s ability to focus and participate in formal testing. It’s a highly structured situation and a one-on-one interaction. Life outside the office is…well, quite different. I want to get a sense of what happens during the hectic morning rush to get out the door, on the playground and the soccer field, and at the family dinner table.
  4. On a related note, people present differently in different settings, and having data helps us make sense of this. Many parents can relate to the concept of “restraint collapse.” Essentially, kids often work hard to keep it together in the academic setting throughout the day and “fall apart” when they come home after a long day of school. Similarly, children are often on the “best behavior” in public settings and with adults other than their parents. For this reason, I often don’t get to see this important aspect of things, so I rely on parent reports.
  5. Some things simply cannot be readily assessed using standardized testing measures in an office environment. Two skill sets that fall into this category are executive functions and social skills. Executive functions, which include skills like working memory, are not easily captured through tests in the somewhat artificial environment of an office. To assess working memory, we rely on tasks such as asking a child to recall strings of numbers. In the real world, working memory applies to more complex tasks, such as following multi-step instructions in a busy classroom or home setting. A child may do well remembering single digit numbers, but this doesn’t always translate to being able to remember and complete a series of directions in the “real world.” Similarly, interacting with one adult in a highly structured environment doesn’t allow a glimpse into a child’s social skills within the more complex, unstructured situations they face day to day.

In short, neuropsychologists rely on information from parents to gain a clear and complete picture of a child and to provide answers to the questions that bring a family to us. One of the ways we obtain this information is through questionnaires, symptom rating scales, and checklists. So, parents, thank you, for taking the time to give us your unique and invaluable perspective. We couldn’t do our jobs without it or without you.

 

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.

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

Rating Scales/Questionnaires – Why Do We Give Them and Why Do They Matter?

By | NESCA Notes 2021

By Yvonne M. Asher, Ph.D. 
Pediatric Neuropsychologist

When you request a neuropsychological evaluation, you are undoubtably inundated with paperwork. Consent forms, confidentiality forms, COVID forms, and credit card forms. Then, to your surprise, you bring your child to their first appointment, and the neuropsychologist hands you…more forms! Why? What are these forms for, and what will you do with the information? These are great questions, and always feel free to ask your neuropsychologist. Here are some answers I give when I am asked:

Why do you need so many forms?

Our goal in completing a neuropsychological evaluation is to have as comprehensive picture of a child as possible. This means gathering information from many sources, including what you and/or others are noticing that is raising concerns (what we discuss in the intake appointment), prior evaluations and documentation (e.g., their IEP, testing done at school), your child’s performance on our assessment measures (what they do when they come to the office), and important people’s perceptions of your child’s functioning in daily settings – this is what we assess through the rating scales (also called questionnaires). The parent/teacher rating scales are an important source of information because they not only capture your concerns, but also show us how your concerns may be similar to or different from parents (or teachers) of same-age children. For example, concerns with “attention and focus” are common for us to hear. Attentional skills develop gradually over time, and having a standardized rating scale that evaluates your concerns (or your child’s teacher’s concerns) with attention helps us understand how far off your child’s skills are from what is expected for their age.

What do the forms ask about?

This depends on why your child is being referred for a neuropsychological evaluation. For example, if your child is referred for a question around autism, you will likely be given forms that ask about their social functioning, such as how they do at playdates, birthday parties, the playground, or other community spaces with peers. Your child’s teacher would also likely be given forms to evaluate how your child interacts with peers at school, such as how they do during lunch, snack, and recess; how well they work in groups; and if they have been successful in forming strong friendships. If the concerns are more related to mental health, you may be given forms that ask about their symptoms of anxiety, depression, etc.

What will you do with the forms?

We will take your ratings (or your child’s teacher’s ratings) and compare them to normative data. This is a fancy way of saying “we will see how your child compares to kids their age.” Then, we will take that information to help us form a more comprehensive picture of your child’s profile and our recommendations for how to best help and support them. For example, something I see often is a concern with kids following directions, remembering what they are told to do, and finishing all the steps necessary for a task or project (e.g., getting ready for school or bed). This can be (though certainly isn’t always) a difficulty with working memory or, holding information in mind. We assess working memory in many ways during testing. However, we can’t always see the deficits that parents and teachers see, because testing is inherently different from “real life.” So, rating scales serve as an important source of information in understanding what is going on day-to-day, which helps us to make more comprehensive recommendations.

How do I fill these out?

Please, please, please – read the directions carefully! Each form is meant to evaluate something different. For example, some ask you about your child’s emotional state “in general,” others ask about how they have been behaving over the last two weeks, and others ask about how well they can complete tasks independently (i.e., without any help or guidance). Do your best to complete each question – skipping questions that seem “irrelevant” or “inappropriate” may impact how well we can use the information later on. We realize that not every question will apply to every child – we are using the best tools we have, and some are designed to assess a wide range of children. If you have questions about the wording or phrasing, please ask your neuropsychologist – we really don’t mind!

I have a teenager. Why don’t you just ask them about how they are feeling?

If your child is old enough, we will absolutely talk to them about their perceptions of what is going on, what their concerns are, and what has been helpful for them. Many rating scales have a “child” or “self-report” version, and we may have them complete those, in addition to talking more conversationally about how they are doing.

 

About the Author

Dr. Yvonne M. Asher enjoys working with a wide range of children and teens, including those with autism spectrum disorder, developmental delays, learning disabilities, attention difficulties and executive functioning challenges. She often works with children whose complex profiles are not easily captured by a single label or diagnosis. She particularly enjoys working with young children and helping parents through their “first touch” with mental health care or developmental concerns.

Dr. Asher’s approach to assessment is gentle and supportive, and recognizes the importance of building rapport and trust. When working with young children, Dr. Asher incorporates play and “games” that allow children to complete standardized assessments in a fun and engaging environment.

Dr. Asher has extensive experience working in public, charter and religious schools, both as a classroom teacher and psychologist. She holds a master’s degree in education and continues to love working with educators. As a psychologist working in public schools, she gained invaluable experience with the IEP process from start to finish. She incorporates both her educational and psychological training when formulating recommendations to school teams.

Dr. Asher attended Swarthmore College and the Jewish Theological Seminary. She completed her doctoral degree at Suffolk University, where her dissertation looked at the impact of starting middle school on children’s social and emotional wellbeing. After graduating, she completed an intensive fellowship at the MGH Lurie Center for Autism, where she worked with a wide range of children, adolescents and young adults with autism and related disorders.

 

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 Dr. Yvonne Asher, please complete our Intake Form today. For more information about NESCA, please email info@nesca-newton.com or call 617-658-9800.