A neuropsychological evaluation, also called neuropsychological testing, is an in-depth assessment of abilities, skills, and behavior for the purpose of diagnosis and to guide treatment. It might conjure up images of patients on gurneys with wires attached to their heads and doctors hovering nearby, that couldn’t be further from reality!  

Neuropsychology looks at the relationship between the brain and behavior. At its core, the goal of assessment is to identify individual strengths and weaknesses. Both standardized tests and behavioral observation are used to measure what is happening with the client. When children and adolescents go for neuropsychological testing, clinicians collect data about the school and home environment. They also provide questionnaires for both parents and teachers. Then the testing data, parent and teacher reports, and behavioral observations are all put together to paint a picture of how the individual is functioning.  

The evaluation measures such areas as cognitive functioning, academic skills, attention, problem solving, memory, language, executive functions, visual-spatial skills, adaptive behavior, and social-emotional functioning. This evaluation is different from tests included in a neurological evaluation (e.g., EEG) or neuroimaging (e.g., CT or MRI scan). 

Who performs a neuropsychological evaluation? 

 A licensed clinical psychologist who has been formally trained in neuropsychology. Psychologists are experts in the diagnosis and treatment of mental health concerns. They are required to complete intensive coursework in diagnostic assessment and testing when obtaining their doctoral degree (PhD or PsyD), and many of us have sought postdoctoral training in assessment as well. 

Some practices work with bachelor’s or master’s level technicians who administer and score tests, while the supervising psychologist selects the tests that are administered, interprets the findings, and writes the report. Our practice finds tremendous value in the first-hand knowledge we gain from working one-on-one with a child and having a psychologist complete all aspects of the evaluation personally. Not only does it deepen our understanding of your child and our confidence in any resulting diagnosis, it also allows us to give more specific treatment recommendations.  

Does my child need a Neuropsychological Evaluation? 

So, does your child truly need neuropsychological testing, or are you over-amplifying the situation in your own mind? That’s the question so many parents grapple with. 

One way to make the decision is to ask yourself: “Is there a persistent problem? Is my child not learning as well as they previously were or as well as peers? Not getting good grades or has there been a change in performance? Having trouble making and keeping friends? Is the teacher making comments about attention or behavior? Is my child overly shy or aggressive?” Answering YES to one of these questions may suggest your child would benefit from a neuropsychological evaluation.  

Additional common behaviors that lead parents to neuropsychological testing are: 

• Inability to sustain attention 
• Anxiety/fear or reluctance to engage in developmentally appropriate activities 
• Atypical social behaviors/inability to establish peer friendships in a manner expected for age 
• Slow acquisition of academic skills 
• Obviously bright but inconsistently performing or under-performing academically 

Some parents also come to us with a prior diagnosis, but they are interested in knowing if their child is benefitting from the interventions they’ve received, or they need more knowledge about how their child is currently impacted in order to advocate for accommodations/services. We receive referrals from families, schools, psychiatrists, and pediatricians. 

Can a school provide the same evaluation as psychologist? 

School assessments are usually performed to determine whether a child qualifies for special education programs or therapies. Schools cannot provide a diagnosis. While many of the same tests are given in school and clinical settings, there are likely to be differences in the way that the tests are interpreted. It is rare for school evaluations to include measures of memory, attention/concentration, executive functioning, and other neuropsychological skills. Further, at Rose Assessment & Therapy Center, our approach to assessment gives us a luxury of time with each child. We prioritize quality assessment, and we pride ourselves on providing families with comprehensive information that is very specific to their child and concerns. Your child is our focus! We devote a great deal of time to each child.  

What can I expect testing to tell me about my child? 

Unlike screening measures like you might get at your pediatrician’s office (e.g., a rating scale that asks whether you see certain symptoms and takes less than 5 minutes to complete), psychological tests give us an in-depth understanding of your child’s areas of strength and challenge. They are standardized, meaning they are given in the same manner to all individuals, and they have established validity and reliability (so we are confident in the findings!). An individual’s scores on tests are interpreted by comparing their score to a normative sample of individuals (i.e., children of similar age, education, gender, etc.) and to expected levels of functioning. Although individual scores are important, the psychologist looks at all the data from the evaluation to determine a pattern of strengths and weaknesses. 

The testing results help those involved in your child’s care in several ways. Testing can explain why your child is having school problems. For example, a child may have difficulty reading because of an attention problem, a language disorder, or a reading disability. Additionally, different childhood disorders result in specific patterns of strengths and weaknesses. These profiles of abilities can help identify the origin of a child’s difficulties. For example, testing can help differentiate between an attention deficit and anxiety or determine whether a language delay is due to a problem in producing speech, understanding or expressing language, social shyness, autism, or cognitive delay. These are just a few examples. Most importantly, testing guides the psychologist’s design of interventions. Results identify what skills need further development and what strategies can be helpful. Testing also provides guidance to teachers, therapists, and other professionals to better understand how to help your child reach his or her potential.  

Next Steps: 

Give us a call or send an email! We will happily walk you through the testing process. Typically: 

• The testing process starts with a one-hour, adults only initial consultation. Parents complete a lengthy developmental history questionnaire that guides the psychologist in gathering additional information. During the consultation, the psychologist will be working to develop the testing battery that best fits your child’s needs. Additionally, this meeting allows you to get to know the psychologist and make sure they seem like the right “fit” for your child. 
• If it’s determined that testing is warranted, we will offer testing dates (please note we do not assume everyone needs comprehensive assessment – we’ll be honest with you if it seems like your questions or concerns are better answered through another avenue!). You can expect testing to take about 6 hours, divided over two mornings. Testing occurs on particular days from 9am-12pm. We will provide a school excuse note if your child is missing school. Sometimes parents worry beforehand about their child’s effort and/or engagement in testing, but rest assured we are experienced at simultaneously getting good data and making it a positive experience for children! 
• About two weeks after testing, parents come in for a 90-minute (adults only) feedback session. During this time, we will present the data collected, discuss diagnoses if there are any, and most importantly provide recommendations for intervention. 
• About one week after the feedback session parents receive the final written report. This report is your property; we will not provide it to anyone without your written consent. 

You can also find additional information on our website: https://www.rosetherapycenter.com/evaluations-2/. Neuropsychological assessment can be a powerful tool for understanding and advocating for your child. Reach out if we can be of help!  

Contact Information: 

Dr. Rose: 972-999-6490 or drrose@rosetherapycenter.com 

Dr. Wurster: 972-827-6023 or drwurster@rosetherapycenter.com 

www.rosetherapycenter.com  

There are many people who advertise that they provide assessment services. What do I look for in a provider?

Pretty much everyone who seeks out assessment has a question they want answered…and generally it’s not a question simple enough for a Google search!

Learning more about a provider’s background and approach can help you determine whether they are a good fit to answer your question. People can mean many different things when they refer to assessment on a website. You will want someone who:

• uses science-based, standardized measures with demonstrated validity and reliability;
• selects the most appropriate tests for your questions, rather than using the same testing battery for everyone;
• uses up-to-date measures;
• seeks out multiple sources of information;
• and has enough knowledge of diagnoses to differentiate between presentations that look similar but have different underlying causes.

Some practices provide assessment that is educational in nature, with staff who have backgrounds in education but who are unable to give mental health diagnoses that might be contributing to or underlying the presenting concern. For example, aspects of ADHD and anxiety can look similar in a young child, and there are also times when both are present and a child will benefit most from receiving both diagnoses and intervention for each.

Why choose a psychologist for assessment?

In short, because training in assessment is one factor that differentiates psychologists from other mental health providers! Psychology is the study of the mind and behavior, and psychologists are experts in the diagnosis and treatment of mental health concerns. Psychologists are required to complete intensive coursework in diagnostic assessment and testing when obtaining their doctoral degree (PhD or PsyD).

Some practices work with bachelor’s or master’s level technicians who administer and score tests, while the supervising psychologist selects the tests that are administered, interprets the findings, and writes the report. Our practice finds value in the first-hand knowledge we gain from working one-on-one with a child and having a psychologist complete all aspects of the evaluation personally.

Why do some practices not take insurance?

Some practices, including ours, choose not to be in-network with insurance companies. Often, this comes from a desire to provide comprehensive assessment where the psychologist and family have autonomy in decision-making based on the family’s presenting concern. This also allows for transparent pricing in the form of a flat fee that covers testing, scoring, interpretation, feedback session, and comprehensive report. Families may be able to receive partial reimbursement from their insurance company. Those interested in this would contact their insurance company and inquire about their out-of-network coverage, deductible, and the percentage they would be reimbursed.

What if my child has a meltdown or doesn’t comply with directions?

Many families who are seeking an evaluation due to behavioral concerns voice this question and our response is…how lovely that we get first-hand knowledge of the challenges you and your child are experiencing! It makes for rich observational data that informs our testing, interpretation, and recommendations. We are skilled clinicians when it comes to working with children and obtaining good, useful data. We genuinely enjoy learning about and connecting with your specific child, and we work hard to make the experience a pleasant one for them.

What happens after I receive the report?

After receiving the report, many families need to take a moment to absorb all the information. Our reports contain information about your child’s strengths as well as areas of challenge or need. Based on your child’s unique ways of thinking and learning, we provide resources and empirically-supported treatment recommendations for how to support your child moving forward. For many families, this serves as a guide that gives them direction in identifying and connecting with professionals who work together to meet their child’s needs.

It is also true that parents/caregivers experience their own emotional reactions to receiving information about their children’s areas of challenge. Some may feel relief to have answers, some may feel guilt for not having sought information earlier, some might need the space and time to grieve aspects of their child’s life that might be harder for them than their peers. Some parents might find themselves eager to connect with resources and implement treatment recommendations, while others might feel overwhelmed. However you feel afterward, know that we are here to support you and make space for that as well. We have a shared goal of seeing your child thrive.

Why are masks triggering anger and a divide among people?

This is my (a psychologist’s) attempt to explain how masks have come to provoke such strong emotional responses from people. This is not meant to be a debate, but to create space for us to understand the “WHY.” When we understand “why” we are feeling, thinking, or behaving in a certain way, THEN we can create change.

What is it about a seemingly neutral piece of protective gear that can be so inflammatory? Like many points of controversy, it’s not the thing itself but what it represents.

A Political Divide

Face masks have become tied to the political conflict over our national response to the coronavirus. Those who lean left politically tend to see the virus as a more dire threat; those on the right are more likely to downplay its seriousness or compare it to less contagious/deadly viruses like the flu, often following the lead of conservative politicians. Accordingly, masks may be seen as a marker of political loyalty, triggering feelings of us-versus-them. A politically liberal person may assume that someone wearing a mask is “on their team,” while those who don’t wear masks must be Fox News-watching Republicans. The anger they feel is not simply about the mask, but about believing the non-mask wearer is a certain type of person. Similarly, a person who does not wear a mask may assume those who do want to take away their individual freedoms. Being asked to wear a mask then becomes not just a request to protect the health of others, but to give up their worldview and political allegiance. For a lighter example, it may feel like asking a San Antonio Spurs fan to put on a Dallas Mavericks jersey!

We don’t like limits placed on behaviors

Our response to a perceived threat or loss of a behavioral freedom is referred to as “psychological reactance.” This reactance throws a person into a state or desire to regain that freedom. According to reactance theory, when people feel coerced into a certain behavior, they will react against the coercion. They often demonstrate an increased preference for the behavior that is restrained and may perform the behavior opposite to that desired. [proposed in 1966 Jack W. Brehm]

**It should be noted that this goes both ways…if people were “banned” from wearing a mask into a business or any place, they would be as equally upset as those being required to wear a mask. **

Now, cue embarrassment! When people feel embarrassed or humiliated, they really have two main ways to respond…they experience shame and/or guilt OR feel anger. When someone is asked to wear a mask in a building or asked to leave for not wearing a mask, the likely feel judged and embarrassed which can result in an aggressive reaction. Now focus is drawn to the feeling they are experiencing, and it's no longer about the mask. 

Conflicting Information

The amount of miscommunication and inconsistent information is alarming at best. Realistically, it has created a communication disaster! People have not received consistent information about the pandemic in general and specifically mask wearing. 

This is not to say that wearing a mask in public is simply a matter of personal choice. Masks aren’t like seatbelts: wearing a seatbelt is about ensuring your own safety. (Though, just like wearing a helmet on a motorcycle or bike, there is a societal benefit to avoiding serious, costly injuries that tax our medical resources and contribute to higher insurance rates.) While a mask helps protect the wearer, its most important benefit is in preventing the spread of coronavirus to others.

Consider viewing these sites for information about mask wearing:

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks

https://www.aap.org/en/news-room/news-releases/aap/2021/american-academy-of-pediatrics-updates-recommendations-for-opening-schools-in-fall-2021/

A Constructive Response

If you’re reluctant to wear a mask when required, question any automatic thoughts you have about others trying to take away your freedom. Try to allow space to be curious about your emotion (what it feels like, where is it coming from, etc.). Most likely their goal is just to keep everyone safe, not to make you buy into a certain worldview.

As a psychologist, I would strongly urge all adults and parents to maintain awareness that children are watching. Whether you are wanting to be a role model or not, children are paying attention to how you talk about others and make decisions! They are watching how we handle conflict, what we do with our emotions, and how we respond to others. Even if you think you are keeping the mask conversation private, children are more perceptive than you think and they are aware of the emotional involved. It's best to talk with then directly about what is happening in a fact based way.

How does Anxiety Develop?

The short answer is…it starts in the brain. There is a tiny, almond shaped part of the brain called the amygdala, located deep into the limbic system or what is commonly referred to as our “emotional brain." The emotional brain is the oldest, most primitive part of our brain, which was only ever designed to ensure physical survival.

Why would we need this?

Because long ago, physical safety was very important and a real problem. Think about cavemen who had to defend themselves against animals, reptiles, and other cavemen. Back then, humans needed a quick, hyper-vigilant brain that functioned automatically and unconsciously.  

Now fast forward several centuries…our brains generally no longer need to have a heightened sense of physical safety to survive. Along the way, likely through evolution, the brain adapted to needs that are different in the modern world. Now, the brain doesn’t have to prepare for physical safety, but more for social or psychological survival.  

So, how does this relate to anxiety?

One belief is that anxiety is related to a hyperactive amygdala. However, scientists have found that anxiety is the result of constant chatter between a number of different brain regions. They refer to this as a fear network (amygdala, hippocampus, and frontal lobe). In short, the frontal lobe, where thoughts and sensations come together, is the “thinking brain.”  When that is overridden by the emotional brain, in this case the amygdala, anxiety happens.

Let me try to explain more…

When we sense danger is present (e.g., you hear screeching tires as you are crossing the street), the amygdala reacts automatically and activates the fight, flight, or freeze response. This allows us to quickly get out of harm’s way. While this is extremely helpful, what about when the fear isn’t physical or logical? The modern world is full of psychological stress, from big (traumatic events in the news, social media, natural disasters) to small (getting a shot, talking in front of a group, going to a party, etc.).  

With these examples, we want to let our thinking brain run the show. The thinking brain (frontal lobe) processes information to determine if danger really is present and finds the most logical response to it.  

In scenarios that present mild to moderate threats, the frontal lobe can override the amygdala and allow you to function (i.e., not have an anxiety attack). However, when a threat is perceived as strong, the amygdala acts automatically and can overpower the frontal lobe.  

Remember the fear network? When we have a physiological response (increased heart rate, blood pumping to extremities, increased ability to take in oxygen) to a stimulus (fearful event, etc.), the hippocampus stores that into memory. So later when you feel the same or a similar physiological response, your brain thinks you are in actual danger and responds…sometimes causing a “false alarm."

How do you treat anxiety?

It’s not as simple as saying something positive! Remember, the amygdala fires automatically and unconsciously, meaning you cannot control that it fires or activates. You will experience physiological symptoms. Your goal is not let those symptoms overpower you.   

Important note: The amygdala only learns when it is activated! That’s right, you have to feel anxious to be able to “teach” your brain to calm down.  When you feel calm and are thinking about interventions to utilize, your amygdala isn’t learning a thing!

The amygdala isn’t trained by language, it is trained by actions!

Below are some steps to consider: 

• Acknowledge that you feel threatened or stressed and that your fight, flight, or freeze response has been activated. For kids, you may help label their feeling (scared, nervous, frightened…).   

• Once you acknowledge the amygdala is activated, then you can work to calm down or control it.  

• Remind yourself that the feeling is an automatic response, not necessarily the “right” or logical response.  

• Breathing cannot be underestimated! Take slow and deep breaths (using the diaphragm). It will take more than 3 to calm down! A simple trick to know if you are breaking correctly: when you inhale, your belly should go OUT…and when you exhale through your mouth, your belly should go IN. (You can also try placing a hand on your belly and a hand on your chest. The hand on your chest should not move, while the hand on your belly will go out and in.) 

• After breathing, now you can activate your thinking brain (frontal lobe). 

• Remember, the amygdala has to be activated for you to teach it new things! This is a part of exposure therapy. We have to approach the feared situation (meaning the amygdala is activated), stay until the physiological response has subsided, and then leave the situation. If you leave the situation before the body has calmed, you have only strengthened the amygdala’s response to that particular situation.  

• This is the time to think about the situation, develop logical solutions, change thoughts.  

• For instance, rather than thinking, “I can’t handle this, it is going to be awful.” Remind yourself “I’ve been here before; I can get through this.” Or “Feelings can’t last forever, this will end.”  

Questions: Please contact Dr. Rose at DrRose@rosetherapycenter.com

Surviving COVID-19 at Home with Your Children

I think it’s relatively safe to say that most of us did not expect to be in this position…schools closed and finding ways to manage work and family at home.  

This can be a very stressful time for parents who cannot easily work from home.  Over the week, I’ve been asked several questions: Why are people buying out toilet paper…how do I talk to my child…what I should do about my own worry…? Here is my attempt to answer these questions and provide support.

Why are people acting crazy?

It’s a valid question… Anxiety and “fear of the unknown” plays a big role.  Here’s why: Our brains are hardwired to sense danger and ultimately protect ourselves.

Unfortunately, emotion sometimes impairs our perception of risk.  In general, we fear unlikely, catastrophic events, more than common deadly events.  In the case of COVID-19, assessing risk has proved difficult because we don’t have enough objective knowledge as the disease is still evolving. 

When humans feel a “perceived lack of control” we start to see people take on more unusual behaviors like stockpiling on toilet paper or panic-buying for months.  Another explanation for this odd behavior is what psychologists call “availability bias” and observational learning.  We (humans) tend to let an example that easily comes to mind affect decision-making or reasoning.  A simple and benign example of observational learning is while out to eat with friends, one person takes a drink of water and shortly after other people at the table pick up their drinks and take a sip.  To us, this happens unconsciously, but our brains have been simultaneously processing the conversation at the table and observing behavior. 

Complicating matters, we are uniquely bad at spotting misinformation online, in part because we don’t take the time, or don’t know how, to properly fact-check.  Our memories play tricks on us, encouraging us to believe things we read repeatedly, to look for information that validates our thoughts, and to remember things that elicit strong emotions.  The non-stop media coverage certainly isn’t helping our brains take a break.    

What can adults do?

*Facts minimize fear: Get information from reputable resources, not necessarily posts being passed around on social media.  The Centers for Disease Control (CDC) and World Health Organization (WHO) are good places to start. 

* Take a break from media (news channels and social media).

*Attempt to reframe how you are thinking about this event.  Instead of viewing it as an inconvenience, think of it as a sort of “pause” button that may allow you to connect with your child or spouse in a way you haven’t been able to in a while.  Pay attention to the "good" and how people are working together to support each other.

* Use HUMOR: Humor is a wonderful gift and reduces worry. 

* Practice healthy hygiene.

*Enjoy your child/children.  This is easier said than done when simultaneously managing work from home.  However, even 5-10 minutes of quality time goes a long way with kids.  Create new memories, teach them a new skill, let them help in the kitchen, get outside, etc. 

Ask yourself, “When this is all over, how do I want to remember this event.”  Let that question dictate your feelings and behaviors!!

How to talk to children?

Most importantly, parents set the tone for how children will respond to this event.  It is very important for you to find ways to control your worry and fear so that it is not placed on children.  Too much information can be a bad thing when it comes to kids.  Here is a great resource for how to talk with children about the virus:

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/talking-with-children.html

Below is a Google doc listing with an enormous amount of educational activities for children.  Remember, there is a lot of good happening in this time of crisis…someone has already worked super hard to compile this list!!

https://docs.google.com/document/d/1fceqmG0nYAI8uGm5Uv_Ilv5PI72b8iTmGdKag3elrDY/edit?usp=sharing

As always, if you need to talk, don’t hesitate to reach out for help.  It is available!

Kristin Rose, PsyD.

DrRose@RoseTherapyCenter.com

www.RoseTherapyCenter.com