Parent and Provider Differences in Ratings of Mental Health and Neurodevelopmental Concerns in Children with Neurologic Disorders.

Children with neurologic disorders face increased risks for mental health and neurodevelopmental conditions, with information often limited to parent report. To better understand mental health and neurodevelopmental needs in this population, a retrospective chart review of a convenience sample of children with neurologic disorders referred for a neuropsychological evaluation was conducted in the present study to explore interrater agreement between care team members (referring providers, parents, pediatric neuropsychologist). Qualitative and quantitative data were collected from the evaluation reports of 129 youth (9:0-17:11 years old; 51.2% of female sex) with neurologic disorders (i.e., 38.0% traumatic brain injury, 27.1% epilepsy, 14.7% premature birth, 7.8% pediatric cancer, 3.9% prenatal substance exposure, and 14.7% other) who completed an evaluation in 2019. Over half the youth were flagged for unmet neurodevelopmental and mental health concerns and analyses revealed low interrater agreement for mental health concerns (κ = .324), better agreement for neurodevelopmental concerns (κ = .511), and low sensitivity of referring providers (Se = .326) and parents (Se = .366). One-way analyses of variance uncovered important factors (e.g., symptom severity, adaptive skills) that may account for missed concerns. Findings guide recommendations to strengthen methods for understanding mental health and/or neurodevelopmental concerns in children with neurologic disorders.

From Evidence-Based Guidelines to Clinical Practice: Pediatric Neuropsychology Care in Multidisciplinary Clinics.

OBJECTIVE: High demand for pediatric neuropsychological care has highlighted the time- and resource-intensive nature of traditional comprehensive evaluations. Emerging care models address these constraints by facilitating tiered neuropsychological services provided in various contexts, including multidisciplinary clinics (MDCs). We aim to demonstrate feasibility and acceptability of tiered neuropsychological care in MDCs through examples from a single institution. METHODS: A review of all current MDC practices at a tertiary pediatric care center was conducted to describe clinic workflow, services provided, and triage strategies. Pediatric neuropsychologists (n = 5) and other health care providers (n = 31) completed a survey focused on experience with neuropsychology consultation in MDCs. RESULTS: Neuropsychologists provided care in 11 MDCs, including universal monitoring with consultative interviews and questionnaires, as well as targeted screening. Neuropsychologists (89%) and other health professionals (100%) reported that tiered neuropsychological services improved patient care within MDCs. Other health professionals reported utilizing results from neuropsychology MDC care to inform their clinical approach (48-90%), referrals (58%), and treatment or surveillance decisions (55-71%). CONCLUSION: Tiered neuropsychological care in pediatric MDCs is feasible, and provider experience ratings indicate high acceptability. Practical steps for development of MDCs are provided, including identifying teams, clinic goals and outcomes, operational logistics, and billing.

To confirm your appointment, please press one: Examining demographic and health system interface factors that predict missed appointments in a pediatric outpatient neuropsychology clinic.

Objective: Missed patient appointments have a substantial negative impact on patient care, child health and well-being, and clinic functioning. This study aims to identify health system interface and child/family demographic characteristics as potential predictors of appointment attendance in a pediatric outpatient neuropsychology clinic. Method: Pediatric patients (N = 6,976 across 13,362 scheduled appointments) who attended versus missed scheduled appointments at a large, urban assessment clinic were compared on a broad array of factors extracted from the medical record, and the cumulative impact of significant risk factors was examined. Results: In the final multivariate logistic regression model, health system interface factors that significantly predicted more missed appointments included a higher percentage of previous missed appointments within the broader medical center, missing pre-visit intake paperwork, assessment/testing appointment type, and visit timing relative to the COVID-19 pandemic (i.e. more missed appointments prior to the pandemic). Demographic characteristics that significantly predicted more missed appointments in the final model included Medicaid (medical assistance) insurance and greater neighborhood disadvantage per the Area Deprivation Index (ADI). Waitlist length, referral source, season, format (telehealth vs. in-person), need for interpreter, language, and age were not predictive of appointment attendance. Taken together, 7.75% of patients with zero risk factors missed their appointment, while 22.30% of patients with five risk factors missed their appointment. Conclusions: Pediatric neuropsychology clinics have a unique array of factors that impact successful attendance, and identification of these factors can help inform policies, clinic procedures, and strategies to decrease barriers, and thus increase appointment attendance, in similar settings.

[Formula: see text] The multifaceted role of neuropsychology in pediatric solid organ transplant: preliminary guidelines and strategies for clinical practice.

The incidence of pediatric solid organ transplantation (SOT) has increased in recent decades due to medical and surgical advances as well as improvements in organ procurement. Survival rates for pediatric kidney, liver, and heart transplantation are above 85% but patients continue to experience complex healthcare needs over their lifetime. Long-term developmental and neuropsychological sequelae are becoming increasingly recognized in this population, although preliminary work is limited and deserves further attention. Neuropsychological weaknesses are often present prior to transplantation and may be related to underlying congenital conditions as well as downstream impact of the indicating organ dysfunction on the central nervous system. Neuropsychological difficulties pose risk for functional complications, including disruption to adaptive skill development, social-emotional functioning, quality of life, and transition to adulthood. The impact of cognitive dysfunction on health management activities (e.g., medication adherence, medical decision-making) is also an important consideration given these patients' lifelong medical needs. The primary aim of this paper is to provide preliminary guidelines and clinical strategies for assessment of neuropsychological outcomes across SOT populations for pediatric neuropsychologists and the multidisciplinary medical team, including detailing unique and shared etiologies and risk factors for impairment across organ types, and functional implications. Recommendations for clinical neuropsychological monitoring as well as multidisciplinary collaboration within pediatric SOT teams are also provided.

School psychologists' perceptions of the effectiveness of neuropsychological evaluation reports.

Referral sources and parents value the report following a neuropsychological evaluation. Nevertheless, key stakeholders have described pediatric reports as excessive in length and jargon. Recent research indicates that it is possible to modify pediatric neuropsychological reports that result in positive outcomes for key stakeholders and clinicians. Evaluating modified pediatric neuropsychological reports for other providers is necessary. School psychologists are key stakeholders who read and interact with such reports. This study assessed school psychologists' perceptions of a modified pediatric neuropsychological report. Forty-one school psychologists were randomly assigned to read either a traditional or modified version of a pediatric report and provide feedback via survey and qualitative questions. Results revealed that school psychologists' perceptions of a traditional and modified report were not significantly different. Qualitatively, respondents noted a disconnect between recommendations and school systems. These findings suggest that pediatric neuropsychologists can create shorter and more easily understood reports that do not impact the effectiveness for school psychologists. Future research should continue to evaluate perceptions of modified pediatric neuropsychological reports for additional key stakeholders. A better understanding of the disconnect between recommendations and their feasibility in schools, as well as barriers to increased interdisciplinary collaboration, is also essential for client care.

Assessing learning and memory among patients with pediatric brain tumor (PBT): a comparison of measures.

Patients with pediatric brain tumor (PBT) can have memory deficits due to tumor location, medical complications, and treatment. The main objective of this study was to investigate whether the California Verbal Learning Test-Children's Version (CVLT-C; 1994) and briefer Child and Adolescent Memory Profile (ChAMP; 2015) similarly identify such deficits. Seventy-five patients with PBT ages 8-16 (x‾ = 13.1 years, SD = 2.1) were administered the ChAMP or CVLT-C. Rote verbal learning, long-term retrieval, and recognition were analyzed using standardized z-scores. Analyses of differences between measures did not reach statistical significance. Both measures indicated significant downward shifts across free retrieval trials from normative means, with scores approximately 1/3 (ChAMP) to 1/2 (CVLT-C) SD below means across learning and long-term retrieval trials. Scores on recognition trials did not differ significantly from the normative mean. Post-hoc analyses using a subset of the sample who received cranial irradiation (n = 45) similarly found no significant differences between memory measures. Additional post-hoc examination of proportion of participants falling within or below the "below average" range (≤8th percentile) revealed comparable performance between the two measures, whereas the proportion of participants falling at or below 1.5 SDs below the mean on retrieval trials was lower using ChAMP Lists as compared to the CVLT-C. Given the ChAMP is less demanding in terms of time and effort and utilizes more updated and representative normative data, this study supports the ChAMP as a useful tool to evaluate learning and memory within this population.

Performing pediatric neuropsychological evaluation with Chinese patients: A narrative review of the literature and recommendations for practice.

Objective: This paper offers a narrative overview of performance-based cognitive tests and behavior rating inventories that can be considered when working with Chinese youth in assessment settings. Methods: A total of 46 articles that focused on assessment tools and normative data in Chinese-speaking patients were reviewed. Based on the gaps in research and patterns of strengths/weaknesses across reviewed articles, we provide recommendations for selection of tests and norms while utilizing the ECLECTIC framework. Results: Our review of literature suggests extant research on neuropsychological tools for Chinese pediatric patients have largely been focused on translated or adapted measures. Findings highlight the need for the development of indigenous measures across multiple cognitive and behavioral domains to optimally integrate cultural considerations in the assessment process. Conclusions: Specifically, cultural factors that may impact test and norm selection, patients' test performance, and diagnostic considerations are discussed. Finally, gaps in literature are highlighted for future research directions.

Clinical utility of teleneuropsychology among pediatric patients with broadly average and low intellectual functioning.

The reliability of teleneuropsychology (teleNP) within pediatric populations, particularly those with low intellectual functioning (LIF; i.e., Intellectual Quotient <80), is largely unknown. This repeated-measures study compared performance on WISC-V and WAIS-IV subtests administered in-person before the COVID-19 pandemic and via teleNP during the pandemic in individuals with LIF versus broadly average (BA) intellectual functioning in a clinically referred pediatric cohort. Data were collected from a retrospective chart review of 35 pediatric patients who underwent in-person neuropsychological evaluation at an academic medical center before the pandemic (Mage = 10.10 years, SD = 2.93) and videoconference teleNP assessment during the pandemic (Mage = 13.47 years, SD = 2.88). Participants completed the Similarities, Matrix Reasoning, and Digit Span subtests from the WISC-V or WAIS-IV at both time points. After controlling for test-retest time interval, partial correlations showed relatively strong associations in test-retest performance across subtests in the whole sample and among the subset of LIF patients. Distribution of significant reliable change indices (RCI) between the LIF and BA groups were similar. Strong correlations were observed between performances on select Wechsler subtests administered in-person and via teleNP. Results lend initial support toward the utility of teleNP administration of these measures in children with a broad range of intellectual functioning.

A survey of pediatric neuropsychologists serving inpatient rehabilitation, Part II: billing, time allocation and tracking, and professional identity and perceptions.

Professional challenges have been documented in broad surveys of neuropsychologists. While previous surveyors have included pediatric neuropsychologists, few, if any, have specifically examined practices among those who primarily work in pediatric inpatient rehabilitation settings. Therefore, the aim of this study was to survey neuropsychologists in this setting. Thirty neuropsychologists from the U.S. and one from Canada that work in inpatient pediatric rehabilitation participated in an online survey. Most respondents (83.3%) billed for their inpatient time. Sixty-four percent indicated that payor type (private vs. public) affected services a moderate amount to a lot; this was primarily due to payor's influence on length of stay. Most providers had productivity expectations (66.7%). Among those that had productivity expectations, three-quarters used "hours billed;" 37.5% were solely or additionally tracked by relative value units (RVUs). The majority of respondents conducted some type of clinical data collection, usually for research purposes. With respect to professional identity, most respondents indicated positivity about their role. The top challenges endorsed were related to workload/ability to meet the patients' needs and billing/productivity. Issues related to billing and payor may influence aspects of pediatric inpatient rehabilitation neuropsychological care. Managing challenges related to billing and the time demands associated with providing inpatient services were top concerns for many respondents. Most sites surveyed were involved in data collection, usually for research purposes; increased data collection efforts are needed to aid with program development and evaluation and to demonstrate the added value of neuropsychological services from a patient care perspective.

Validation of the Attention, Memory, and Frontal-Executive Abilities Screening Test (AMFAST) in children, adolescents, and young adults with complex medical conditions.

The objective of this study was to validate the Attention, Memory, and Frontal-Executive Abilities Screening Test (AMFAST) in a sample of children, adolescents, and young adults with complex medical conditions characterized by frontal-subcortical dysfunction. Toward this goal, we first report on scoring corrections to the AMFAST for younger participants (ages 8-10), thereby expanding its use beyond the age range (i.e., ages 11+) that we had validated in our previous study. We then examined the diagnostic utility of the AMFAST at identifying different levels of neurocognitive dysfunction in a clinical sample of 61 children, adolescents, and young adults (ages 8-20) with complex medical conditions who also underwent comprehensive neuropsychological testing. We identified two AMFAST cutoff scores; one that optimally distinguished participants with significant neurocognitive dysfunction from non-impaired participants and another that differentiated participants with more subtle, mild neurocognitive dysfunction from non-impaired participants. These findings demonstrate that the AMFAST is a highly effective screening test that can be used to identify varying levels of frontal-subcortical deficits in younger patient populations.

Implications of attention and executive functioning weaknesses in youth with Fontan circulation.

Youth with Fontan circulation (Fontan) are at-risk for impairments in attention and executive functioning (EF) due to a confluence of genetic, prenatal, surgical, and medical risk factors. We sought to describe attention and EF in this population, measured via standardized performance-based tests and caregiver rating scales. We then examined how weaknesses in attention and EF were related to outcomes in other neurobehavioral domains, including adaptive behavior and academic achievement. Our sample included 93 youth with Fontan who were referred for neuropsychological evaluations as part of standard clinical care. The cohort as a whole measured between 0.18 to 0.99 standard deviations below normative means across domains of attention, EF, academic achievement, and intellectual ability. In addition, caregiver-reported concerns for attention, EF, anxiety, and depression were elevated, and approximately 0.35 to 0.85 standard deviations above normative means. Lastly, caregiver-reported adaptive behavior measured 0.93 to 1.24 standard deviations below normative values. Academic outcomes were differentially affected by demographic and attention/EF variables, while depression and caregiver-reported EF predicted adaptive behavior. Findings from this study underscore the importance of routine neuropsychological evaluation as part of comprehensive, multidisciplinary care for individuals with Fontan, with the goal of enhancing neurobehavioral and functional outcomes across the lifespan.

Test Review of the Feifer Assessment of Reading (FAR).

The Feifer Assessment of Reading (FAR) is a comprehensive reading test for children ages 4 through 21 years. The FAR was designed to evaluate the underlying cognitive and linguistic processes of reading. It has 15 subtests to evaluate aspects of phonological development, orthographical processing, decoding, reading fluency, and comprehension skills. Academic achievement tests endeavor to evaluate core neuropsychological and theoretical perspectives that identify students at risk. However, reading tests have historically not focused on why a student may struggle with reading interventions. A neuropsychological approach to reading posits that multiple neural pathways assist the reading process. These processes include orthographic mapping, phonemic awareness, fluency, decoding, and comprehension. The aim of the test is to help the evaluator learn why a student is struggling with reading, as well as to inform intervention. This review explores the Feifer Assessment of Reading (FAR), and its contribution to the neuropsychological evaluation of reading.

Outcomes of pediatric neuropsychological services: A systematic review.

Objective: The primary aim of this project was to apply systematic review methods to synthesize the literature on outcomes of pediatric neuropsychological services. The secondary aim was to use the results of the systematic review to identify gaps in the extant literature and describe priorities for future research. Method: We identified the relevant studies using a rigorous search strategy, collected data on methodological variables, assessed the risk of bias in the studies, summarized findings by topic and subtopic areas, identified strengths and weaknesses of the literature, and provided recommendations for future research. The outcomes measured were satisfaction, changes in resource or strategy utilization, and changes in symptoms or functioning (i.e. changes in child emotional, behavioral, cognitive, or academic problems, parent stress, or family functioning). Results: The final sources of data were 26 records, pertaining to a total of 974 children who received neuropsychological services. Parents were generally satisfied with services and reported high clinician empathy and increased level of knowledge, based on the evaluation. However, they reported less often that the neuropsychologist provided actual help. Informal home and school-based strategies were implemented more often than other types of recommendations. The research on changes in child symptoms and functioning was limited, but suggests improvements. Conclusions: This is the first systematic review of outcomes of pediatric neuropsychological services. Larger studies involving data collection at multiple time points are needed in order to further clarify mechanisms leading to outcomes and potential targets for improving them.

The dimensionality of the Behavior Rating Inventory of Executive Function, Second Edition in a clinical sample.

The parent-report Behavior Rating Inventory of Executive Function, Second Edition (BRIEF-2) is a widely used pediatric neuropsychological measure. Unfortunately, despite meaningful changes from its predecessor, few studies have examined its internal factor structure (now with Behavioral Regulation [BRI], Emotion Regulation [ERI], and Cognitive Regulation [CRI]), and no available literature has investigated higher order models for the BRIEF-2. This study sought to address this shortcoming in the literature by investigating and reporting on the dimensionality of the parent-report BRIEF-2 in a clinical sample. Two hundred and two (202) pediatric neuropsychology examinees (M age = 9.90; 68% males) with complete data for the parent-report BRIEF-2 were included. Descriptive results revealed generally elevated scores across BRIEF-2 scales (Global Executive Composite M T = 70.16). Exploratory factor analyses suggested two factors (CRI and BRI/ERI) should be extracted, and that higher order models should be considered. Confirmatory factor analyses suggested that a direct hierarchical/bifactor two-factor structure (which was more parsimonious than the theoretical three-factor model) provided the best fit, with a bulk of the variance explained by the general GEC factor. The BRIEF-2 may be best interpreted at the overall level, with relatively less weight given to the index variables, particularly within clinical samples with high levels of reported executive functioning difficulties. Implications of these findings, limitations of the present study, and appropriate directions for future inquiry were discussed.

Test Review of the Feifer Assessment of Writing (FAW).

The Feifer Assessment of Writing (FAW) is a comprehensive test of writing that was designed to measure three subtypes of written language disorders. Academic achievement tests endeavor to evaluate core neuropsychological and theoretical perspectives that identify students at risk. Written assessments have historically focused more on the ability to write, putting ideas together in a sentence, and being able to do so efficiently. Missing from these evaluations is the impact of working memory and other executive functioning abilities, such as the ability to strategically develop a plan, evaluate, monitor, draft, and revisit the text. This review explores the FAW, and its contribution to the neuropsychological evaluation of writing.

New cut-score to improve performance of the Memory Validity Profile (MVP) in heterogenous clinical populations.

The Memory Validity Profile (MVP) is a standalone performance validity test developed specifically for use with children. Prior research has demonstrated the MVP's strength in its ease of administration to children with a wide range of intellectual abilities. However, it has been found to lack sensitivity in detecting noncredible performance in select clinical populations using published cutoffs. The current study examines the MVP's performance in a diagnostically heterogeneous clinical sample and proposes a new cutoff for optimization of sensitivity and specificity. Archival clinical data were examined from 96 participants referred for a comprehensive neuropsychological evaluation (ages 6-18). Receiver operating characteristic analysis was used to assess the discriminative ability of MVP in detecting cases of noncredible performance defined as failures on both the Test of Memory Malingering and Reliable Digit Span. Using published cutoffs, the MVP demonstrated perfect specificity (100%) but suboptimal sensitivity (33.3%). Receiver operating characteristic analysis revealed strong discrimination using MVP Total score (AUC = 0.891 (p < 0.001)) and a MVP Total cut-score of ≤30 resulted in optimal sensitivity (89%) and specificity (63%). Our findings provide additional evidence that published MVP cutoffs may be too lenient to adequately capture instances of noncredible performance and indicate an MVP Total score cutoff of ≤30 may be more appropriate for use with heterogeneous clinical populations.

[Formula: see text] The role of family burden on informant discrepancies between parents and youths with protracted recovery from mild traumatic brain injury.

Previous literature shows that family burden can lead to symptom-report discrepancies between parents and children. The present study sought to extend this research by investigating the influence of family burden factors, including socioeconomic status (SES) and family stress on informant discrepancies between parents and youths with mild traumatic brain injury (mTBI). Participants were clinically referred youths with mTBI ages 8-17, consecutively seen in a hospital-based neuropsychology concussion clinic (N = 81; females = 54.3%). Parents and children completed the Behavioral Assessment for Children System (BASC) and the Postconcussive Symptom Scale (PCSS). Parents rated changes in family stress related to the mTBI (categorized as "no change," "minor change," or "major change") and provided information to calculate SES. Results revealed that family stress but not SES influenced parent-child report discrepancies for the BASC Internalizing Symptoms Index (F = 8.72(2, 79), p <.000), and that the discrepancies were independent of postconcussive symptom severity. Clinical implications of these findings are discussed.

"How to" operate a pediatric neuropsychology practice during the COVID-19 pandemic: Real tips from one practice's experience.

This paper aims to provide pediatric neuropsychologists with suggested processes and procedures to continue to provide neuropsychology services during the COVID-19 global pandemic. Our practice is located within an academic medical center/children's hospital, and setting-specific recommendations may not extend to all practices, though our hope is that others find guidance from our approach to providing pediatric neuropsychology evaluations when physical distancing is required. With consideration of ethics, equity, and assessment validity, we provide suggestions for a) modifying practices around seeing patients during COVID-19, b) tele-health for the pediatric neuropsychologist, c) safety standards and requirements, and d) working with special populations (e.g., Autism Spectrum Disorder, bilingual populations, immunocompromised patients, and acute inpatient assessment).

COVID-19 issues related to pediatric neuropsychology and inpatient rehabilitation - challenges to usual care and solutions during the pandemic.

Objective: To describe the challenges related to COVID-19 affecting pediatric neuropsychologists practicing in inpatient brain injury rehabilitation settings, and offer solutions focused on face-to-face care and telehealth.Methods: A group of pediatric neuropsychologists from 12 pediatric rehabilitation units in North America and 2 in South America have met regularly since COVID-19 stay-at-home orders were initiated in many parts of the world. This group discussed challenges to clinical care and collaboratively problem-solvedsolutions.Results: Three primary challenges to usual care were identified, these include difficulty providing 1) neurobehavioral and cognitive assessments; 2) psychoeducation for caregivers and rapport building; and 3) return to academic instruction and home. Solutions during the pandemic for the first two areas focus on the varying service provision models that include 1) face-to-face care with personal protective equipment (PPE) and social distancing and 2) provision of care via remote methods, with a focus on telehealth. During the pandemic,neuropsychologists generally combine components of both the face-to-face and remote care models. Solutions to the final challenge focus on issues specific to returning to academic instruction and home after an inpatient stay.Conclusions: By considering components of in-person and telehealth models of patient care during the pandemic, neuropsychologists successfully serve patients within the rehabilitation setting, as well as the patient's family who may be limited in their ability to be physically present due to childcare, illness, work-related demands, or hospital restrictions.

Relationships between Physiologic and Neuropsychologic Functioning after Fontan.

OBJECTIVE: To investigate potential relationships between neuropsychologic functioning and cardiac, gastroenterologic/hepatologic, and pulmonary complications in the single ventricle heart disease (SVHD) post-Fontan population. STUDY DESIGN: Following the initiation of a Fontan Multidisciplinary Clinic, patients with SVHD were evaluated systematically according to a clinical care pathway, and data from multiple subspecialty evaluations were collected prospectively from 2016 to 2019. Biomarkers of cardiology, pulmonary, and hepatology/gastroenterology functioning were abstracted, along with neuropsychologic testing results. Bivariate correlations and regression analyses examined cross-sectional relationships between physiologic predictors and neuropsychologic outcomes. RESULTS: The sample included a cohort of 68 youth with SVHD age 3-19 years, after Fontan palliation. Sleep-disordered breathing was related to poorer visual-motor integration skills (r = -0.33; P < .05) and marginally related to poorer executive functioning (r = -0.33; P = .05). Lower arterial blood oxygen content was related to poorer executive functioning (r = .45; P < .05). Greater atrioventricular valve regurgitation was related to lower parent-rated adaptive functioning (ρ = -0.34; P < .01). These results were maintained in regression analyses controlling for history of stroke and/or seizures. CONCLUSIONS: We demonstrated associations between neuropsychologic functioning and potentially modifiable aspects of physiologic functioning in a prospectively evaluated cohort of patients with SVHD with Fontan physiology. Our findings emphasize the importance of multidisciplinary screening and care after a Fontan procedure and suggest avenues for intervention that may improve patient outcomes and quality of life.