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PEDIATRIC NEUROPSYCHOLOGICAL EVALUATIONS

By Karen Kane, PhD

This is some information about why a child might benefit from an evaluation, as well as some details about the process. If you would like more details, there is a brochure that can be downloaded from our website.

What is Pediatric Neuropsychology?

Pediatric neuropsychology is a professional specialty concerned with learning and behavior in relationship to a child’s brain. The pediatric neuropsychologist conducts the evaluation, interprets the test results, places the results in a report, and makes recommendations

How Does a Neuropsychological Evaluation Differ From a School Psychological Assessment?

School assessments are usually performed to determine whether a child qualifies for special education programs or therapies to enhance school performance. They focus on achievement and skills needed for academic success. A neuropsychological evaluation is broad; it is designed to understand and promote a child’s functioning across settings.

Why Are Children Referred for Neuropsychological Assessment?

Children are referred by a doctor, teacher, school psychologist, or other professional because of one or more problems, such as:

•        Difficulty in learning, attention, behavior, socialization, or emotional control;

•        A disease or inborn developmental problem that affects the brain in some way; or

•        A brain injury from an accident, birth trauma, or other physical stress.

What is Assessed?

A typical neuropsychological evaluation of a school-age child may assess these areas:

•        General intellect

•        Achievement skills, such as reading and math

•        Executive skills, such as organization, planning, inhibition, and flexibility 

•        Attention

•        Learning and memory

•        Language

•        Visual–motor skills

•        Behavioral and emotional functioning

•        Social skills

What Will the Results Tell Me About My Child?

By comparing your child’s test scores to scores of children of similar ages, the neuropsychologist can create a profile of your child’s strengths and weaknesses. The results help those involved in your child’s care in a number of ways.

•        Testing can explain why your child is having school problems.

•        Testing can help detect the effects of developmental, neurological, and medical problems

•        Testing provides a better understanding of the child’s behavior and learning in school, at home, and in the community

What Should I Expect?

A neuropsychological evaluation usually includes an interview with parents about the child’s history, observation of and interview with the child, and testing. Testing involves paper and pencil and hands-on activities, answering questions, and sometimes using a computer. Parents and teachers will likely be asked to fill out rating forms. Parents are usually not in the room during testing, although they may be present with very young children. The time required depends on the child’s age and problem.

What you tell your child about this evaluation depends on how much he or she can understand. Be simple and brief and relate your explanation to a problem that your child knows about such as “trouble with spelling,” “problems following directions,” or “feeling upset.” Avoid the word “testing” and let your child know he or she will complete a variety of activities. Tell your child that you are trying to understand how he or she thinks and learns so that you can make life easier for him or her.

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Mindfulness

By:  Donal MacCoon, PhD.

For years now, I have used mindfulness with patients, in my personal life, and as a scientist, conducting randomized controlled trials funded by the NIH (see, for example, MacCoon, et al., 2012). In fact, my interest in mindfulness led to my graduate studies in Clinical Psychology with a focus on the role of attention in emotion regulation.

Mindfulness has been defined as the process of “paying attention, on purpose, to what is happening right now without judgement” (Kabat-Zinn, 1990).  Pretty easy to say. Can be hard to do.

This leads to two questions: (1) Why is mindfulness important to my well-being? and (2) How do we mess it up?

Why is mindfulness important to my well-being?

There is a good deal of empirical evidence that mindfulness — and Mindfulness-Based Stress Reduction or Mindfulness-Based Cognitive Therapy, in particular — is helpful for a variety of forms of suffering, including chronic pain, anxiety, depression, and substance use (see, for example, Barnhofer et al., 2007; Davidson et al., 2003; Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007; Kabat- Zinn et al., 1998; Ma & Teasdale, 2004; Pradhan et al., 2007; Speca, Carlson, Goodey, & Angen, 2000). We should note, in passing, that MBSR is like every other effective psychological intervention studied — it is as helpful as any other treatment that includes the factors common to all healing therapy (MacCoon, et al., 2012). The main point here is simply that you will be helped by a treatment that makes sense to you and is of interest to you, and find a provider who represents a good fit.

Theoretically, it makes sense that mindfulness would be helpful if we think of mindfulness as a form of attention and emotion training integral to self-regulation, a perspective articulated in a model I’ve published in which mindfulness is conceived of as “context-appropriate balanced attention” (CABA, MacCoon, Wallace, & Newman, 2004). The model is illustrated with anxiety, depression, and psychopaths. The premise is that the best any human can do in a given situation is to base their behavior on as much data as possible, including body sensations, emotions, and thoughts. In the long run, and on average, this strategy will lead to less suffering because our behavior will be as congruent with reality as possible.

How do we mess it up?

We can imagine an internal landscape of neural networks like a stereo equalizer (see picture, left), with each bar representing a thought, emotion, body sensation, or habit.  In any given context, our brain automatically activates the networks that are most relevant for that context given our genes and learning history. Since every situation is different in some way from every situation that has ever occurred, our brain activates multiple networks at different strengths. When we are on autopilot, it is likely we will behave according to the most activated network. This is a real blessing to behave according to those automatic habits without much thought and often those automatic habits are fairly good for a given situation. In this way, we drive without thinking about it. Even when the automatic habit is wrong or inaccurate, there are certainly situations, like when we may be in physical danger, that it makes sense to jump from the snake and discover it is a stick later.

However, for most situations, it is likely that for a small cost in increased time, we can pause and survey all of the available networks and act more appropriately when we do so. This is mindfulness. Thus, whereas in the presence of a snake, the appropriate balance of attention is on the most activated network (run away, it’s a snake), most of the time, the appropriate balance most of the time is to focus on all of the available networks or data. It is easy to mess this up because in our culture we are typically not trained to do this pausing; instead, we value speed and focus on “important” work or “productivity.”

For example, William James tells us that Archimedes was made aware of the Battle of Syracuse by receiving his own death wound. One can imagine this genius of geometry so focused on his work that he failed to allocate any attention to his surroundings — in this case, it was a fatal misallocation of attention. In that particular context, obviously, it would have been more important for Archimedes to attend to his surroundings than his work. The problem is that he had developed that habitual style of focus over an entire lifetime, in which he was (presumably) rewarded time and again for concentrating on geometry (“productive work”) to the exclusion of other stimuli. We all have bad habits that can be activated or primed by our current context and lead us to behave in ways that are not helpful for ourselves and others.

It is no great secret that emotion can hijack our attention, a process that can lead to unhealthy rumination, self-criticism, hyper-vigilance, and fight-flight physiological responses. All of these are characterized by an unbalanced use of our attention — attending to one set of cues to the exclusion of others. It is ironic that our culture has responded to these unpleasant tendencies largely by emphasizing avoidance strategies (e.g., distraction, suppression, denial, “positive” thinking) to cope with reality, strategies that usually give a short-term gain for a long-term cost. One particular category of data that we seek to avoid is unpleasant emotion even though doing so might be negative for our lives (see this article on the important distinction between positive and pleasant, on the one hand, and negative and unpleasant on the other).

When I give public talks, I’ll give people this pop quiz: If your hand is on a hot stove, do you (a) disconnect the pain nerves in your hand, or (b) take your hand off the stove? Obviously, we use the pain of our burning hand as information that damage is occurring and remove our hand. Unfortunately, when confronted by unpleasant emotion, we are often trained that the emotion is a problem rather than data about reality that we need to deal with.

Mindfulness emphasizes intimacy with reality rather than avoidance, whether that reality comes in the form of pleasant or unpleasant emotion. In practice, mindfulness means training ourselves to focus on all of the data available in a given moment, including body sensations, emotions, and thoughts. I would call this wisdom. And, that definition means two things: (1) We all have the capacity to be wise, and (2) just because we can be wise does not mean we will achieve the outcomes we want — to make mistakes is an inevitable part of being human.

How do you train yourself to focus on all of the data available? There are probably dozens of ways, but one way is the practice of returning your attention to a neutral (and boring) stimulus like the breath even when it is hijacked by more interesting stimuli. That way, even when interesting stimuli occur in your life, like someone flipping you off or complaining about you or causing some unpleasant emotion, you can pause, notice that stimulus, return your attention to your breath (thus preventing a hyper-focus on those stimuli), and notice all the other data your brain views as relevant before acting.

In our avoidance culture, we train people to punish themselves when something occurs that makes them feel unpleasant emotion. For many people, self-criticism is a fairly compelling habit, one that will attract and hold attention, especially if we are in fight-flight mode. It is also a habit associated with depression (see, for example, Abramson’s work on the role of stable, global, internal attributions on depression, e.g., Abramson et al, 2002; Alloy, et al., 2006). Let’s also notice, though, that self-criticism is always inaccurate and counterproductive. If your hand is on a hot stove and you are spending your limited capacity calling yourself an idiot, that is not helpful for learning what to do differently next time (“be more careful in the kitchen”); furthermore, it is not likely that your mistake is due to poor intelligence.

From a mindfulness perspective, our task is simply to notice the causes of what happened and train ourselves — one moment at a time — to do something different next time. This involves attending to all of who we are in a given moment — as represented by all of the data represented in our brains and bodies — a form of compassion that has simple pragmatism as its foundation.  

Bibliography

Abramson, L.Y., Alloy, L.B., Hankin, B.L., Haeffel, G.J., Gibb, B.E., & MacCoon, D.G. (2002). Cognitive vulnerability-stress models of depression in a self-regulatory and psychobiological context. In I.H. Gotlib & C.L. Hammen (Editors), Handbook of depression. New York: Guilford Press.

Alloy LB, Abramson LY, Whitehouse WG, Hogan ME, Panzarella C, Rose DT. (2006). Prospective incidence of first onsets and recurrences of depression in individuals at high and low cognitive risk for depression. J Abnorm Psychol. 2006 Feb;115(1):145-56.

Barnhofer, T., Duggan, D., Crane, C., Hepburn, S., Fennell, M., & Williams, J. M. (2007). Effects of meditation on frontal alpha-asymmetry in previously suicidal individuals. Neuroreport, 7(18), 709-712.

Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S. F., et al. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65(4), 564-570.

Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2), 336-343.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. New York: Delacorte.

Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, A., Scharf, M. J., Cropley, T. G., et al. (1998). Influence of a mindfulness meditation-based stress reduction inter- vention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychoso- matic Medicine, 60(5), 625-632.

Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72(1), 31-40.

MacCoon DG, Imel ZE, Rosenkranz MA, Sheftel JG, Weng HY, Sullivan JC, Bonus KA, Stoney CM, Salomons TV, Davidson RJ, Lutz A. (2012). The validation of an active control intervention for Mindfulness Based Stress Reduction (MBSR) Behav. Res. Ther. 2012; 50:3–12. doi: http://dx.doi.org/10.1016/j.brat.2011.10.011.

MacCoon, D. G., Sullivan, J. C., Davidson, R. J., Stoney, C. M., Christmas, P. D., Thurlow, J. P., et al. (2011). Health-enhancement program (HEP) guidelines. Retrieved from Permanent URL: http://digital.library.wisc.edu/1793/28198.

MacCoon, D. G., Wallace, J. F., & Newman, J. P. (2004). Self-regulation: the context- appropriate allocation of attentional capacity to dominant and non-dominant cues. In R. F. Baumeister & K. D. Vohs, (Editors) Handbook of Self-Regulation Research (pp. 422-444), New York: Guilford Press.

Pradhan, E. K., Baumgarten, M., Langenberg, P., Handwerger, B., Gilpin, A. K., Magyari, T., et al. (2007). Effect of mindfulness-based stress reduction in rheumatoid arthritis patients. Arthritis and Rheumatism, 57(7), 1134-1142.

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New Year and Insurance Changes

The New Year always brings change, and the healthcare industry is no different. Many insurance plans run on a calendar year, which means your copays and deductibles apply from January 1st to December 31st of that year. Insurance benefits can change even if your employer sticks with the same company. Just because your employer decided to stick with Anthem Blue Cross Blue Shield in the New Year doesn’t necessarily mean that you will have the same benefits. An unexpected benefit change or change in provider network status can mean surprise costs for you. Here some things you can do to be ready for any changes that may impact your insurance:

1.      Verify if your plan runs on a calendar year: Though many insurance plans do follow a calendar year for benefits, some do not. These run on plan years, which means their start and end dates can be at any point in the year. For example, a plan year could run 2/1/17-1/31/18, so any deductibles or copays would apply during that period. Knowing which benefits apply when is vital to tracking your benefit accumulations and preparing for your healthcare costs.

 2.      Verify that your providers are in network with the new insurance: Many health insurance plans utilize networks of providers, and may provide little to no coverage if you see an out of network provider. Checking prior to the New Year or new policy effective date will give you more time to make arrangements should you find out that your provider is out of network. This is a good idea even if your insurance doesn’t company doesn’t change as provider’s contracts can always change and affect network status.

3.      Check through your benefits: I know that reading through your plan documents can be quite tedious and time-consuming, but it is an important part of planning for your healthcare costs. If you come across something you don’t understand, do not be afraid to reach out to your insurance. Taking a little extra time getting to know your policy will be worthwhile when it comes time to make healthcare decisions.

We at MPA hope you have a great and informed New Year!

Regards,

Joel Campnell

Billing Specialist

Madison Psychiatric Associates

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Insurance Tips for New Patients

Beyond the important clinical considerations for finding a new mental health provider, don’t let the insurance aspects fall by the wayside. Unexpected costs arising from insurance confusion can be a significant source of stress.

 To help reduce your risk these, follow these tips before scheduling your first appointment:

 1.     Call your insurance to verify your benefits and the provider’s network status.

 Many insurance plans will utilize provider networks and encourage members to seek in-network providers. Seeing an in-network provider will in most cases reduce your out-of-pocket cost as a patient. Additionally, understanding your plan’s benefits beforehand will help you estimate potential costs for services. Knowing whether or not a copay will apply or if you need to meet a deductible first is a powerful first step towards making informed choices regarding the cost of your healthcare.

 2.     Verify with the clinic/provider to make sure they accept your insurance.

 I know this part seems unnecessary from the first tip, but there are several scenarios that make it important. Sometimes providers might work at two different locations, but will only be contracted at one of them. Other times a provider may have just terminated their contract and the insurance has not updated their network status just yet. Don’t be blindsided! After you get an idea from your insurance which providers might be in network for you, always verify it with the provider’s office directly.

 3.     If you are looking to pay for services out of pocket, verify the fees.

 If you are not insured or don’t want to bill your insurance, be sure you have a clear understanding of how much each session will cost and when that payment is due.

If you want to learn about our self-pay policy, check out the Policies page on our website.  http://www.madisonpsychiatricassociates.com/policies

For current rates at MPA, contact us in the billing department at 608-274-4273.

Joel Campnell

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Avoidance - the root of all evil

“Nature has placed mankind under the governance of two sovereign masters, pain and pleasure. It is for them alone to point out what we ought to do, as well as to determine what we shall do. They govern us in all we do, in all we say, in all we think”.

      Jeremy Bentham

Friedrich Nietzsche stated: “What Doesn't Kill You Makes You Stronger”. Nevertheless, our own experience and a few gazes at the people around us are enough to prove that this statement is valid for only part of the cases. In reality, what doesn’t kill us won’t necessarily make us stronger. We often survive difficult experiences; however, those experiences keep hurting us intensively, even to an extent of significant functional impairment.

What does one do, when facing anticipated suffering or distress? Three main coping styles are available:

Bearing and carrying the distress and somehow functioning despite its presence. After a social encounter, with lots of alcohol, I woke up in the morning, sensing the beginning of the familiar headache. I thought to myself ‘After a nice shower, a cup of tea and a cookie, I will probably feel better’, and then acted accordingly.  

Escaping from the predicted distress source when experienced. The moment I woke up sensing the beginning of the headache, I thought ‘Oh no! I can’t stand such a headache now. I have to take a Tylenol’ - and swallowed 2 pills to avoid any further distress. In other words, I learned through my personal experience what was the most effective distress terminating response and now I just automatically implement my learning, to eliminate any active distress.  

The third coping type is Retroactive avoidance from a situation that is suspected, or perceived as a potential distress generator. Due to the headache I started to feel, I concluded: ‘that’s it, I will never attend social events again. I just end up suffering when I do that’. Behaviorally, from that moment on, I quit attending social events, and by doing so, I am sure that this is the reason why I don’t suffer from headaches anymore.    

I would like to focus now on the third coping style - the AVOIDANCE pattern, as this is the most hazardous and harming one. What differentiates the escaping coping style from the avoiding one? ESCAPING stops an unpleasant stimulus experienced in the present. While not always a necessary behavior, it is a response anchored in reality. However, AVOIDANCE prevents the individual from experiencing reality altogether, before sensing any unpleasant stimulus. ESCAPING happens because of the real present, as opposed to AVOIDANCE which happens because of a predicted future.

Clearly, AVOIDANCE is the most harmful of the three coping styles. It derives from one’s subjective catastrophic prediction, rather than from an objective reality experienced by the individual. This prediction is triggered by a priming sign, which symbolizes and predicts an approaching negative reality. Therefore, AVOIDANCE is not a response to a stimulus. It simply prevents any chance of it happening. It is tragic that by becoming accustomed to avoidance, one does not react to actual reality any more, but to a virtual reality, generated and alive in the individual’s mind. Thus, virtual reality generates negative predictions, causing negative emotions (fear, shame, guilt, anxiety…), resulting in avoiding behavior. This is a self-sustained vicious circle.

Correcting one’s cognitive distortion is not an easy task, because from the avoiding person’s point of view, he/she is behaving at that moment in the most appropriate manner possible, merely trying to avoid suffering, using familiar ways.

Avoidance plays a primary role in a substantial variety of human distress situations. Avoidance is a major and crucial factor in generating and preserving all anxiety disorders, as well as depression, low self-esteem, and many other disorders and discomforts. Cognitive-Behavioral Psychotherapy offers evidence-based therapeutic interventions to help cope and overcome those distresses, while fundamentally referring to avoidance as a prime component of the distress.

Noam Gordon, M.Sc. Cognitive Behavioral Psychotherapist