To most parents hearing it for the first time, the term “neuropsych eval” is mysterious, a phrase that never comes up in toddler music classes, playground chat, or the mainstream parenting manuals. Parents facing the possibility that their child has developmental problems, however, must quickly become accustomed to it, because the neuropsychological evaluation is integral to parenting and educating a child with special needs. If a child is experiencing difficulties, and parents or educators suspect that a neurological condition such as Autism Spectrum Disorder (ASD) is the root cause, a neuropsych evaluation can confirm or rule out that hypothesis.
Ideally, however, the neuropsychologist’s written report does more. It should communicate clear information about the child’s needs—and how best to meet those needs—to parents, educators, and sometimes advocates, lawyers, hearing officers, or judges—not just to other neuropsychologists or members of the medical community. To write the most user-friendly and effective report, the neuropsychologist needs to speak not just medical-ese, but also parent-ese, educator-ese, and legal-ese. This article examines the needs and perspectives of three of these sub-cultures—neuropsychogical/medical, educational, and legal.
The Neuropsychological Perspective
The most comprehensive assessment available, the neuropsych, provides an overview of a child’s functioning, drawing on the child’s history, the clinician’s observations, and test scores in various cognitive domains, including language, memory, visual-spatial skills and so on. “We look at each specific skill and integrate them all into a holistic picture of the child’s functioning,” says Ann Helmus, Ph. D., founder of Neuropsychology and Education Services for Children and Adolescents (NESCA), a pediatric neuropsychology practice in Newton, Massachusetts. The neuropsych evaluation can serve many purposes. Among them, it determines whether developmental problems are present, establishes a diagnosis, guides treatment and educational planning, measures progress, and demonstrates eligibility for special education services.
Ideally, the process starts with seeking a skilled neuropsychologist who has a thorough understanding not only of the clinical aspects of the process, but also its educational and legal implications. However, identifying who to work with can be challenging. Currently there is no specific licensing for a neuropsychologist. “Almost anybody can call themselves a neuropsychologist whether they have training or not,” says Dr. Helmus. Parents should make sure the evaluator is a licensed psychologist who has undergone two years of formal postdoctoral training in neuropsychology, primarily with children. In private practice, similarly, the evaluator should specialize in children and adolescents. “The developmental and educational needs of children are very different from those of adults,” says Sangeeta Dey, Psy.D., a clinical neuropsychologist who practices privately in Lexington, Massachusetts and is a member of the AANE Board of Directors. “If your child needs medical help, you would like them to be seen by a physician who specializes in children.”
Traditionally, neuropsychologists’ training has had a clinical focus (evaluating seizure disorders or brain injuries, for example) rather than a focus on the educational goals that have come to dominate private pediatric practice. “When we’re learning how to do the job, we’re taught to write for the professor and supervisor. In the real world, though, we are rarely writing for other psychologists. The burden on the neuropsychologist is to translate recommendations into the language of the special education system,” says Joseph Moldover, Psy.D., a developmental neuropsychologist who practices independently in Wellesley, Massachusetts and frequently works with children who have AS. Neuropsychologists acquire insight into the education system—to varying degrees—through practice and exposure. Before commissioning an evaluation, parents should clarify what the psychologist usually will or will not do. Will the neuropsychologist write educational recommendations? Is the person familiar with school districts and programming? Can the person meet any relevant deadlines (for example, completing the report in advance of a team meeting)? Is the person willing to make classroom observations and attend team meetings at the child’s school? Should mediation or litigation with the school district become necessary, will the evaluator collaborate with an educational advocate or attorney?
To begin the evaluation process, the child’s parents and teachers fill out questionnaires and supply other information (including medical and school records) to the neuropsychologist. At the intake meeting between the parents and the clinician, parents can further articulate their concerns and goals. (At this stage, a conscientious evaluator might decide a neuropsych evaluation is not merited and the child can be better served by more prosaic means. “Sometimes I say to parents, ‘Spend the money on tutoring’,” says Dr. Helmus.)
The intake meeting is followed by four to eight hours of testing the child. Because some children require frequent breaks and other accommodations, testing may be spread over two to five appointments. By arrangement (and perhaps at an additional charge), some neuropsychologists will observe the child at school or in another environment more typical than their own office. While many evaluators consider this essential for a complete picture of the child’s functioning, others won’t (or can’t) provide the service at all. “Neuropsychologists work with the brain/behavior relationship,” says Dr. Dey. “But if they work with children they should go to school to look at the program, and if they can’t do this they should disclose it before they start.” The evaluation process concludes with a parent feedback session.
The evaluator’s attention can be more carefully targeted if he or she comes to the testing with a clear sense of the issues. “If parents go into the process with a clearly formulated question, they will end up with a better answer,” says Dr. Moldover. “‘The child has a hard time with writing,’ is a general concern. If you say, ‘His homework and vocabulary are good but he can’t get started when he’s asked to write a composition,’ that is much more specific. Similarly, ‘He has poor social skills and doesn’t have many friends,’ is a general concern, versus the more specific, ‘He seems to be socially motivated but can’t interpret facial expressions or sarcasm.’” Asking for educational recommendations is less specific than asking whether an inclusion program is appropriate. However, parents who are new to the process shouldn’t worry if their initial concerns are more general.
In making an assessment, the evaluator draws on three categories of information. First, the child’s history includes relevant psychiatric or neurological disorders within the family; a narrative covering pregnancy, birth, and development from infancy on; the problem that prompted referral—including the emotional impact on the child and family—and the educational history, including what special supports or interventions have already been tried. The second category is observations of the child’s behavior and functioning, which incorporate input from the parents and teachers, in addition to the neuropsychologist’s own observations. The third component is testing. When an AS diagnosis may be indicated, areas of testing include verbal and nonverbal reasoning, organization and executive functioning, language pragmatics, social processing and visual-motor skills.
Ideally, the neuropsychologist should review the written information they receive from both parents and educators prior to the face-to-face intake meeting with the parents, and prior to the testing. “One goal of the neuropsychologist is to ferret out specifics,” says Lynne Mitchell, MSW, an AANE trainer and private educational consultant who works for school districts in Eastern Massachusetts. “If neuropsychologists don’t review the parents’ responses until they put the report together later, they’re wasting a huge opportunity to use the parent sessions more effectively.”
Test scores are interpreted in the context of the other information. “Two children might show exactly the same score on a test, but that could mean entirely different things based on the history of the child and the observations,” says Dr. Helmus. “Just showing me a score tells me very little if I don’t know how it was achieved.” In a geometric design test involving blocks, for example, a child who gets even one block wrong would score zero (suggesting an impulsivity or attention problem). A child who simply throws the blocks also scores zero (suggesting a serious cognitive or behavioral issue).
Some deficits cannot be quantified. Social skills and executive functioning, for example, are assessed to a large extent through observation. “My office desk is near the window and often my evaluation starts when I see the parent park the car and try to get their child out,” says Dr. Dey. “If the child stamps her foot and there are difficulties in the transition, and she arrives in the office and won’t initiate conversation, or has absolutely no regard for my perspective, that could be an important clinical indicator of the child’s functioning in unfamiliar settings. All these observations are documented.”
Confusion around diagnosis is not uncommon. AS is a relatively new label (added to the Diagnostic and Statistical Manual IV in 1994) and shares traits with conditions including ADHD and Non-verbal Learning Disorder. “What a neuropsychologist calls Asperger Syndrome, a neurologist or speech and language therapist might call something different,” says Dr. Moldover. The background of evaluators can incline them more toward one diagnosis than another. A psychologist particularly knowledgeable in ADHD, for example, might overdiagnose it. “Sixty to seventy per cent of all kids I see with Asperger’s have been misdiagnosed with ADHD. If you know how to use a hammer everything looks like a nail,” says Dr. Dey. “But there are other signs–their social interactions and play are unusual, or the child is overly fixated with certain themes, like dinosaurs–that can’t be explained by ADHD.”
Conversely, some psychologists may assume a child with social difficulties has AS, when the real issue might be ADHD or social anxiety disorder. If a child is given different diagnoses by two different professionals, parents can ask the evaluators to explain their criteria or reasons. Says Dr .Moldover: “You’re trying to understand whether it’s an issue of language–two different professionals or disciplines using different terms for the same thing–or a substantive disagreement about what’s being observed in your child.”
A skilled evaluator, says Dr. Helmus, “integrates all the data available from the developmental history, testing, and behavioral observations into a diagnostic formulation that explains why a child can do well in one situation but not in another.” (As an example of a report that failed to integrate all the evidence, she cites a child with visual-spatial-perceptual problems who was inappropriately given the Rorschach inkblot test and misdiagnosed as psychotic.)
Educational recommendations are arguably the most important part of the report—so it is all the more problematic that some evaluators don’t provide them. “Many neuropsychologists tell parents it isn’t their job to write educational recommendations, that’s the job of an educational consultant,” says Dr. Dey. “Parents should clarify this at the outset. It’s important that a neuropsychologist who works with children is capable of writing educational recommendations or performing program evaluations if needed.”
The recommendations are most persuasive when closely related to an individual child’s performance and circumstances. “The recommendations are usually not a direct extension of the test results, but are a product of the child’s interaction with his or her environment,” says Dr. Moldover. “A particular school or program may work well for one child with a given disability, and not for another.” The recommendations should be accompanied by an assessment of the risk to the student if his or her needs are not met.
A detailed description of appropriate services adds weight to the report. “The consumer must demand very specific recommendations which are operational,” says Dr. Moldover. “If the report recommends extra help with social skills, the child can wind up in a lunch bunch, which may not be helpful. It is more useful to say, ‘The student needs pull-out social pragmatics instruction at least three times a week using a formal social skills curriculum, delivered by a graduate level special education teacher with experience in Asperger’s, in a group of no more than three children, with peers who are well matched in IQ and behavior.’”
Independent neuropsychological evaluations are costly. In Massachusetts, the average fee for private evaluations is often $3,000-$3,500 (covered in full or in part by some insurance plans, and perhaps lower for preschoolers). However, families do not necessarily have to pay out of pocket for comprehensive testing. By law, school districts are required to provide testing in all areas of suspected need to determine the eligibility of a student for special education support, and to re-evaluate students on Individualized Education Plans (IEPs) every three years (and more frequently in some circumstances). However, in most cases it will be the school’s choice who conducts the evaluation. If parents are not satisfied with the findings of the neuropsychologist chosen by the school, they can request that the school pay for a second opinion: an independent educational evaluation by a neuropsychologist of the parents’ choice. Because the funding for this is limited, and payment rates are set by the state, the pool of available professionals is small. (Many of the large Boston hospitals will make these evaluations, but their waiting lists can be long.) In some cases a school district may decline to fund an independent evaluation, arguing that their own testing was comprehensive and complete. Disagreements in such cases can be settled in a hearing of special education appeals.
By whatever route the parents make their way to an independent neuropsychologist, they can help ensure their expectations are met by considering, first, their own questions, and second, the type of professional who can best answer them. “All neuropsychologists are not the same,” says Dr. Helmus: “It’s not like going to get a manicure.” Parents should feel free to call AANE to get a referral to a trusted provider.
The Educational Perspective
As the primary source of information guiding the education of a child with AS, neuropsychological evaluations serve several functions: establishing eligibility for special services, providing insight into the way a child learns, describing how to address the child’s needs, and informing decisions about school accommodations and placement.
“A neuropsych report is so much more than the diagnosis,” says Jean Stern, M.Ed., AANE Director of Children’s Services, who has over 30 years’ experience in teaching and educational consultation. “It helps the educational team formulate the best educational and treatment plan for the child. The specific recommendations can translate directly into the services, accommodations, and modifications in the IEP.”
By law, schools are required to review independent neuropsych reports. The reports should be used to guide educational planning and substantially inform students’ IEPs. (Testing provided by public schools also serves this purpose.) “I take the recommendations in a neuropsych and transfer them into a new user-friendly document, the IEP,” says Natalie Labouchere, Lead Teacher at the EDCO Manville Partners Program (based at Brookline High School) for students with AS, Nonverbal Learning Disorder and similar profiles. “I use the neuropsych report to guide goal development and to summarize the student’s current performance. The teachers are more likely to receive the IEP, not the student’s whole file.”
Schools are not required to accept the recommendations, only to consider them at a meeting within ten school days of receiving the report. If possible, having the neuropsychologist participate in the meeting can help the team understand and accept his or her recommendations. If differences arise and cannot be resolved, parents can revoke their consent to any part of a current IEP, or reject a new IEP. In Massachusetts, they will then receive information from the Department of Education about applying for mediation or a hearing at the Bureau for Special Education Appeals.
Even if a school accepts the recommendations, however, the process by which neuropsych reports are translated into action in schools can be “extremely variable district to district, and sometimes within a district,” says Lori Hodgins Brazell, M.S. Ed., an independent special education consultant who works for schools and families. The reasons for this vary. Most neuropsychologists have been trained to write reports for other medical professionals, not for educators. Their reports— typically 8-20 pages crammed with scores, statistics and technical language—can be confusing to those not well versed in psychology, including parents and most mainstream teachers. Even some special educators, with their broad responsibilities for many different types of students, may not have expertise in autism spectrum disorders, and might misconstrue references the neuropsychologist takes for granted. “After parents or educators receive these reports, there can be misunderstandings,” says Jean Stern.
In some cases the process begins with tension around the role of the neuropsychologist in diagnosing the student and advising the teachers—tasks that school administrators may feel their district is equipped to handle in house. Providing services to a child with AS may place additional burdens on schools that are already strapped for resources. (Federal and state laws mandate that eligible students receive services, but do not fully fund them.) In addition, educators are preoccupied with high stakes testing (such as MCAS in Massachusetts) that holds them accountable for students’ progress in math and literacy, but not for some skills that are critical to children on the spectrum, such as social pragmatics or emotional self regulation. As a result, parents and educators sometimes come to the team meeting with frustratingly different perspectives. “You’re thinking of one child, the people across the table are thinking of them all,” says Terri McLaughlin of the Federation for Children with Special Needs, a leading Massachusetts support and advocacy organization. “Parents need to understand the process and what the school is responsible for, what the parent is responsible for, and how can they all work together? Ultimately a working partnership has to be the goal.” In this somewhat challenging context, the responsiblity belongs to parents and neuropsychologists, not just to educators, to ensure that recommendations in a report are effectively implemented.
Once the child’s testing is completed, a competent neuropsychologist schedules a meeting with the parents to discuss the test results and observations, and explain the recommendations. This conversation should equip parents to help interpret the neuropsych report for the child’s educational team, which is particularly important if the educators are relatively new to AS. The completed report should be available to parents and educators with time to spare before the team meeting (“Sometimes the parents wait for months, and the IEP meeting comes and they don’t have the document,” says Jean Stern.) This time frame allows for the report to be reviewed by special education staff, who should be prepared to interpret the report for general education teachers. “Even if the school department accepts the report, it’s not going to be put into practice if the teacher doesn’t understand what the recommendations mean. I’m not blaming the teacher—it’s just that sometimes someone has to translate,” says Lynne Mitchell. In some situations, for example if parents anticipate resistance to the report and its recommendations, the neuropsychologist may need to attend the team meeting. (This usually entails an additional fee. Not all neuropsychologists provide this service, a point that should be clarified up front.)
A neuropsych report goes far beyond traditional academic assessment. Usually it is the other areas of need–social and motor skills, emotional and behavioral issues, and executive function problems–that may entitle a child to services. “Sometimes a child is refused eligibility because he’s not failing academically,” says Jean Stern. “The neuropsych report should make the statement that even with a child who gets straight As, it’s the deficit neurological areas around which you build an IEP, not the strengths.”
With AS, social issues are central. The report is likely to recommend direct instruction in social skills, and tracking the frequency and quality of peer interactions. “The report should cover how a child may interpret social situations and perspective-taking challenges in the classroom,” says Lori Hodgins Brazell. “It needs to make the point that for these students the social is academic. You don’t just expect reading to happen—you teach it directly. You give kids examples and practice and feedback, and then you go onto the next level. With AS, the same thing has to happen for social development.” The neuropsychologist, and then the educational team, should also consider how a child’s social naiveté makes him or her vulnerable to teasing and bullying, and the necessity of including in the IEP protective measures, and teaching the child skills and strategies to keep him or herself safe.
A strong report should also address a student’s emotional needs, which may not be obvious, especially if the child doesn’t exhibit behavioral problems at school. “A good neuropsychologist should identify not only how much anxiety is there, but the impact it has on this particular child,” says Joan Toussaint, an educational consultant and advocate based in Maynard, MA. “There’s almost no greater challenge than being able to get the team to understand that, whether teachers see it or not.” Author and educator Kari Dunn Buron recommends that an IEP also include a goal for relaxation and self-calming.
The neuropsych report should also address the need to teach independent living skills, a deficit that tends to be highlighted when students with AS undertake major transitions (for example, to high school or college). There is increasing awareness that the foundations for success in that transition need to be laid when the child is much younger. “We need to be proactive, not reactive,” says Robin Lurie-Meyerkopf, M Ed, AANE Associate Director and a classroom educator for more than twenty years. “Services must be put in place even though some difficulties might not be obvious, because without support they will become more obvious. A good neuropsych report, especially for a young child, contains information about the need to teach independent skills at every age.” Promoting independence requires addressing executive function difficulties. “Some neuropsychologists could do a better job explaining that executive function isn’t just about your materials. It’s about how you approach and organize anything, including your thoughtsm,” says Lori Hodgins Brazell. Evaluations for an older teen should assess whether the person’s executive functioning is sufficient to enable him or her to transition to an independent life after high school.
For educators, the crux of a neuropsych report is its recommendations. Evaluators need to funnel the student’s testing scores and history, and their own impressions, into a meaningful approach to the child’s education. Sometimes, however, recommendations are not clearly spelled out. They may be scattered throughout the report, buried in psychological jargon. They can be too numerous—overwhelming and paralyzing educators—or too generic. And sometimes parents find themselves with a report from which recommendations are absent altogether, a situation comparable to “leaving the doctor’s office without a script,” according to Terri McLaughlin. “According to the law, recommendations should be part of the report. Parents need to make sure the recommendations are in place, and if they do not understand the test results they should call the evaluator.”
The strongest neuropsych reports use structure and language, as well as professional expertise, to make their case. It’s helpful to assemble the recommendations in one location, focus on the highest priorities for that child, and express them in language geared towards teachers. Natalie Labouchere says, “A neuropsych whose report I liked picked five strong goals, the most salient ones, and explained them. She didn’t overwhelm us with twenty.”
Recommendations are more powerful when delivered in straightforward language rather than medical-ese. “I want the language to be so clear there is no equivocating about what is recommended for services,” says Joan Toussaint. “If it’s too clinical—or too vague or generic—it’s very difficult for the school to implement. How can this translate into functional terms? A good neuropsych report makes the evaluator’s findings applicable to daily life at school and at home—what it means for that particular student.”
Evaluators can accomplish this by backing up their points with realistic classroom examples. These help clarify terms such as “chunking” (breaking down an assignment into smaller ones with separate due dates) and concepts such as sensory integration, an issue often poorly understood by mainstream teachers. “A report might talk about ‘diminished auditory comprehension due to filtering difficulties’, which is not necessarily helpful to a teacher without translation,” says Lynne Mitchell. “Not being able to filter background noise has huge implications in the classroom. Teachers need to understand that this recommendation actually means not seating this particular student with Asperger’s by an open window when Kindergarten is at recess.”
Recommendations should be specific, both to guide educators and to help hold schools accountable. Recommending a “small class” is less useful than specifying, for example, a class of six to ten students with a similar learning profile, taught by a certified special education teacher with expertise in AS. Specificity also reduces the chance of common misinterpretations. “Schools may think that if they throw an extra body in there that’s the same thing as a smaller class size,” says Lynne Mitchell. “But a better teacher: student ratio is different from smaller class size. Sometimes for students with AS the problem is the sheer number of people in the room; more adults can make it worse, not better.” Some neuropsychologists include attachments providing detailed strategies, explanations, and further resources.
Parents can follow up with special educators to help ensure that the IEP is implemented. Even a basic reference–such as “clear explicit language”–might require supervision to be effectively realized, says Lori Hodgins Brazell: “Regular ed teachers may think they’re being clear and explicit, but actually they’re not being clear and explicit enough, because a child is not understanding complex or figurative language and the teachers are not fully aware of the metaphors they use.”
Neuropsychologists should specify the attributes of the school that best meets the child’s needs. For students with AS, that list might include social pragmatics embedded throughout the day, staff skilled at handling anxiety, and a language-based approach to programming. The recommendations should be justified in terms of the particular child’s needs, and the risk to that child if they are not implemented. The neuropsychologist should avoid statements such as “This child requires and outof- district placement,” or even “This child is eligible for special education services,” as these are judgments that are up to the child’s educational team.
For parents, the evaluation process can feel disquieting, the stakes uncomfortably high. However, the neuropsych evaluation with its educational focus, is not only about analyzing the ways that a child perceives and understands the world. It is also about enhancing the way the world perceives and understands that child. “Testing that is thorough, candid, and credible,” says Terri McLaughlin, “affords parents the opportunity to raise expectations, think big, and dream about what could happen, what could be—their child’s capabilities.”
The Legal Perspective
If a dispute between parents and school administrators moves from a school conference room into a courtroom, the neuropsychological assessment assumes another function. With its diagnosis, expert impressions and recommendations, this report is the key piece of evidence in establishing the legal rights of a student with AS to appropriate services at school.
“At a hearing, the hearing officers want a current neuropsych exam by someone credible, and if that’s missing the case is not going anywhere,” says Tim Sindelar, an attorney in private practice with fifteen years’ experience in special education law.
The likelihood of ending up in litigation is small. In Massachusetts, 160,000 students have IEPs. During fiscal year 2008, the Bureau of Special Education Appeals—which conducts mediations, advisory opinions and hearings to resolve disputes between parents and school districts—mediated 906 cases, most of which were settled. Only 34 resulted in full hearings and decisions. However, additional families might go to hearing if they were fully aware of their rights and could afford legal representation.
A strong neuropsych report provides the means to ensure that a child’s needs are addressed from the outset within the legal framework of the special education IEP process. The report provides parents and educators struggling to work out their differences with the means to do so. Educators are less likely to challenge a report that makes an airtight case for the student’s needs. “A strong report can give the team the information and motivation they need to unlock the puzzle,” says attorney Julia Landau, Director of the Autism Special Education Legal Support Center at Massachusetts Advocates for Children, a non-profit organization and leader in special education advocacy. “The stronger the report is, the more likely parents are to avoid the need for mediation and litigation.”
Several features make a neuropsych report particularly credible.
A clear and accurate diagnosis is essential. “Sometimes a neuropsychologist uses words like ‘Asperger’s-like’ but doesn’t actually give a diagnosis,” says Jean Stern, Director of Children’s Services at the AANE. This can be an obstacle to reaching agreement on whether or not a student has a disability, the first step to establishing eligibility for an IEP and services.
Next, the report must establish whether the student is making effective progress or could be expected to do so if its recommendations were implemented. Effective progress is legally defined as documented growth in the acquisition of knowledge and skills, including social and emotional development. Effective progress is evaluated with reference to developmental expectations, the individual potential of the student, and the standards set forth in the state and district curricula. A neuropsychologist can highlight a student’s progress or struggles by using comparable tests over time. “If a previous evaluation used the Wechsler, use the Wechsler again, unless there is good reason for doing the Woodcock instead, in which case describe that in the narrative,” says Tim Sindelar.
The impressions and recommendations presented in the report are most persuasive when rooted in the clinician’s knowledge of the child. “The neuropsychologist’s personal observations are a critical part,” says Beth Simon, Staff Attorney at Massachusetts Advocates for Children, who also practices privately. There are benefits, she adds, in working with the same neuropsychologist over the years. “The evaluator gains credibility by knowing the child better.” A thorough evaluator goes beyond describing the interaction in the office, also observing the child in school and perhaps at home or another social environment. “That’s particularly important with Asperger’s kids, because testing is usually their strong suit, but they have difficulty generalizing their skills in less structured situations,” says Joan Toussaint. Incorporating input from family, neighbors, teachers and other caregivers adds weight to the report. Tim Sindelar says, “The best evaluators will either visit the school program, have someone on staff who will do that, or have discussions with teachers and therapists. This improves the quality of the report and ensures that schools, having been consulted, will be more invested in the findings and recommendations.”
When the evaluator has targeted the testing and observations to specific goals and concerns about that student, the report can offer more insight. “I don’t usually need another neuropsych report to tell me the student has Asperger’s,” says Tim Sindelar. “I might need to gather information about the student’s emotional rather than neurological state, and how to address that: whether this student is in turmoil or not, whether he’s grounded in reality, and what kinds of feelings are dominant.”
Similarly, neuropsychologists’ recommendations should be closely related to the profile of the student in question, rather than cut and pasted from some generic list of accommodations associated with an AS diagnosis. “An evaluation is more persuasive when it is clear from the report how the program, services or accommodations recommended are necessary to meet the unique needs of the individual child,” says Julia Landau.
Recommendations can backfire if couched in terms of what is “best,” “optimal,” or “ideal” for the student. “The school might view those as nice suggestions but not essential, and discount them,” says Eileen Hagerty, an attorney with Kotin, Crabtree and Strong, LLP, a Boston practice with a notable history of advocating for children with special needs. “The law doesn’t entitle the child to the best available education, but one sufficient to meet his needs and make effective progress. As a judge said, this child is not entitled to a Cadillac, but is entitled to a Chevy that runs.” The report should state what the student requires in order to make effective progress. The more specific a report’s recommendations, the more effectively schools can be held to its standard. Ideally, the neuropsychologist should identify not just the type of service a child needs (such as social pragmatics instruction), but its frequency and duration, the qualifications of the provider, the size and composition of the group, and the setting. Even if the neuropsychologist thinks the child needs an out-of-district placement, he or she should not name a specific school in the report. Instead, a good evaluator describes the specific characteristics a program needs in order to be able to satisfy this student’s specific needs.
Stating the risks to the student if the recommendations are not followed can make an assessment more compelling. The child may become increasingly socially isolated, for example, or lose the motivation to keep trying at school. “It can be moving and helpful to include statements the child made, such as feelings of social rejection or thoughts of suicide,” says Eileen Hagerty. “One evaluation I saw commented that the child had bitten her fingers till they were red and bleeding. Or a detail to convey how anxious a child is: they erased the paper so hard they tore a hole in it. That picture of the child is helpful, especially for the hearing officer.”
However persuasive the report, the role of a skilled neuropsychologist goes further. Evaluators sometimes need to attend team meetings (or participate by phone) to explain and defend their recommendations. “As the process becomes more challenging, the family needs better communication between the evaluator and the team,” says Terri McLaughlin. Some evaluators may not expect to participate at this level. However, if a dispute goes before the Bureau for Special Education Appeals, a neuropsychologist who declines to attend the hearing seriously erodes the value of his or her report.
At the hearing, evaluators who establish their objectivity can advocate more effectively. “When I go to hearings and listen to neuropsychologists criticize a public school program or services, sometimes that’s warranted, but other times it looks like they don’t have an open mind about the program or the success the child has had there,” says Attorney Mary Ellen Sowyrda, who represents public schools and an educational collaborative. “They need to acknowledge the parents’ concerns, but if they approach the task with an open mind they will have more credibility.” The neuropsychologist can demonstrate objectivity by acknowledging the strengths of what the school district is offering as well as its weaknesses, by varying his or her recommendations (for example, not routinely advising out of district placements), and by avoiding potentially provocative statements such as: “This child cannot be served in a public school.” Neuropsychologists’ testimony is more persuasive— whether on the witness stand or in the written report—if they have observed the child in a non-clinical setting, talked to teachers about how the child functions at school, and reviewed the documented history, including previous evaluations and IEPs. As chief witnesses, neuropsychologists are an intrinsic part of the effort to ensure that children with Asperger Profiles receive an appropriate education. Despite its challenges, that effort is worthwhile.
Individual neuropsychologists vary in the way they practice their science or art, and may have good reasons for their methods and choices. The points and suggestions made above do not negate the value of neuropsychological reports that may vary from the standards and suggestions in this article.