Pediatric neuropsych: is it the same?

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psychddd

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I wonder what everyone’s thoughts, especially those who are neuropsychologists, are on pediatric neuropsych? I’m finding more and more that the vast majority of their work is diagnosing neurodevelopmental disorders (like ADHD or LD), which doesn’t feel like real neuropsych to me? It seems easier?
 
That's a pretty broad question. I'm not a peds person, and that may be why, but it's always seemed to me that my peds colleagues have a much more difficult job than me. A lot more "moving parts" in terms of what's going on, what conditions may be at play, what developmental milestones should look like, etc.

Even with adults, I find ADHD evals can be some of the more challenging cases out there if you're actually interested in getting an accurate diagnosis. Few and far-between, at least in my experience/practice, are the cases in which you really only potentially have ADHD as a differential; most of those don't get sent our way.
 
Peds neurpsych is way more then ADHD/LD. It may be what you see a lot of, like run of the mill dementia for us generalist adult people, but the knowledge base to rule in out the countless disorders that could look like those things is a fairly broad knowledge/training base. This is the reason I do not trust the vast majority of people who claim to be lifespan people. I have seen very few training sequences that would adequately prepare one for expertise in both areas.
 
Pediatric populations are way harder dude. Imagine all the contextual factors that adults have control over. Now take away most "choice" in their environment and make them referred patients. Throw in health/genetic disorders, chemo, etc., and it's a lot harder. They're also usually referred patients.

I recently saw a kiddo whose mom was in rehab at the start of the eval, dad (also born prematurely) went into the hospital for diabetic ketoacidosis during our third appointment, mom got out and became the primary historian, all during the course of the evaluation. Poor as hell, but making it. Throw in the prematurity, possible drug exposures, cerebral palsy, lack of decent special ed paperwork from the school of the patient.

The "art" in pediatric testing, is crafting an evaluation that is likely to be useful for this family, who I actually admire because they are doing their best and clearly loving and protective parents. Hence mother going to rehab when she relapsed.

If you look at the contextual information I provided above, I'm basically saying that the family demonstrates poor problem solving skills (which is true). That contextual information can actually inform our differential. How do I craft an eval/recs knowing this?

I'm not saying the parents also had intellectual disability in this case, but we do know that cultural-familial and genetic causes of intellectual disability exist. We also know that if both parents are lower IQ, we would expect the kiddo be higher cognitively (regression to the mean). How does that inform the differential? Just like when you have two doctor parents in your office, you would actually expect the kid to be lower IQ than the parents.

In this case, the kiddo ended up meeting criteria for mild intellectual disability and the evaluation finally got the kid qualified for hab/respite services through our states developmental disability bureaucracy. This will likely ease some of the contextual burdens on this kiddo as we are effectively outsourcing supports away from family and providing some basic monetary support.

Trauma fools would be just like "oh he tested low because he's gone through adversity" without actually understanding that chaos is actually pretty normal for this kid and he's pretty well adjusted and he has cp.

The most annoying pediatric neuropsychology evals are the ones where they diagnose a neurocognitive disorder in executive functions (or some other neuropsych babble) without also listing ADHD on their diagnostic impression. I actually see this from an academic medical center in town.
 
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borne_before said:
Pediatric populations are way harder dude. Imagine all the contextual factors that adults have control over. Now take away most "choice" in their environment and make them referred patients. Throw in health/genetic disorders, chemo, etc., and it's a lot harder.

I recently saw a kiddo whose mom was in rehab at the start of the eval, dad (also born prematurely) went into the hospital for diabetic ketoacidosis during our third appointment, mom got out and became the primary historian, all during the course of the evaluation. Poor as hell, but making it. Throw in the prematurity, possible drug exposures, cerebral palsy, lack of decent special ed paperwork from the school of the patient.

The "art" in pediatric testing, is crafting an evaluation that is likely to be useful for this family, who I actually admire because they are doing their best and clearly loving and protective parents. Hence mother going to rehab when she relapsed. Because parents might not be the best problem solvers themselves and this kiddo has very little control of his context.

It's so much more than just tossing tests and rating scales.

In this case, the kiddo ended up meeting criteria for mild intellectual disability and my evaluation finally got the dude qualified for hab/respite services through our states developmental disability bureaucracy. Trauma fools would just "oh he tested low because he's gone through adversity" without actually understanding that chaos is actually pretty normal for this kid and he's pretty well adjusted.

The most annoying pediatric neuropsychology evals are the ones where they diagnose a neurocognitive disorder in executive functions (or some other neuropsych babble) without also listing ADHD on their diagnostic impression. I actually see this from an academic medical center in town.
Click to expand...

One can have deficits on tests of executive function for many reasons that are not ADHD.
 
WisNeuro said:
One can have deficits on tests of executive function for many reasons that are not ADHD.
Click to expand...
This is such a joocy comment and it made me think. Thank you. Like I totally get what your getting at, but I should have clarified the kids clearly have ADHD.

Honestly, I think most of the time it's done through a diagnostic overshadowing process. For example, the kid has a tbi/epilepsy etc. in their background or whatever is viewed as a more organic cause of the executive functioning deficits and the neuropsych views that more essential to the patient's narrative. But they also let that perceived "organic" cause diagnostically over shadow the other info like the strong familial history of ADHD, prior functioning, etc.
 
WisNeuro said:
One can have deficits on tests of executive function for many reasons that are not ADHD.
Click to expand...
One reason, I find this particularly interesting because, when consulting on an autism case with a colleague, I often joke, "How do you know a kiddo has autism?" The answer? "Because you or I say they do." It’s a tongue-in-cheek way of acknowledging the role of professional judgment in diagnosis—as licensed psychologists, our expertise plays a crucial part in interpreting the data and autism is a messy disorder.

Which is why, when I feel confused or uneasy about a diagnosis, I sometimes find myself saying, "Only God truly knows the etiology—may He forgive me for relying on professional judgment, consultation, flawed tests, and probabilities."

So I try not to hate on our pediatric neuropsychologists too much 🙂
 
borne_before said:
This is such a joocy comment and it made me think. Thank you. Like I totally get what your getting at, but I should have clarified the kids clearly have ADHD.

Honestly, I think most of the time it's done through a diagnostic overshadowing process. For example, the kid has a tbi/epilepsy etc. in their background or whatever is viewed as a more organic cause of the executive functioning deficits and the neuropsych views that more essential to the patient's narrative. But they also let that perceived "organic" cause diagnostically over shadow the other info like the strong familial history of ADHD, prior functioning, etc.
Click to expand...
I'm not a peds person, but I'll say that it's not uncommon for me not to diagnose ADHD, even if I think it may be present, if I didn't sufficiently assess for it in my evaluation. I may discuss it in my summary/conclusions, but I'm not going to assign a diagnosis based solely on cognitive test results. If I were a peds person, I'd be wanting a parent and/or teacher interview (or checklist) as well.

It may be a bit different for the peds neuropsych folks, but if it's not part of the referral question, my time and resources are limited and I may just not have a chance to really get into that.
 
The relative complexity of differential diagnosis depends to a great extent on the age of the pediatric population. I'm limited to under 36 months (and mainly under 24 months), almost all non-verbal. I have my youngest client ever this week at just turned 12 months last week. There's not a lot of psychiatric conditions to rule out in these very young ones, and in my case by the time they get to me several professionals have already determined that ASD is the leading contender. You do need to be more aware of typical early development and mindful of the differences that a month can make (seriously- my scaled score norm tables for most tests are are group into month-long age bands). You also need to be able to assess motor development. Typically (90% percent of the time?), differential diagnosis is limited to ASD, global delays, or pure language delay. Mood and thought disorders really aren't a thing for kiddos this young, and they all meet criteria for ADHD at that age (as well as narcissistic PD!). If anything, it can be a relatively easy process.
 
ClinicalABA said:
The relative complexity of differential diagnosis depends to a great extent on the age of the pediatric population. I'm limited to under 36 months (and mainly under 24 months), almost all non-verbal. I have my youngest client ever this week at just turned 12 months last week. There's not a lot of psychiatric conditions to rule out in these very young ones, and in my case by the time they get to me several professionals have already determined that ASD is the leading contender. You do need to be more aware of typical early development and mindful of the differences that a month can make (seriously- my scaled score norm tables for most tests are are group into month-long age bands). You also need to be able to assess motor development. Typically (90% percent of the time?), differential diagnosis is limited to ASD, global delays, or pure language delay. Mood and thought disorders really aren't a thing for kiddos this young, and they all meet criteria for ADHD at that age (as well as narcissistic PD!). If anything, it can be a relatively easy process.
Click to expand...
That gives me chills dude. Im amazed yall are catching 'em that early. Good work dude.
 
borne_before said:
That gives me chills dude. Im amazed yall are catching 'em that early. Good work dude.
Click to expand...
It's takes a lot of collaboration with our local early intervention (what we call our birth-to-three programs in Mass) providers to make those referrals early. Part of this was our decision to pretty much limit our assessment practice to under 30 months. Just increasing that age limit by 12 months means hundreds of new referrals and and and adding a year to our wait-lists, which would mean kids are at least 30-42 months by the time I'd see them. It was a difficult decision (lowering max age limit) that probably resulted in a cohort of kids not being seen (we are one of the only games in town), but now we get the young ones referred as soon as any potential ASD signs are noted. No more "waiting to see if they grow out of it" by the early intervention staff (which they rarely do), which in turn has somewhat influenced pediatrician referrals. It sucks that there aren't people out there doing evals on the preschool and early elementary kids (unless you can afford private pay, which young families can't), and turning away desperate families sucks even more.

It does mean I've seen a really young (12-14 months) kids where I just couldn't make a diagnosis or- if motor development too delayed- use an ADOS. For those kids I either do the intake and make a plan to see them when they are a little older and natural development has has more of a chance, or do the testing and get some baselines to compare them against when they come back. I'm about 50/50 with the really young ones who I don't give an initial dx- they come back in 3-6 months and have then get an ASD dx and half don't. End of the day, we get young kids in fast (1-3 month wait) and get them into treatment soon after.

From a practical standpoint, it means that I almost exclusively work sitting on the ground, as the littles don't/can't sit at my little table, and my knees are definitely feeling it. It also means that I can get out of practice with the older kids (36-48 months is old in my books), so I will occasionally scheduled an older kiddo for a reval (or sometimes see an older sibling of someone I diagnosed) so that I keep up my skills with that age group and some of the "big kid tests" (WPPSI, CASL, NEPPSY, etc.). Also, parents of very young children also tend to be very young, thus more likely to be low SES and having Medicaid for insurance. That means that if my company wants to pay me fairly (which, imho, they do), a stand alone, toddler ASD diagnostic clinic is not viable, which is why you see them (us included) increasingly as part of a bigger ABA service provider. It also means that I am hyper vigilant about doing my job, billing what I'm expected (and more!), and doing other "value added" stuff, such as clinical supervision, staff training, senior clinical consultation, and teaching in affiliated grad programs.
 
ClinicalABA said:
It's takes a lot of collaboration with our local early intervention (what we call our birth-to-three programs in Mass) providers to make those referrals early. Part of this was our decision to pretty much limit our assessment practice to under 30 months. Just increasing that age limit by 12 months means hundreds of new referrals and and and adding a year to our wait-lists, which would mean kids are at least 30-42 months by the time I'd see them. It was a difficult decision (lowering max age limit) that probably resulted in a cohort of kids not being seen (we are one of the only games in town), but now we get the young ones referred as soon as any potential ASD signs are noted. No more "waiting to see if they grow out of it" by the early intervention staff (which they rarely do), which in turn has somewhat influenced pediatrician referrals. It sucks that there aren't people out there doing evals on the preschool and early elementary kids (unless you can afford private pay, which young families can't), and turning away desperate families sucks even more.

It does mean I've seen a really young (12-14 months) kids where I just couldn't make a diagnosis or- if motor development too delayed- use an ADOS. For those kids I either do the intake and make a plan to see them when they are a little older and natural development has has more of a chance, or do the testing and get some baselines to compare them against when they come back. I'm about 50/50 with the really young ones who I don't give an initial dx- they come back in 3-6 months and have then get an ASD dx and half don't. End of the day, we get young kids in fast (1-3 month wait) and get them into treatment soon after.

From a practical standpoint, it means that I almost exclusively work sitting on the ground, as the littles don't/can't sit at my little table, and my knees are definitely feeling it. It also means that I can get out of practice with the older kids (36-48 months is old in my books), so I will occasionally scheduled an older kiddo for a reval (or sometimes see an older sibling of someone I diagnosed) so that I keep up my skills with that age group and some of the "big kid tests" (WPPSI, CASL, NEPPSY, etc.). Also, parents of very young children also tend to be very young, thus more likely to be low SES and having Medicaid for insurance. That means that if my company wants to pay me fairly (which, imho, they do), a stand alone, toddler ASD diagnostic clinic is not viable, which is why you see them (us included) increasingly as part of a bigger ABA service provider. It also means that I am hyper vigilant about doing my job, billing what I'm expected (and more!), and doing other "value added" stuff, such as clinical supervision, staff training, senior clinical consultation, and teaching in affiliated grad programs.
Click to expand...
I recommend Birkenstock clogs. So you can go shoeless. Way more comfy on the floor w/o shoes.
 
WisNeuro said:
One can have deficits on tests of executive function for many reasons that are not ADHD.
Click to expand...
Off topic, but I’ve seen a couple peds neuropsychs die on the hill that EF deficits should be seen in ADHD cases, and they have withheld diagnosing when the test scores did not support the dsm criteria being met. I’m an adult neuro student so I do not see too many neurodevelopmental conditions, but I’ve been confused by this as I thought literature was clearly moving away from using neuropsych testing to diagnose ADHD…
 
BrainStormer said:
Off topic, but I’ve seen a couple peds neuropsychs die on the hill that EF deficits should be seen in ADHD cases, and they have withheld diagnosing when the test scores did not support the dsm criteria being met.
Click to expand...

People look to EF measures largely as SVTs, even though the correlation between objective EF measures and ADHD symptoms found in clinical interview is modest and has been modest for a really long time. Also, it's a misunderstanding of ADHD, which focuses just on the attention/concentration components to the exclusion of the broader self-regulation problems that characterize the disorder.
 
R. Matey said:
I've been strongly contemplating this life decision. Some of the docs here do it, and it just seems better.
Click to expand...
I recently got a pair of blundstone chelsea boots. Easy slip on and off (i keep them on in the office, but take off when i'm doing home-based therapy), and work well in the 4 inches of snow/slush/muddy water hybrid that will be on the ground here for the next two months.
 
BrainStormer said:
Off topic, but I’ve seen a couple peds neuropsychs die on the hill that EF deficits should be seen in ADHD cases, and they have withheld diagnosing when the test scores did not support the dsm criteria being met. I’m an adult neuro student so I do not see too many neurodevelopmental conditions, but I’ve been confused by this as I thought literature was clearly moving away from using neuropsych testing to diagnose ADHD…
Click to expand...
Pretty much every insurance testing pre-auth form I've had to fill out has a section along the lines of following:
1740519321115.png

I've never had reason to check any of those boxes. I've always assumed that "routine" in the first item was referencing a standard 90791 type session. If any of you ever did check any of that boxes, I'm curious as to whether or not the testing was approved.
 
ClinicalABA said:
I recently got a pair of blundstone chelsea boots. Easy slip on and off (i keep them on in the office, but take off when i'm doing home-based therapy), and work well in the 4 inches of snow/slush/muddy water hybrid that will be on the ground here for the next two months.
Click to expand...

Oooo...those are nice. What do you do for a summer shoe?
 
R. Matey said:
I've been strongly contemplating this life decision. Some of the docs here do it, and it just seems better.
Click to expand...
I got mine on the rei seconds website. I put a little obenauf's oil on them and they're pretty dope.
 
R. Matey said:
People look to EF measures largely as SVTs, even though the correlation between objective EF measures and ADHD symptoms found in clinical interview is modest and has been modest for a really long time. Also, it's a misunderstanding of ADHD, which focuses just on the attention/concentration components to the exclusion of the broader self-regulation problems that characterize the disorder.
Click to expand...
Thisssss mannnnnn.
 
ClinicalABA said:
I have a lighter weight Chelsea boot (Clark's), and some mesh sneaker/shoes from OluKai.
Click to expand...
Lol. I basically only wear Clark's desert boots, my birks, and OluKai flip flops. I'm also on the west half of the country. Buisness casual out here includes golf polos and anything button down - even short sleeve stuff.

Also, may I add, get some khaki's or chinos with a little stretch. I personally am a fan of Bonobos 2.0 athletic fit (because I have a booty).
 
Sanman said:
Don't do it. Leave the comfortable shoes for us older folks. It was bad enough when Arizonas got popular and harder to find.
Click to expand...
I've graduated to low-top white sneakers (puma's right now), I suspect suede loafers are 5 years off at which point all bets are off.
 
I absolutely love my Blundstone’s. One of the best shoe purchases of my life
 
psychddd said:
I wonder what everyone’s thoughts, especially those who are neuropsychologists, are on pediatric neuropsych? I’m finding more and more that the vast majority of their work is diagnosing neurodevelopmental disorders (like ADHD or LD), which doesn’t feel like real neuropsych to me? It seems easier?
Click to expand...

I think it depends on the setting. I see pediatric patients in two settings: an outpatient developmental center that receives community referrals and an outpatient hospital clinic that receives specialty referrals.

At the developmental center, a lot of the referrals are autism questions. In my state, you have to have an "official" diagnosis to receive services. Any pediatrician who catches a whiff of autism in a young one sends them to our center. Many are super straightforward cases, some are more behavioral. In my opinion, you don't need a neuropsychologist to do any of these. However, we get between 20-30 referrals a day for 5 providers, and our waitlist is 18 months. It's all hands on deck (and we're hiring if you are a psych who loves autism assessment!).

At the hospital, I see patients referred for pre-surgical epilepsy, demyelinating conditions, cerebral palsy, dystrophies, genetic conditions, traumatic brain injury, pre-BMT and post, brain tumors, etc. Those are closer to your "traditional" neuropsychological evaluation. There might be a diagnosis of ADHD or LD in that population, but my primary job is describing strengths and weaknesses and making recommendations to the patient and treatment team.

Regardless of the setting, you also need to be very aware of school services and early intervention. You also have to be very, very familiar with typical development, especially in expectations for many of the domains we're assessing. I've found that I use a lot of clinical skills when talking to parents about their child's performance or diagnosis, and a good ped neuropsych can deliver uncomfortable news in a tactful, empathetic, clear manner.

I wouldn't say peds is easier. Every specialty has it's challenges. But I would suggest that peds is a lot more fun (in some aspects)
 
megamaramon said:
I think it depends on the setting. I see pediatric patients in two settings: an outpatient developmental center that receives community referrals and an outpatient hospital clinic that receives specialty referrals.

At the developmental center, a lot of the referrals are autism questions. In my state, you have to have an "official" diagnosis to receive services. Any pediatrician who catches a whiff of autism in a young one sends them to our center. Many are super straightforward cases, some are more behavioral. In my opinion, you don't need a neuropsychologist to do any of these. However, we get between 20-30 referrals a day for 5 providers, and our waitlist is 18 months. It's all hands on deck (and we're hiring if you are a psych who loves autism assessment!).

At the hospital, I see patients referred for pre-surgical epilepsy, demyelinating conditions, cerebral palsy, dystrophies, genetic conditions, traumatic brain injury, pre-BMT and post, brain tumors, etc. Those are closer to your "traditional" neuropsychological evaluation. There might be a diagnosis of ADHD or LD in that population, but my primary job is describing strengths and weaknesses and making recommendations to the patient and treatment team.

Regardless of the setting, you also need to be very aware of school services and early intervention. You also have to be very, very familiar with typical development, especially in expectations for many of the domains we're assessing. I've found that I use a lot of clinical skills when talking to parents about their child's performance or diagnosis, and a good ped neuropsych can deliver uncomfortable news in a tactful, empathetic, clear manner.

I wouldn't say peds is easier. Every specialty has it's challenges. But I would suggest that peds is a lot more fun (in some aspects)
Click to expand...

Think this post does a good job of highlighting training vs job/practice referrals. I feel like the question the OP is asking is what kind of assessments am likely to encounter at typical job, which a difficult question to answer without more details and likely plans.
 
megamaramon said:
I wouldn't say peds is easier. Every specialty has it's challenges. But I would suggest that peds is a lot more fun (in some aspects)
Click to expand...
I’ve found peds neuro training to be super helpful for connecting the dots for developmental breadcrumbs that can pop up during an adult intake. Our fellowship did all adult & peds didactics together, which was a great prep for licensure, but a lot of extra hours at the time.

I knew bc of the logistics of peds (navigating school BS & parent issues in particular) I wouldn’t regularly want to see pts <18, but it was helpful for the 16-18 gap that can pop up sometimes with referrals.

The thing w neuro assessment & consultation is most of the time providers can work in a niche and have plenty to do to keep things interesting, but cradle to grave providers still surprise me. Waaaaay too much needed in regard to testing materials and staying up to date with the field, but some people still do it. Since I do a lot of legal consulting, the more narrow my focus the better.
 
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