USES OF ASSESSMENT
Psychological assessment has a wide variety of purposes in pediatric rehabilitation. These purposes encompass issues directly related to the medical setting, but often have equal utility in educational planning.
Unique to the field of pediatric rehabilitation is this necessity for interaction between what are arguably the two biggest public systems for children: medicine and education. Both have their productive and counterproductive forces and hold a vital place in the individual child’s or teen’s life. Furthermore, both can act to hinder or potentiate the salutary effect of the other. The needs and parameters of engagement with both is at the crux of the navigation of development for our patients, and psychological assessment contributes significantly to this process.Psychological testing is often associated solely with IQ testing. The intelligence quotient (IQ) concept of intellectual development is too narrow for many of the applications in a pediatric rehabilitation setting. Instead, the evaluation of the broader aspect of cognition is the more important activity. Cognitive assessment covers testing the wide array of known components of the brain’s thinking skills. Assessing these intake, processing, and output modalities of thinking, their individual elements or the combination of these skills are vital factors in school or in medical rehabilitation. School is children’s work, and the interface with this system is critical, as it is the arena where many key adjustment and developmental issues are played out. Psychological adjustment—indeed, overall functioning—is intimately tied to cognitive status. Coping with frustration, functioning within a group, and inhibiting for long-term goals, are examples of processes vital to school that have cognitive capacity at their center.
Within the schools, the psychological assessment performed has typically included only intellectual and achievement testing as prime components.
Though that is changing in some settings, it is not yet common that cognitive processes are assessed. For the populations common to a rehabilitation medicine practice, many conditions have brain involvement (eg, traumatic brain injury). Their needs are clearly beyond the limitations of typical school testings. Eligibility for services within the special education system under the qualifying conditions of traumatic brain injury (mandated by the federal government in 1998) cannot be done without consideration beyond IQ and achievement testing. Indeed, traumatic brain injury (TBI) as its own inclusion category was done to reflect the serious misunderstanding of the disorder when only evaluated by IQ and achievement testing alone. The intellectual assessment of children with spina bifida needs explication beyond IQ testing as well. Often, the component parts of the Full-Scale IQ score are so divergent in children with spina bifida and other brain conditions that it does not represent a true summary score. To understand a child's condition fully, further assessment of cognitive processes needs to be done. Pertinent abilities are attention, concentration, memory, and executive functions. In the wide array of conditions known to affect brain functioning there are primary and secondary effects. Primary effects are seen from brain tumors, seizure disorders, or cancer processes. Secondary effects on cognitive processes are seen in the process of infectious disease or cancer treatment. It is necessary to evaluate a broader array of abilities rather than relying solely on IQ to understand the full spectrum of required cognitive skills for competent development.In order to promote the fuller understanding of medical conditions and their effects on cognitive functioning, the rehabilitation practitioner will often be consulted for more specialized assessment to capture the full nature of functioning within his or her patients. Input into the Individualized Educational Plan (IEP), which is the centerpiece of planning in the special education system, is essential in brain-based disorders to ensure full consideration of the medical condition, its own process, and its unique effect on brain functioning.
The dynamic nature of recovery is notably absent from most students receiving special education services, but is often a primary part of the course in traumatic brain injury, brain infectious processes, cancer, or strokes. The need for frequent reassessment, specific remediation-focused services, or specialized support in re-entry to school are several of the unique concepts that are vital to sound educational planning in our population but are largely unknown to the traditional process of special education. This is the most critical juncture of school and medical factors in a pediatric rehabilitation process.As per Section 504 of the Rehabilitation Act, accommodations are often sought on either a long-term or transitory basis in rehabilitation medicine patient groups. These are efforts to “level the playing field” within the school setting in acknowledgement of disability that skews a student's ability to benefit from the standard educational setting. These students do not require the breadth or type of actual intervention or service gained through special education classification, but instead need modifications in the system in order to demonstrate their capacities or adequately access the learning environment. Results of psychological/ neuropsychological evaluations can be useful in demonstrating such need related to cognitive issues. For example, deficits in information processing speed can have a global effect on functioning within the group instructional environment of school. Accommodations such as reduction in homework, extended time for tests, or lecture notes, among others, can all be sought with the documentation provided by evaluation results. The issue of how long the accommodations are required can be answered by repeated testing. An example is in the case of a brain injury where recovery occurs and accommodations may no longer be needed.
It is important for the clinician to recognize the role he or she can play in securing vital, but not typical, medical treatment for a patient. This includes speech and language or occupational therapy, cognitive remediation, or adjustment-focused cognitive behavioral work.
The documentation of that need, based on the medical diagnosis or history, can be obtained much quicker and with the proper focus through the medical system in terms of both insurance coverage and proper treatment frequency and formulation. Obtaining assessment from a public school system can be a lengthy process. For rehabilitation patients, this can waste valuable time and, therefore, cannot meet the time frame needed for an acute recovery. A typical school psychological assessment could miss acute issues and be even less likely to detect weaknesses that could hamper development or skill acquisition distant from the injury or illness. Such evaluation needs the medical framework of rehabilitation psychology to be timely and pertinent. Furthermore, with a rehabilitation psychology perspective and knowledge, appropriate documentation emerges to secure services covered by medical insurance or from legal settlement funds, if such exists. Keeping the intervention within the medical perspective can make it more integrated with disease or injury sequelae and, therefore, more targeted and appropriate in terms of goals and treatment techniques.It can be seen that the assessment of a child's or teen's learning process is essential to both the school and medical setting. Memory processes, language abilities, planning, or capacity to inhibit are essential functional elements in either system. The preference of one modality over another, or the explication of memory functioning, can be of great use in school issues and in rehabilitation. The need to master specialized tasks, such as wheelchair skills or self-catheterization, can be enhanced when general learning styles of an individual patient can be discerned.
This understanding of a patient's cognition can inform educating the patient about his or her medical disorder, or the rationale about a medical procedure. The feelings of victimization that can evolve around a painful surgery and the subsequent effect on adjustment or even personality formation are secondary sources of potential morbidity in a child's development.
The child's or teen's sense that he or she was regarded enough in the consideration of procedures to be included in the decision and planning process. The experience of this and the skill to be a meaningful participant are vital long-term skills and are promulgated by knowing the proper way to present material in a way to ensure understanding. Decisions about a child's ability to benefit from a specific treatment such as biofeedback, relaxation training, or the varieties of behavioral programming available are part of diagnostics that guide treatment.Change as the result of intervention can be quantified by assessment. However, change without overt intervention, but to chronicle the long-term outplay of a medical condition, is arguably the most common use of assessment in rehabilitation. The risk for long-term sequelae in traumatic brain injury or from cancer processes and treatment is well known (13,19). The serial assessment of a patient, particularly through known critical developmental periods or illness interventions, is at the core of sound pediatric rehabilitation practice. A developmental lag becomes the object of treatment, whether to spur development or to teach compensatory strategies. As the physical process of a disease is monitored through traditional outpatient clinic visits, so the status cognitive/behavioral of functioning in relation to the demand of one's medical condition or to changing developmental expectations is equally important to monitor.
Baseline assessment is the initiation of such a process. It most often has been understood as measuring function at the outset of illness or injury against which to calibrate future change. Now this concept has been expanded to include the characterization of a healthy child or teen prior to exposure to risk. Specifically, this paradigm defines the process of baseline assessment in sports as regards the risk of concussion. Participation in all sports has exploded in recent years in children of all ages (20).
With the use of baseline cognitive testing, the determination of a child's or teen's unique cognitive profile prior to a concussion are quantified (21). In a much shorter time frame than the one implied previously for more serious illness or injury processes, the degree of concussion and recovery are discerned by repeated testing post-concussion within weeks or months. Cognitive assessment is generally regarded as essential in the diagnosis and monitoring of concussion, as delineated by the International Conference on Concussion in Sport held in Zurich in 2008. The increased vulnerability of the adolescent athlete relative to adults is well recognized as to duration of symptoms and differential recovery pattern. Furthermore, the effect of repeat concussion, treatment options, school demands, restriction of exposure to risk (continued sports participation)—both during recovery and subsequently—and the potential effect on a developing brain (22) are all factors that argue for the role of neuropsychological assessment in the care of such patients. In the next section, the nature of this type of baseline testing will be explored.Understanding the individual experience of a child or teen in relation to his or her body experience is another use of assessment. Understanding the experience, whether through a questionnaire about pain, assessment of specific mood states like depression or anxiety, or a general personality assessment of that patient, can be quite useful. Differential diagnosis can be important, as in the case of post-traumatic stress disorder, where cognitive symptoms of that disorder can be mistaken for the effects of a mild brain injury or concussion. In that circumstance, the deficits are due to the effects of the stress and not to the mechanical disruption of trauma.