Lecture notes with School Neuropsychology at the University of Groningen - 2014/2015

Lecture 1

Neuropsychology is becoming increasingly important at schools. An important question is what can be done in assessment and treatment at schools, and what teachers can do to help.
Most children who have problems at school are comorbid. ADHD is the biggest problem at schools, with a prevalence rate of 3 to 6% in school-aged children. Thereby, 30 to 40% of the referrals to child guidance clinics considers children with ADHD. Teachers are part of the assessment of ADHD, but do not always know how to handle children who suffer from this disorder. The children with ADHD have difficulties in complying with the rules and instructions. Therefore, teachers sometimes misjudge the behavior of a child with ADHD as unmotivated, unwilling and disruptive. These low expectations influence their behavior towards an ADHD child, working as a self-fulfilling prophecy. The teachers experience certain behavior as disruptive, develop low expectations, which in their turn influence their behavior towards the child. This of course does not have a stimulating effect on the child, who therefore acts in a way that confirms the low expectations of the teacher. Luckily, nowadays there’s more awareness for the symptoms of ADHD.
Boys show more externalizing symptoms of ADHD and therefore their behavior is often experienced as more disruptive than the behavior of girls with ADHD. Girls with ADHD mostly show the inattention symptoms and are considered to be dreamy. These expectations create the possibility of a gender based referral bias. The male to female ratio in ADHD is 3,4:1.
The diagnosis of ADHD is based on the following core symptoms;

• inattention

• hyperactivity

• impulsivity

The main clinical picture we see shows excessive task-irrelevant activity and motor restlessness. We do have to consider that ADHD is a huge spectrum, which means that not all people who are affected have all the symptoms. Not everybody with ADHD shows the same behavior, and we all show behavior related to ADHD. The diagnosis has to do with severity and frequency. Diagnosis can be tricky though, because the DSM is often ambiguous (what does ‘driven by a motor’ means?) in how to make judgements. To date, there is no physical objective diagnostic test for ADHD, it still depends heavily on subjective reports.

An important question that often arises is whether the intellectual abilities of a child with ADHD are lower than those of a child without the disorder. Research shows that children with ADHD on average score 7 points below the IQ of healthy children. However, their impaired performance can often be attributed to unfair testing. IQ-tests require skills that are significantly impaired in children with ADHD, but this isn’t their IQ. In a well-characterized, good assessment; the best study ever on the IQ of children with ADHD, researchers found an average of 100 and a standard deviation of 15. This is the same as in healthy people, and thus there is no difference.

One of the reasons to send children to school is to socialize them. However, children with ADHD have difficulties getting into contact with peers. This is often the biggest problem they experience themselves, and what they want to resolve the most with therapy .

There is still a lot of uncertainty regarding the aetiology of ADHD. A lot of factors seem to play a role in the development of the disorder. The latest trend is to focus on genetic factors and the structures of the brain. The main conclusion is that the whole brain appears to be different. Moreover, knowing what gene results in developing ADHD will never result in a treatment.

Lecture 2

Neurochemical findings in ADHD are mostly considering dopaminergic, noradrenergic and serotonergic hypothesis of ADHD aetiology. We mustn’t see those neurochemicals as loose parts, but as interacting substances. There are different neurosystems and neurotransmitters involved in the development of ADHD.

You cannot cure someone from ADHD, but you can help to control the symptoms. We have known for a few years now that we overmedicate children. The problem is that there isn’t a solution or an equally good or better alternative. Stimulant medication like Ritalin can have a positive effect on the behavior of children with ADHD, but this isn’t always enough. If therapists stop subscribing Ritalin, they would have to come up with a suitable alternative. A lot of people who use Ritalin and experience positive effects are afraid to lose those benefits when they stop using them. Fact is that we have to be more critical in what’s working and what isn’t.

Different medications (stimulants) can be effective in treating ADHD. When something doesn’t work, there’s a chance that the patient is comorbid and doesn’t respond to the medication because it suffers from other disorders as well. Currently there’s a lot of discussion going on about the most effective way for the intake of medication. Some say it’s best to take medication every single day, others think it’s better not to take medication in weekends or on holiday. The precise mechanism of action of methylphenidate (MPH) treatment is unknown, but there are assumptions that it releases dopamine and blocks the reuptake of the dopamine and noradrenaline in the synaptic cleft. MPH can also cause side effects, even at low doses.

In research people focus too much on conditions we can control, but this isn’t real life. In real life you cannot control everything.

There are also some non-pharmacological treatments for ADHD. In the beginning, people thought they had to be very strict to control their kids with ADHD. Nowadays we have a lot of information we can share with the parents to help them cope with the ADHD of their child. Therefore, providing information is the first important step of treatment. Because there are still a lot of misunderstandings about ADHD, this step is very relevant. Furthermore, children with ADHD get treated with Cognitive Behavioral Therapy (CBT). For secondary effects of ADHD, psychotherapy can be useful. There are also a lot of alternative options, such as a change of diet or acupuncture, but these are less controllable.

Parents or teachers often end up in a vicious circle of communication with a child with ADHD. When there is no reaction of the ADHD child on questions of the parent, the parent often doesn’t give enough positive feedback which leads to the fact that the child doesn’t learn any skills. Therefore it’s often useful for parents or teachers to go to a parent/teacher training. During the training they learn the effectiveness of punishment, but especially the power and importance of verbal reinforcement. With verbal reinforcement they encourage the self-esteem of the child, and it is often effective to work with a so-called token plan. When children behave in the way that’s expected from them they earn token which they can later on use for favors such as gaming or watching television. This approach works best when they can also loose the tokens when they behave poorly.

In the classroom it is very important to try to keep the child with ADHD from facing windows, open doors and colored posters. The best position for the child’s desk is as close as possible to the teachers. At school it is important to create structures and routines. Teachers should remember not to try to change everything at once.

Handwriting, as a human tool, is a very complex task which requires mastery and integration of a lot of skills, and eventually should be an automaticity or fluency. Disorders of written expression cause poor handwriting with all its consequences. Disorders of written expression are usually associated with other learning disorder, and about 60% of the children with ADHD also meet the criteria for a disorder of written expression.

Graphology is about judging someone based on his handwriting, while graphonomics is about handwriting assessment. This assessment is done by digital recording of handwriting movements, whereby the focus lies on the increase and decrease of velocity. A smooth course demonstrated by a bell shaped profile is seen as decent handwriting, in contrast with a not automated, unskilled handwriting.

For the analysis of someone’s handwriting, researchers ask the participants to write two ‘L’s with their dominant hand. This is because everybody writes this letter the same and this way handwritings can be compared. When people write with their non-dominant hand they show a not-skilled pattern.

What our brain produces is not the same as what our hand produces. Children with ADHD often show impairments in their handwriting. They experience problems with the complex figure of Rey, what means that they have difficulties copying something. Children with ADHD need a lot of encouraging! Practicing helps to improve the handwriting.

Where handwriting of children with ADHD improves significantly after medication treatment in some studies, others show that the medication made it worse. Apparently fluent handwriting doesn’t depend on visual feedback, and does rely on instructions given and motivational factors.

Lecture 3

Everybody walks in the same way, because this is an automatic process. On the contrary, handwriting is unique to every person. The goal of automaticity is that you don’t have to pay attention in order to perform the action. This is what methylphenidate does for children with ADHD: it enables them to write fluently without paying special attention. Fluent movements do not need visual control, and when attention is paid to things that do not need attention it often goes wrong. Handwriting is often seen as an important tool for a successful academic career, though, handwriting possibly shouldn’t be neat but fast and legible, for it’s a tool.

Learning disabilities are processing disorders causing academic deficits, and that are not due to another disability or disadvantage. Dyslexia is one of these learning disabilities, also referred to as developmental reading disorder. This specific learning disorder with a neuropsychological etiology is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. This deficit is often not expected in relation with the other cognitive abilities of the dyslexic person. The difficulties often result from a deficit in the phonological component of language. As a result of the expressed difficulties, children with dyslexia may develop problems with reading comprehension because they have a reduced reading experience, which leads to an impaired vocabulary. Dyslexia occurs throughout the life span.

Dyslexia mostly presents itself around the age of 7/8 years old, therefore showing the first difficulties in the school setting. There are also non-language skills which indicate neuropsychological deficits and therefore predict dyslexia. Approximately 5 to 10 percent of the school-aged children are diagnosed with dyslexia, of which the majority consists of boys. It affects all people, regardless of their social class or level of IQ. The fact that the majority of children with dyslexia are boys can be explained by multiple factors. One of them is that boys show more disruptive behavior anyway, and therefore more often get referred.

Only half of the children with dyslexia are pure dyslectics. Most of the individuals who suffer from dyslexia also have other comorbid disorders like dyscalculia or ADHD.

There are two routes that we can use to read words. The direct route processes words as a whole and therefore works by recognition of familiar words. This is why unfamiliar words are a problem when reading through this route. The indirect route decodes the word by accessing the pronunciation of graphemes and assembling these sounds. This makes it possible to read unfamiliar or non-existent words. Children start learning to read by using the indirect route, and as they become more skilled they start to use the direct route more often.

It’s important to determine which subtype of dyslexia a child has, and therefore if it has trouble with the direct- or indirect route, in order to link it with the proper intervention. For example, people with phonological dyslexia can read words, but have difficulty reading unfamiliar words or pronounceable non-words. Surface dyslexia enables children to read phonetically, but they have trouble understanding what they just read because they show poor whole-word reading. In mixed dyslexia children suffer from both impairments. This is the most severe subtype. Acquired dyslexia results from brain pathology in individuals who previously didn’t have problems with reading.

The most important intervention is early diagnosis, in order to help them achieve in school and life. There is no medical intervention for these reading problems, but adjustments in the school setting can help a child to perform better (e.g. more time to finish an exam).

Lecture 4

50% of the children suffering from ADHD are in the general education, with numbers increasing because of the ‘law for inclusive education’. Teachers often experience children with ADHD as unmotivated and unwilling, influencing their behavior towards the child (self-fulfilling prophecy). This is often caused by a lack of knowledge of the teacher.

The three-tier classification of evidence-based interventions consists of three levels of intervention. The primary intervention is situated in the tier 1. These interventions are school- or classroom wide and can be beneficial for all students, like classroom structure and classroom management. These interventions cover 80% of all treatment plans. Tier 2 offers selective interventions for at-risk children in specialized groups. Tier 3 consists of individually, specialized and intensive treatment approaches for children with high-risk.

Functional behavior assessment is a method for developing classroom interventions with goals as establishing a relation between behavior (B) and environmental events or conditions (A), and develop hypotheses and interventions enabling students to show desirable classroom behaviors (C). As you can see, this method works with the ABC assessment model. In order to develop an intervention, a hypothesis has to be developed first. Next, this hypothesis has to be tested and finally an intervention can be developed.

Interventions can be antecedent-based or consequence-based. Antecedent-based interventions are meant to prevent certain behavior to occur, like providing structure in the classroom. Consequence based interventions manipulate environmental events following a specific behavior to alter the frequency of that behavior. All consequence-based interventions are based in the principles of operant conditioning. Self-regulating interventions focus on the development of self-control skills and problem-solving strategies to regulate behavior. They often work with target-behaviors like on-task behavior and classroom completion.

Lecture 5

Most interventions in the school-setting are antecedent interventions. They have beneficial effects for all pupils but require a great deal of effort from the teachers.

The shared decision making process involves health professionals as well as parents and teachers in the process of diagnosing a child. This is not only necessary to understand different perspectives and effectively treat ADHD in close collaboration, but also a necessary condition in order to diagnose the child with ADHD. The fact is that ADHD symptoms have to present themselves in two different settings in order to get the diagnosis of ADHD. A part of the shared decision making process is collaborative consultation: a cooperation between teachers and professionals.

There are a lot of misconceptions of teachers about the aetiology of ADHD. They often think that is caused by the genes of the child or its environment, but they don’t know that it’s about the interaction between those two. Luckily, knowledge is increasing. Also, teachers do not stigmatize a child for having ADHD, but are even more willing to help because of the seriousness of the disruptive behavior. Therefore parents should involve the teacher in the diagnosis.

There are a lot of difficulties in the parent-teacher communication. Especially parents with a low income, less educated and single parents are less involved in their child’s schooling. Communication can be improved by the use of home based involvement, e.g. letting the parents help their child with its homework. School based involvement can improve communication when the parent for example volunteers to help with a field trip. Home school collaboration involves parent-teacher conferences and for example the Daily Behavior Reportcards systems. These cards are school-home notes by which the teacher informs the parent about a child’s behavior. Parents provide (positive) consequences based on these behaviors.

An upcoming intervention is physical exercise. Exercising increases blood flow to the brain, increases dopamine and noradrenaline levels and results in more optimal use of the executive functions. It thereby stimulates cognitive control and improves behavior. Therefore it is more and more considered as an addition to medication for non-responders to education. Providing more recess-time, motor breaks, provide a child with multiple desks so it can move around or let it sit on a stability ball instead of a chair may be helpful interventions. However, the evidence is limited but promising.

Lecture 6

We consider it weird to buy a bottle of beer for a baby, but is there any difference between this and a mother drinking a glass of wine? Not really. A teratogen embodies everything that is harmful for the fetus, including alcohol as the most harmful.

Fetal Alcohol Spectrum Disorder (FASD) is an umbrella term for several disorders linked with alcohol abuse of the mother during pregnancy. It is not a diagnostic term, since FASD is nog in the DSM. The most familiar disorder, Fetal Alcohol Syndrome (FAS), is a medical diagnostic term.

A baby younger than 18 weeks startles in the uterus: it moves up and down, behavior triggered by developing neurosystems. This phenomenon should disappear after 18 weeks though, but this continuous with children whose mothers have been drinking alcohol. This a sign of illness, namely abnormal developing neurosystems.

Children with FAS experience different effects of the alcohol their mother is drinking during different stages in the pregnancy. In the first trimester, the baby develops morphological abnormalities, especially in the face. The second trimester is the most sensitive for spontaneous abortion and in the third trimester they show decreased fetal growth and are at risk for premature birth.

Alcohol freely crosses the placenta , so dose and timing highly contribute to its effect. The simple view of causation only focusses the timing, frequency and amount of drinking of the mother. But it isn’t that simple! The effects are affected by other maternal traits like metabolism, which varies greatly in all humans, and research is limited. Furthermore, the course of the pregnancy and the environment are also great influential factors.

FAS is characterized by facial abnormalities, growth retardation and central nervous system abnormalities. Also, baby’s with FAS often do not have a corpus callosum and show other brain malformations. Their appearance is characterized by a flat philtrum: the groove between the nose and the upper lip, and smaller widths of the eye-openings. Children around the age of 7 are most optimal for an accurate diagnosis because they most obviously show the facial symptoms and their mothers may be more honest about their drinking behavior after 7 years. Before the age of 5 there is too much ‘noise’ to make an effective diagnosis and when children turn older than 7 years their facial features disappear again.

Overall prevalence rates vary from 0,5-2%. In the Netherlands 30-50% of the mothers drink alcohol during their pregnancy. Most of the drinking occurs in highly educated, Caucasian women above the age of 30 years old. 94% of the children with FAS evidently end up with psychological issues, which sometimes result in dropping out of school, getting in trouble with the law or showing deviant sexual behaviors. This is caused especially by the seriously damaged executive functions. Their adaptive social functioning is much lower than their IQ, and they show multiple deficits crossing many different domains. Comorbidity is more the rule than the exception, with especially high prevalence rates for ADHD.

Public-awareness campaigns could work as a prevention. Moreover, broad based screening and identification is needed. A stable family environment and careful coaching and supervision are helpful interventions for the child itself. At school, consistency, structure, repetition and sensory regulation are key factors. It is most important to avoid overstimulation.