To confirm your appointment, please press one: Examining demographic and health system interface factors that predict missed appointments in a pediatric outpatient neuropsychology clinic.

Objective: Missed patient appointments have a substantial negative impact on patient care, child health and well-being, and clinic functioning. This study aims to identify health system interface and child/family demographic characteristics as potential predictors of appointment attendance in a pediatric outpatient neuropsychology clinic. Method: Pediatric patients (N = 6,976 across 13,362 scheduled appointments) who attended versus missed scheduled appointments at a large, urban assessment clinic were compared on a broad array of factors extracted from the medical record, and the cumulative impact of significant risk factors was examined. Results: In the final multivariate logistic regression model, health system interface factors that significantly predicted more missed appointments included a higher percentage of previous missed appointments within the broader medical center, missing pre-visit intake paperwork, assessment/testing appointment type, and visit timing relative to the COVID-19 pandemic (i.e. more missed appointments prior to the pandemic). Demographic characteristics that significantly predicted more missed appointments in the final model included Medicaid (medical assistance) insurance and greater neighborhood disadvantage per the Area Deprivation Index (ADI). Waitlist length, referral source, season, format (telehealth vs. in-person), need for interpreter, language, and age were not predictive of appointment attendance. Taken together, 7.75% of patients with zero risk factors missed their appointment, while 22.30% of patients with five risk factors missed their appointment. Conclusions: Pediatric neuropsychology clinics have a unique array of factors that impact successful attendance, and identification of these factors can help inform policies, clinic procedures, and strategies to decrease barriers, and thus increase appointment attendance, in similar settings.

"It starts with a knock on the door": Caregiver and provider perspectives on healthcare communication for youth with intellectual and developmental disabilities.

OBJECTIVES: Effective healthcare communication (HCC) is critical for youth with intellectual and developmental disabilities (IDD) who may have complex healthcare needs. The goal of this study was to gain family caregiver and provider perspectives on facilitators and challenges to effective HCC for youth with IDD. METHODS: Caregivers of, and providers for youth with IDD were recruited from the community to participate in virtual focus group (FG) sessions. FGs were 60-90 min long and were facilitated by a research team consisting of caregivers and providers. The FGs were recorded, transcribed, and coded inductively for HCC themes. RESULTS: Nineteen stakeholders participated in the FGs (caregivers: n = 14; providers: n = 5). Twenty-three themes were coded from the transcripts and were categorized by whether they focused on providers, caregivers, or healthcare systems. CONCLUSIONS: Provider behaviors such as active listening and demonstrating humility were found to be critical for effective HCC. Fewer caregiver factors, such as advocacy, and systems factors such as visit format, emerged from the FG data. FG themes represent challenges that future interventions must address. PRACTICE IMPLICATIONS: Efforts to improve HCC, and thus healthcare outcomes for youth with IDD, should address challenges identified by caregivers and providers.

Association of Time in Bed, Social Jetlag, and Sleep Disturbances With Cognitive Performance in Children With ADHD.

OBJECTIVES: Children with ADHD commonly exhibit sleep disturbances, but there is limited knowledge about how sleep and sleep timing are associated with cognitive dysfunction in children with ADHD. METHODS: Participants were 350 children aged 5 to 12 years diagnosed with ADHD. Three sleep-related constructs-time in bed, social jetlag (i.e., discrepancy in sleep timing pattern between school nights and weekend nights), and sleep disturbances were measured using a caregiver-report questionnaire. Linear regression models assessed the associations between sleep-related constructs and cognitive performance. RESULTS: After adjustment for sociodemographic variables, there were few associations between time in bed or sleep disturbances and cognitive performance, however, greater social jetlag was negatively associated with processing speed (ß = -.20, 95% CI [-0.35, -0.06]), visually-based reasoning (ß = -.13, 95% CI [-0.27, 0.00]), and language-based reasoning (ß = -.22, 95% CI [-0.36, -0.08]); all p < .05). CONCLUSION: Social jetlag, but not time in bed or disturbances, was associated with lower cognitive performance among children with ADHD.

Bootstrap Exploratory Graph Analysis of the WISC-V with a Clinical Sample.

One important aspect of construct validity is structural validity. Structural validity refers to the degree to which scores of a psychological test are a reflection of the dimensionality of the construct being measured. A factor analysis, which assumes that unobserved latent variables are responsible for the covariation among observed test scores, has traditionally been employed to provide structural validity evidence. Factor analytic studies have variously suggested either four or five dimensions for the WISC-V and it is unlikely that any new factor analytic study will resolve this dimensional dilemma. Unlike a factor analysis, an exploratory graph analysis (EGA) does not assume a common latent cause of covariances between test scores. Rather, an EGA identifies dimensions by locating strongly connected sets of scores that form coherent sub-networks within the overall network. Accordingly, the present study employed a bootstrap EGA technique to investigate the structure of the 10 WISC-V primary subtests using a large clinical sample (N = 7149) with a mean age of 10.7 years and a standard deviation of 2.8 years. The resulting structure was composed of four sub-networks that paralleled the first-order factor structure reported in many studies where the fluid reasoning and visual-spatial dimensions merged into a single dimension. These results suggest that discrepant construct and scoring structures exist for the WISC-V that potentially raise serious concerns about the test interpretations of psychologists who employ the test structure preferred by the publisher.

Improved parent self-efficacy following pediatric evaluation: Evidence for value of a telemedicine approach in psychological and neuropsychological assessment.

Objective: While considerable inquiry is currently underway into the comparability of psychological test results obtained in onsite/in-person settings versus telemedicine settings, there has been less attention given to the comparability of the impact/outcome of the assessment process across settings. The current quality improvement study conceptualized impact/outcome according to the model of Austin et al. and sought to determine whether the prior finding of increased parent self-efficacy following onsite neuropsychological assessment was also observed when psychological and neuropsychological assessment was conducted via a telemedicine modality. Method: In the course of standard care delivery, ratings from Austin et al.'s four parent self-efficacy items were obtained at time 1 prior to patients' assessment visits and then again at time 2 either (1) following their last assessment/feedback visit (the Complete Assessment group; n = 157) or (2) in the middle of the assessment process prior to the last planned visit (the Incomplete Assessment group; n = 117). Results: Analyses revealed significant findings for time and time × group. Parent self-efficacy ratings improved over time in both groups, with significantly higher ratings in the Complete Assessment group at time 2. When compared to reference means from the in-person/onsite Austin et al. study, ratings from the current study found comparable improvement in parent self-efficacy achieved via telemedicine assessment in the Complete Assessment group. Conclusions: These data support the use of telemedicine based psychological and neuropsychological evaluation and provide preliminary evidence that the impact/outcome is comparable with in-person/onsite assessment.

Characterizing and comparing adaptive and academic functioning in children with low average and below average intellectual abilities.

Objective The recent American Academy of Clinical Neuropsychology (AACN) consensus statement on uniform labeling of performance test scores places children who were previously characterized as having "borderline intellectual functioning" within the low average (LA; full scale intellectual quotient (FSIQ) between 80-89) or below average (BA; FSIQ between 70-79) categories. Given limited research examining functional differences across FSIQ groups using AACN's uniform labeling, this study examined adaptive and academic functioning by FSIQ group in youth referred for (neuro)psychological evaluation. Primary comparisons of interest were between LA and BA groups. MethodParticipants were 2,516 children between 6 to 13 years with standardized measures of intellectual, adaptive, and academic functioning. Participants were included if their FSIQ ranged from average to exceptionally low. Group differences in adaptive functioning and academic achievement were examined. ResultsThe LA group did not differ from the BA group in overall adaptive functioning and several domains of adaptive functioning (i.e. social, practical), but demonstrated slightly stronger adaptive skills in the conceptual domain. While the LA group evidenced slightly better word reading and math computation scores than the BA group, these statistically significant differences were not clinically -meaningful. ConclusionsIn this clinically referred sample, children with LA and BA intellectual abilities demonstrated similar adaptive skills, but slightly different academic achievement. Both groups demonstrated lower adaptive and academic functioning than children with average range FSIQs. These results suggest that adaptive functioning should be assessed during (neuro)psychological evaluations even when children do not have extremely low FSIQs.

Can We Expand the Pool of Youth Who Receive Telehealth Assessments for ADHD? Covariates of Service Utilization.

BACKGROUND: During the COVID-19 pandemic, telehealth became widely utilized for healthcare, including psychological evaluations. However, whether telehealth has reduced or exacerbated healthcare disparities for children with Attention-Deficit/Hyperactivity Disorder (ADHD) remains unclear. METHODS: Data (race, ethnicity, age, insurance type, ADHD presentation, comorbidities, and distance to clinic) for youth with ADHD (Mage = 10.97, SDage = 3.42; 63.71% male; 51.62% White) were extracted from the medical record at an urban academic medical center. Three naturally occurring groups were compared: those evaluated in person prior to COVID-19 (n =780), in person during COVID-19 (n = 839), and via telehealth during COVID-19 (n = 638). RESULTS: Children seen via telehealth were significantly more likely to be older, White, have fewer comorbid conditions, and live farther from the clinic than those seen in person. CONCLUSIONS: The current study suggests that telehealth has not eliminated barriers to care for disadvantaged populations. Providers and institutions must take action to encourage telehealth use among these groups.

Does Assessment Format Matter? A Comparison of In-Person Versus Teletesting Scores for Youth with ADHD.

OBJECTIVE: This study examined test score equivalency between traditional in-person assessment and teletesting among youth diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). METHOD: In all, 896 youth with ADHD, ages 5-21 years, were administered cognitive, academic achievement, and verbal fluency measures via either teletesting (n = 448) or traditional in-person assessment (n = 448). The teletesting and in-person groups were matched on age, sex, and insurance type (as a proxy for income). RESULTS: Results indicated no significant differences in test scores obtained via in-person and teletesting evaluations across all examined measures. CONCLUSION: Clinically referred youth with ADHD perform similarly on measures of cognitive functioning, academic achievement, and verbal fluency, regardless of whether these measures are administered in-person or via teletesting. While additional evidence for equivalent psychometric properties of neuropsychological instruments administered remotely is needed, this study offers support for the validity of remote administration among youth with ADHD.

An abbreviated WISC-5 model for identifying youth at risk for intellectual disability in a mixed clinical sample.

OBJECTIVE: The correct "dosing" of neuropsychological assessment is of interest for the purposes of cost management and the personalization of medicine/assessment. In this context, embedded IQ screening, rather than routine comprehensive IQ testing, may be useful in identifying youth at risk for Intellectual Disability (ID) for whom further assessment is needed. This retrospective, cross-sectional study examined subtests from the Wechsler Intelligence Scale for Children-Fifth Edition (WISC-5) needed to identify youth with Full Scale IQ (FSIQ) ≤75. METHOD: Data were obtained from a large pediatric clinically referred sample (N = 4,299; Mean Age = 10.7 years; Range = 6-16y; 66% male; 54% White; 29% receiving Public Insurance), divided into training (n = 2149) and test (n = 2150) samples. RESULTS: In the training sample, sequential and additive regression-based models for predicting FSIQ comprised of one (Block Design [BD]), two (BD + Similarities [SI]), three (BD + SI + Matrix Reasoning [MR]), and four (BD + SI + MR + Digit Span [DS]) subtests of the WISC-5 explained 61.3%, 82.7%, 88.5%, and 93.0% of FSIQ variance, respectively. Using a predicted FSIQ ≤ 80 as a cut score to identify persons with observed FSIQ ≤75, the two subtest (BD + SI) model showed strong sensitivity (83.4), specificity (90.5), and negative predictive value (96.2) in the test sample; however, positive predictive value was low (65.3%). Three and four subtest models provided incremental, but modest gains in classification metrics. CONCLUSIONS: Findings suggest the first several subtests of the WISC-5 can be used to identify clinically referred youth at risk for ID who subsequently require full administration of the WISC-5 for consideration of an ID diagnosis.

Long-term stability of Wechsler Intelligence Scale for Children-fifth edition scores in a clinical sample.

This study investigated the stability of Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V) scores for 225 children and adolescents from an outpatient neuropsychological clinic across, on average, a 2.6 year test-retest interval. WISC-V mean scores were relatively constant but subtest stability score coefficients were all below 0.80 (M = 0.66) and only the Verbal Comprehension Index (VCI), Visual Spatial Index (VSI), and omnibus Full Scale IQ (FSIQ) stability coefficients exceeded 0.80. Neither intraindividual subtest difference scores nor intraindividual composite difference scores were stable across time (M = 0.26 and 0.36, respectively). Rare and unusual subtest and composite score differences as well as subtest and index scatter at initial testing were unlikely to be repeated at retest (kappa = 0.03 to 0.49). It was concluded that VCI, VSI, and FSIQ scores might be sufficiently stable to support normative comparisons but that none of the intraindividual (i.e. idiographic, ipsative, or person-relative) measures were stable enough for confident clinical decision making.

Pediatric neuropsychological evaluation via telehealth: Novel models of care.

Objective: As the coronavirus pandemic extends across the globe, the impacts have been felt across domains of industry. Neuropsychology services are no exception. Methods for neuropsychological assessments, which typically require an in-person visit, must be modified in order to adhere to social distancing and isolation standards enacted in an effort to slow the pandemic. How can providers continue to meet the needs of patients referred for neuropsychology evaluations, while respecting federal and state guidelines for safety and ethical mandates? We offer a novel, tiered model of care, successfully implemented in response to mandated social distancing, in a large, pediatric neuropsychology program.Method: We describe the considerations and challenges to be addressed in transitioning a large neuropsychology department to a new model of care, including triaging referrals, developing -or rediscovering - types of services to meet the needs of a virtual patient population, and helping patients, parents, and providers to adjust to these new models.Conclusions: Lessons learned as a function of rapid changes in care models have implications for the field of neuropsychology as a whole as well as for future flexibility in meeting the needs of pediatric patients and their families.

Transitioning to telehealth neuropsychology service: Considerations across adult and pediatric care settings.

Objectives: In response to the 2020 COVID-19 pandemic, traditional, in-person neuropsychological assessment services paused in most settings. Neuropsychologists have sought to establish new guidelines and care models using telehealth neuropsychology (teleNP) services. The need to adapt to remote technology became the most difficult challenge to date for existing practice models. Results: Primary considerations for transitioning to teleNP include scope and limitations of the telehealth modality, informed consent for telehealth services, patient privacy and confidentiality, test security, and validity of telehealth assessments. Given timelines for fully re-opening clinical settings, access to traditional models of neuropsychological care remains unclear. These considerations will remain relevant even upon return to an in-office practice, as many assessment models will likely continue with teleNP to some extent. Specialists will need to consider the unique needs of their populations in ensuring quality care, as diagnostic differences and patient age will impact participation in teleNP. Conclusions: As the COVID-19 pandemic lingers, teleNP presents an opportunity as well as a challenge for neuropsychologists looking to provide patient care in the context of social distancing and stay-at-home restrictions. In this transformative time, the field of neuropsychology has opportunities to advance beyond traditional settings and focus on alternative delivery of patient care.

Construct Validity of the WISC-V in Clinical Cases: Exploratory and Confirmatory Factor Analyses of the 10 Primary Subtests.

Independent exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) research with the Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V) standardization sample has failed to provide support for the five group factors proposed by the publisher, but there have been no independent examinations of the WISC-V structure among clinical samples. The present study examined the latent structure of the 10 WISC-V primary subtests with a large (N = 2,512), bifurcated clinical sample (EFA, n = 1,256; CFA, n = 1,256). EFA did not support five factors as there were no salient subtest factor pattern coefficients on the fifth extracted factor. EFA indicated a four-factor model resembling the WISC-IV with a dominant general factor. A bifactor model with four group factors was supported by CFA as suggested by EFA. Variance estimates from both EFA and CFA found that the general intelligence factor dominated subtest variance and omega-hierarchical coefficients supported interpretation of the general intelligence factor. In both EFA and CFA, group factors explained small portions of common variance and produced low omega-hierarchical subscale coefficients, indicating that the group factors were of poor interpretive value.

Initial Examination of the BRIEF2 in Clinically Referred Children With and Without ADHD Symptoms.

Objective: Clinical utility of the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2) was examined in 1,381 clinically referred youth (62.5% male, 5 to 18 years) with and without ADHD symptoms. Method: Participants included children with restricted inattentive symptoms (IA only), restricted hyperactivity/impulsivity symptoms (HI only), symptoms in both domains (Combined), and non-ADHD clinical comparison. Results: Greater hyperactivity (Combined, HI only) was associated with higher Behavior Regulation (BRI) and Emotion Regulation (ERI) scores, whereas greater inattentiveness (IA only, Combined) was associated with higher Cognitive Regulation scores. Effect sizes were largest for Inhibit, Working Memory, and Organization of Materials scales; these scales discriminated children with and without ADHD symptoms and restricted inattentive and hyperactive presentations. Conclusion: The BRIEF2 distinguishes associated features of ADHD and the day-to-day executive impact. Sensitivity was consistently poorer than specificity. The referred nature of the sample and examination of restricted presentations suggest additional work is needed to examine whether ERI and BRI are dissociable.

Jitter Reduces Response-Time Variability in ADHD: An Ex-Gaussian Analysis.

OBJECTIVE: "Jitter" involves randomization of intervals between stimulus events. Compared with controls, individuals with ADHD demonstrate greater intrasubject variability (ISV) performing tasks with fixed interstimulus intervals (ISIs). Because Gaussian curves mask the effect of extremely slow or fast response times (RTs), ex-Gaussian approaches have been applied to study ISV. METHOD: This study applied ex-Gaussian analysis to examine the effects of jitter on RT variability in children with and without ADHD. A total of 75 children, aged 9 to 14 years (44 ADHD, 31 controls), completed a go/no-go test with two conditions: fixed ISI and jittered ISI. RESULTS: ADHD children showed greater variability, driven by elevations in exponential (tau), but not normal (sigma) components of the RT distribution. Jitter decreased tau in ADHD to levels not statistically different than controls, reducing lapses in performance characteristic of impaired response control. CONCLUSION: Jitter may provide a nonpharmacologic mechanism to facilitate readiness to respond and reduce lapses from sustained (controlled) performance.

Incremental validity of neuropsychological assessment in the identification and treatment of youth with ADHD.

Comprehensive neuropsychological assessments for youth with ADHD allow for thorough consideration of co-occurring disorders and provide targeted recommendations for treating ADHD and comorbid conditions. This study offers a preliminary evaluation of the added value (compared to routine care) associated with neuropsychological assessment in the identification and treatment of ADHD in youth ages 3-17 years. First we describe a novel measure developed to evaluate broad-based outcomes for youth with ADHD following neuropsychological assessment. Next we compare parent ratings of child symptoms and quality of life between two groups of youth with ADHD: those who have recently received neuropsychological assessments (NP+), and those who have not (NP-). Participants were surveyed again 5 months after baseline to assess changes in symptoms, quality of life, and service utilization. While both groups experienced significant improvements in behavioral/emotional symptoms, the NP+ group had greater initiation of parent behavior management training and special education services and greater initiation of medication management over the follow-up period, compared with the NP- group. Satisfaction with neuropsychological assessment was high overall but slightly decreased over the course of the follow-up period. The findings offer preliminary support for the incremental efficacy of neuropsychological evaluation in the diagnosis and management of ADHD.

Classification of intellectual disability using the Wechsler Intelligence Scale for Children: Full Scale IQ or General Abilities Index?

AIM: We examined the implications of using the Full Scale IQ (FSIQ) versus the General Abilities Index (GAI) for determination of intellectual disability using the Wechsler Intelligence Scales for Children, fourth edition (WISC-IV). METHOD: Children referred for neuropsychological assessment (543 males, 290 females; mean age 10y 5mo, SD 2y 9mo, range 6-16y) were administered the WISC-IV and the Adaptive Behavior Assessment System, second edition (ABAS-II). RESULTS: GAI and FSIQ were highly correlated; however, fewer children were identified as having intellectual disability using GAI (n=159) than when using FSIQ (n=196). Although the 44 children classified as having intellectual disability based upon FSIQ (but not GAI) had significantly higher adaptive functioning scores than those meeting intellectual disability criteria based upon both FSIQ and GAI, mean adaptive scores still fell within the impaired range. FSIQ and GAI were comparable in predicting impairments in adaptive functioning. INTERPRETATION: Using GAI rather than FSIQ in intellectual disability diagnostic decision-making resulted in fewer individuals being diagnosed with intellectual disability; however, the mean GAI of the disqualified individuals was at the upper end of criteria for intellectual impairment (standard score 75), and these individuals remained adaptively impaired. As GAI and FSIQ were similarly predictive of overall adaptive functioning, the use of GAI for intellectual disability diagnostic decision-making may be of limited value.

Factor structure of a sluggish cognitive tempo scale in clinically-referred children.

"Sluggish cognitive tempo" (SCT) is a construct hypothesized to describe a constellation of behaviors that includes daydreaming, lethargy, drowsiness, difficulty sustaining attention, and underactivity. Although the construct has been inconsistently defined, measures of SCT have shown associations with symptoms of attention-deficit/hyperactivity disorder (ADHD), particularly inattention. Thus, better characterization of SCT symptoms may help to better predict specific areas of functional difficulty in children with ADHD. The present study examined psychometric characteristics of a recently developed 14-item scale of SCT (Penny et al., Psychological Assessment 21:380-389, 2009), completed by teachers on children referred for outpatient neuropsychological assessment. Exploratory factor analysis identified three factors in the clinical sample: Sleepy/Sluggish, Slow/Daydreamy, and Low Initiation/Persistence. Additionally, SCT symptoms, especially those loading on the Sleepy/Sluggish and Slow/Daydreamy factors, correlated more strongly with inattentive than with hyperactive/impulsive symptoms, while Low Initiation/Persistence symptoms added significant unique variance (over and above symptoms of inattention) to the predictions of impairment in academic progress.

The role of neuropsychological assessment in the functional outcomes of children with ADHD.

The value of evidence-based services is now recognized both within clinical communities and by the public at large. Increasingly, neuropsychologists must justify the necessity of often costly and time-consuming neuropsychological assessments in the diagnosis and treatment of common childhood disorders, such as Attention-deficit/Hyperactivity Disorder (ADHD). Published medical guidelines and prominent researchers, however, have argued against the need for formal neuropsychological assessment of ADHD. The present review examines the literature on developmental outcomes in childhood ADHD, with emphasis on the utility of formal neuropsychological assessment among children diagnosed and treated in primary care settings. The review yields three central findings: 1) adherence to published diagnostic guidelines for ADHD is poor among pediatric and primary care physicians; 2) ADHD most often co-exists with other disorders, thus diagnoses made without formal psychometric assessment can be incomplete or incorrect, ultimately increasing treatment costs; and, 3) untreated children with ADHD, and those who have untreated comorbidities, are at greater risk for poor outcomes in social, academic, vocational, and practical settings. The available literature suggests that neuropsychological assessment provides information that can potentially reduce risks for poor outcomes and improve quality of life among children with ADHD. Controlled studies directly examining the impact of neuropsychological assessments in improving outcomes among children with ADHD are needed.