Introduction to Cerebral Palsy (CP)

Subtypes of CP

• Spastic CP is the most common type of CP. It is caused by damage to the part of the brain that controls motor movements (the motor cortex) or the motor pathways as they descend down to the spinal cord. In this type of CP, muscles appear stiff, and movements may be stiff or jerky.
• Dyskinetic or dystonic CP is caused by damage to the basal ganglia or associated pathways. In this type of CP, you see involuntary movements.
• Ataxic CP is caused by damage to the cerebellum. In this type of CP, you see unsteady, imprecise movements and balance difficulties.

Understanding terminology in CP

Learning and development in CP

• About 45% of individuals with CP have an Intellectual Disability (ID).
• Many of those who have CP without ID have some learning differences.
• As a group, those with hemiplegia (paralysis on one side of the body) or spastic diplegia (paralysis of both corresponding limbs, usually legs) tend to be less cognitively impacted than those who have all 4 limbs involved[footnote]Reid, S. M., Meehan, E. M., Arnup, S. J. and Reddihough, D. S. (2018). Intellectual disability in cerebral palsy: A population‐based retrospective study. Dev Med Child Neurology, 60, 687-694.[/footnote].

• Multiple short sessions
• Frequent breaks
• Appropriate seating support
• Materials presented in an ergonomically appropriate manner

Adaptations/modifications and validity of data

Setting up the test materials

Alternate response options for multiple choice tests

• “Multiple and severe” or "profound and complex" disabilities are the terminology which are likely to be most helpful when searching for more information.
• A lot of good work for children with multiple and severe disabilities has come out of the field of professions who work with children who are Deafblind.
• Much of the “assessment” work in this population is classroom assessment or curricular-based assessment. This type of work provides excellent models for “creative” or non-standardized psychology assessments.

Highly recommended resources for further education

• Set BC hosts online webinars (open to all), school district training, and has an extensive list of self-directed trainings online for free: http://www.setbc.org/
• POPARD has an extensive video training library: https://www.autismoutreach.ca/
• Curriculum and Strategies section of the Inclusion Outreach website has a range of helpful resources and videos: http://www.inclusionoutreach.ca
  • For example, how to teach the sign “more”: http://www.inclusionoutreach.ca/content/cs/Communication/Developing%20aRequest%20for%20More.pdf
• The United Kingdom Department of Education has a series of 16 online modules, available for free, entitled: Training materials for teachers of learners with severe, profound and complex learning difficulties. http://complexneeds.org.uk/

Assessment in individuals with multiple, severe disabilities

• Guidelines for Assessment of and Intervention With Persons With Disabilities: http://www.apa.org/pi/disability/resources/assessment-disabilities.aspx
• Horn, E. M., & Kang, J. (2012). Supporting Young Children With Multiple Disabilities: What Do We Know and What Do We Still Need To Learn? Topics in Early Childhood Special Education, 31(4), 241–248. http://doi.org/10.1177/0271121411426487
• Assessing Communication and Learning in Young Children Who are Deafblind or Who Have Multiple Disabilities, Edited by Charity Rowland, Ph.D. and published in 2009 by Design to Learn Projects of Oregon Health & Science University. Available free here: https://www.designtolearn.com/uploaded/pdf/DeafBlindAssessmentGuide.pdf

Parent perspective

• Stronger Every Day Podcast - http://www.portlandrootsmedia.com/strongerpodcast: Episode 8: Going through an autism evaluation, and Episode 197: what it feels like to hear difficult things about your child, even if you know those things already. What is helpful to hear from a professional.
• Also, this article provides a parent's frustration with the clinician's focus on what their child cannot do: "I Have a Question for the Person Evaluating My Child With Special Needs" by the person behind the Stronger Every Day podcast: https://themighty.com/2015/02/evaluating-a-special-needs-child-cant-be-multiple-choice/

Diagnosing level of disability (mild, moderate, severe, profound)

British Columbia & Canadian Federal government services/supports

• Children and Youth with Special Needs (CYSN): Provides  a number of services including funding for respite care, youth workers, and behavioural support. Requires a psychologist's DSM-5 diagnosis of Intellectual Disability or Global Developmental Delay.
• At Home Program: Provides all the benefits of CYSN + medical benefits (including equipment and supplies) and/or funding for school aged therapy (speech and language therapy, occupational therapy, physiotherapy). Physician referral required. To qualify, the child must be assessed by the program as dependent in at least three of the four activities of daily living (eating, dressing, toileting and washing).
• Community Living BC (CLBC): Provides residential, inclusion, respite, behavioural, and employment support to adults (19+) with intellectual disabilities. Requires a DSM-5 intellectual disability which was present before age 18. Or, for the Personal Supports Initiative, a diagnosis of  Fetal Alcohol Spectrum Disorder (FASD) or Autism Spectrum Disorder (ASD) + overall adaptive functioning 3 standard deviations below the mean. CLBC legislation currently REQUIRES IQ below 70 (+/- confidence interval) on “standardized intelligence tests.” When you are not able to present a formal IQ score, provide a formal DSM-5 diagnosis of Intellectual Disability with explanation:
  • Say what you tried.
  • Say why it did or did not work.
  • Give whatever scores you have, even if they are based on raw scores of zero.
  • A developmental assessment is “better than nothing” in terms of CLBC eligibility, and if a formal developmental assessment is not possible, classroom observation and notes on developmental capabilities would be appropriate.
  • Provide relevant history of development and current everyday functioning skills.
• Services to Adults with Developmental Disabilities (STADD): Offers Navigator services for youth transitioning to adult services and their families in 116 communities across B.C. Navigators act as the primary point of contact for individuals in coordinating transition planning and access to supports and services through the transition period of 16-24 years old.
• Choice in Supports for Independent Living (CSIL –pronounced SEE-sul): CSIL is a self-directed option for eligible adult home support clients. CSIL clients receive funds directly from their local health authority to purchase their own home support services.  The BC Cerebral Palsy Association offers a series of workshops on CSIL.
• Home Adaptations For Independence (HAFI): Provides financial assistance for home modifications for eligible low-income British Columbians with mobility or health issues.
• Child Disability Tax Credit (CDTC): There are different ways to qualify for the Canadian federal Disability Tax Credit. Application can be completed by a Registered Psychologist for individuals with an Intellectual Disability. Other applications require a medical or other professional.
• Registered Disability Savings Plan (RDSP): A RDSP is a Canadian federal savings plan to help parents and others save for the long-term financial security of a person who is eligible for the disability tax credit. Contact any participating financial institution for more information once the Disability Tax Credit is approved.

BC Ministry of Education Provincial programs

• Inclusion Outreach (previously “PISP”) provides child specific strategies to maximize learning for students who have multiple disabilities (physical, sensory, neurological) combined with severely impaired cognitive functioning. Most students are non-verbal. See the Curriculum and Strategies section of the Inclusion Outreach website for a wealth of educational resources.
• SET-BC (Special Education Technology-BC) lends assistive technologies to the school district (reading, writing & communication tools) to ensure students’ access to educational programs. The program also assists school districts in training students & educators to use these technologies. Districts are allotted a certain number of SET-BC spots per year, and must request the service. When providing technology, SET-BC includes 1 year of intensive training to the team + 4 years of equipment only support. Their website has a wealth of information on special technology (e.g., how to use speech to text programs)..
• Provincial Outreach Program for Autism and Related Disorders (POPARD) provides consultation, training and support services to public and independent schools across the province of British Columbia with a primary focus on increasing the capacity of school district staff to support students with an autism spectrum disorder (ASD). POPARD can provide short-term intensive intervention to students with significant behaviour difficulties which are beyond the current skill levels of District staff.
• Provincial Outreach Program - Deaf and Hard of Hearing (POPDHH) collaborates with school districts in meeting the needs of all Deaf and Hard of Hearing learners.
• Provincial Resource Centre for the Visually Impaired (PRCVI) provides schools with alternate formats of provincially recommended learning resources and with specialized equipment to support the educational needs of students with visual impairments. It also provides consultations to schools.

Health/Mental Health Services

• Developmental Disabilities Mental Health Services (DDMHS) provides individualized assessment, treatment and education for adolescents (12+) and adults with developmental disabilities and complex mental health needs. Referral may be needed through CYSN. The diagnosis of intellectual disability must be formalized.
• Sunny Hill Health Centre, provides inpatient acute rehabilitation and respite care as well as outpatient services including Assistive Technology, Developmental Coordination Disorder diagnostic clinic, Feeding & Nutrition, Hearing Loss, Positioning & Mobility, Therapeutic Recreation, Tone Management, Visual Impairment, Neuromotor, Autism, Complex Developmental Behavioural Conditions (CDBC), and Gait Assessment.
• ACCESS Clinic at BC Women’s Hospital & Health Centre offers cervical cancer screening (Pap tests) to adolescents and women with disabilities, or who have had difficulties with routine screening at their health care provider's clinic.  They aim to help any woman who has experienced barriers to cervical cancer screening, menstrual management, or who requires specialized contraception counselling. Referral is not required.
• The BC Children’s Hospital Orthopaedic Cerebral Palsy Clinic cares for children with cerebral palsy and similar neuromotor conditions. Referral is required.

Community Services/supports

• The Developmental Disabilities Association provides community-based programs and services for children, youth, and adults with intellectual disabilities.
• Family Support BC provides support to individuals with disabilities and their families. They provide family support, have a database of support workers, provide webinars on estate planning, and more.

Community funding sources for children to participate in sports activities

• KidSport: http://www.kidsportcanada.ca/ provides funding for sports programs for low income families.
• Athletics for kids: https://www.a4k.ca/ funding for sports programs for low income families.
• Jump Start: http://jumpstart.canadiantire.ca/content/microsites/jumpstart/en/apply.html funding for sports programs for low income families.

Community funding sources for equipment, therapies, education, and entertainment

• Access2 Card: https://access2card.ca/ is a program that provides free access to entertainment and recreational opportunities for a support person of a person with a physical disability.
• BC Cerebral Palsy Association: http://bccerebralpalsy.com financial support to individuals and families of children with CP through Summer Camperships, Tanabe Bursaries for post-secondary students, and Assistive Devices and Equipment Subsidies.
• BC Epilepsy Society: http://www.bcepilepsy.com/ has scholarships available for post-secondary students who have a diagnosis of epilepsy.
• BC Rehab: http://www.bcrehab.com/content/individual-grant-programs funding for equipment and therapy based on financial need.
• CKNW Kid’s Fund: https://www.cknwkidsfund.com/ for equipment, therapy, or special education bursary.
• Jennifer and Gregory Louie Foundation for Cerebral Palsy http://www.jglfoundation.com grants for children with cerebral palsy who live in BC.
• Jordan’s Principal: www.can​ada.ca/jordans-principle support with access to education, healthcare, therapy and equipment for First Nation’s children.
• Maple Ridge Lions Club: http://www.mapleridgelionsclub.org/Support.html for equipment or funding for services for children in Maple Ridge.
• March of Dimes of Canada: https://www.marchofdimes.ca funding for equipment or devices for adults with physical disabilities and financial need.
• Military Police Fund for Blind child: http://www.mpfbc.com funding for children and young adults to age 21 with visual impairments.
• President’s Choice Charity http://www.presidentschoice.ca/.
• Rick Hansen Foundation: https://www.rickhansen.com/ funding for organizations to improve accessibility to a building or site for people with disabilities.
• Shriners: https://www.bcshriners.com/ for “medically necessary equipment”
• Spina Bifida and Hydrocephalus Association of British Columbia http://www.sbhabc.org/ Funding for recreational programs, education, equipment, drivers assessments, and transportation for medical appointments.
• Vancouver Island Bear Essentials: https://islandkidsfirst.com/bear-essentials/ funding for travel costs for health care, equipment, and therapeutic resources for children who live on Vancouver Island or the Gulf Islands.
• Variety: http://www.variety.bc.ca/ grants for therapy, equipment, orthotics and learning disability tutoring for low income families.
• Western Society for Children: http://wsfc.ca/ direct support to families and children with disabilities including financial support for therapies.

Integrated report format

If you are looking for a way to write reports which fits with the approach presented in this book, consider using what I call the “integrated report format”. In this format, you include all of the same information you would in any assessment report, but organized in a different way, integrating the assessment findings across sources. This format recognizes that your assessment is not just based on test results, but rather on the integration of multiple sources of information. It also has the benefit of lending itself very easily to discussing strengths and what a child is able to do. It is quick to write and easy to read. Using an integrated report format, you would include:

1. Reason for referral.
2. List sources of information including tests administered.
3. Relevant background information. Note here that many children with multiple, severe, disabilities have very extensive medical histories, including complicated birth histories, multiple surgeries, a list of medical diagnoses, etc. For children who are well cared for by medical teams who know them well, there is no need to summarize all of their history. Rather, note the key points that are essential to your case conceptualization.
4. General observations/adaptations/structure of the assessment. In this section, discuss general alertness, cooperation, and overall presentation of the child.  Also discuss the format of the assessment (e.g., play based, combination of standardized measures + observation), any adaptations or modifications provided, anyone else who was present for the assessment and the role they played.
5. Results section. This is where the flexible report format may be very different from your standard report. The results section may be broken down into domains of functioning, similar to other formats. In each domain, integrate parent report of current functioning, your observations, adaptive functioning report, teacher report of functioning, and standardized test data.  Domains may include Communication (sometimes broken up by expressive/receptive), Behaviour, Socio-emotional/play skills, Physical/motor/sensory, Learning/Cognitive, Pre-academic (or combined with cognitive), Self-help skills (not covered elsewhere). In each section, say what the child can do, while acknowledging what limitations are present.
6. Very brief “Summary/impressions section” which ties it all together. “Julia is a child who…”. Be clear and definite about diagnoses (i.e., do not say “appears to meet criteria for”).
7. Recommendations & Resources - keep this to the essentials.
8. Data table with standard scores. I suggest including adaptive functioning standard scores (with 95% confidence interval) as community services are sometimes based on these numbers. If there is no contraindication to doing so, I would also suggest including the 95% confidence interval for the Full Scale IQ (or whatever IQ score you are using), particularly at the mild to moderate borderline of functioning.

 Results Section - Examples

Summary/Impressions Section - Examples

Acknowledging and building on strengths

• Motivated by social connections, friendly, cheerful, eager to please others
• Sense of humor, playful
• Engagement with learning, curious, agreeable to trying new things
• Motivated by special personal interests
• Loves animals
• Loves music/singing/dancing
• Easy-going nature, patient, able to stay calm when frustrated
• Exuberant, high energy, strong, energetic
• Thrives with routine/adaptable to change
• Learns through repetition, learns by watching others
• Responds well to encouragement, proud of successes
• Persistent, likes to try to do things for self
• Able to use communication strategies when frustrated (e.g., looks away from book rather than throwing book when does not want to read book)

Important areas to address in recommendations

• Building communication skills is often an important areas for development in children with multiple, severe disabilities.
• Are there factors in the child’s presentation that are impeding development or the ability to function to their greatest personal capacity? (e.g., sleep issues, undiagnosed Autism, safety or behavioural issues).
• What accommodations/supports/interventions would be helpful?
• What opportunities/activities would enrich the child’s life?
• What community supports and services would the child/family qualify for?
• Can we help the child to have a voice in decision making? Helping the child develop choice making skills is important.

Considerations for test selection

Review of IQ/developmental tests in special populations

• Wechsler Intelligence Scale for Children - 5
• Differential Abilities Scale - II
• Stanford Binet - 5
• Kaufman Assessment Battery for Children - 2
• Reynolds Intellectual Assessment Scales - 2
• Woodcock Johnson Tests of Cognitive Abilities - 4

• Wechsler Nonverbal Scales of Ability
• Leiter International Performance Scale - 3
• Universal Nonverbal Intelligence Test - 2
• Comprehensive Test of Nonverbal Intelligence - 2
• Other nonverbal, single domain tests

• Bayley Scales of Infant and Toddler Development - 4
• Batelle Developmental Inventory -2
• Mullen Scales of Early Learning

General intelligence tests

• Age range 6:0 to 16:11
• Benefits:
  • Most common test of IQ in children; is well known.
  • Most subtests can be completed without motor manipulation of items.
  • Has a Nonverbal Index (but this requires the motor ability to do Coding).
  • Q-interactive (iPad administration) makes administration and scoring simple and quick.
  • WISC-V Integrated can be used in conjunction with the WISC-V in order to "break down" the task demands of WISC-5 subtests. WISC-5 Integrated is designed to identify the underlying cognitive processes that may be impairing performance on the WISC-V (e.g., what happens when the child is given extra time, or given multiple choice instead of needing to generate responses).
• Potential drawbacks/considerations:
  • Children with developmental level below 5 or 6 years may have difficulty understanding the task demands of some subtests on the WISC.
  • Only a few subtests are appropriate for children who are completely nonverbal and who do not have use of their hands (Matrix Reasoning, Figure Weights, Visual Puzzles and possibly Picture Span). These subtests would require some adaptation depending on the child's communication strategies (e.g., use of gestures, eye gaze, etc.)
  • WISC-V Integrated subtests should not be interpreted as measures of IQ. In some cases, it may be appropriate to administer a WISC-V Integrated subtest without first administering the corresponding WISC-5 subtests. For example, if a child is not able to speak, but is able to point or otherwise indicate choices, the verbal multiple choice subtests will give you an idea about the child's language based knowledge and reasoning. However, WISC-V Integrated scores should never be interpreted as a measure of a child's intelligence.

• Age range 2:6 to 17:11.
• Early years record form: 2:6 to 6:11, out-of-level normative data available for up to age 8:11.
• School-age record form: age 7:0 and up.
• Benefits:
  • Extended opportunities for teaching the tasks.
  • Abbreviated testing time due to special rules for start and stop points.
  • Out-of-level normative data can be very useful for children ages 7 and 8 as they can be administered the young child battery.
  • Some core subtests (Pattern Construction, Matrices, Recall of Digits) as well as quite a few Diagnostic subtests span the entire age range (2:6 to 17:11).
  • For the most part, the DAS does not require motor skills (except for early items on Verbal Comprehension, Copying and Pattern Construction). Other subtests can be easily adapted to give oral responses instead of motor responses (e.g., Picture Similarities).
  • Special Nonverbal Composite (SNC) is a 4 subtest composite, but is not appropriate for children with limited motor function. There is a 2 subtest Nonverbal Reasoning Index that is appropriate for children with limited motor functioning (Upper Level Early Years and School Age).
  • Includes signed nonverbal subtest administration instructions for children who use American Sign Language.
• Potential drawbacks/considerations:
  • Early Years Verbal subtests are inappropriate for children with significant visual impairments, and at the earliest level, inappropriate for children with significant motor impairments.
  • No Canadian normative data.

• Age range 2:0-85+ within a single series of subtests.
• Five areas (Fluid Reasoning, Knowledge, Quantitative Reasoning, Visual Spatial, and Working Memory) are assessed in both the Verbal and the Nonverbal domains.
• Benefits:
  • The fact that all subtests are given to all ages (at the appropriate level) makes this an excellent test for evaluating children whose developmental level is 2+, but whose cognitive functioning is highly discrepant from their age level.
  • Nonverbal routing subtest starts with manipulatives which can be helpful for children who do not understand concepts on paper (such as bigger/smaller).
  • Extensive guidance is provided in the manual on the use of SB-5 in hearing impaired individuals.
• Potential drawbacks/considerations:
  • “Nonverbal” tasks require a fair bit of receptive and expressive language.
  • Some nonverbal tasks cannot be easily modified for individuals with motor impairments.
  • Early verbal tasks require visual inspection of pictures and visual manipulation of objects. Therefore, this limits the utility of this test in children with visual impairments. Adaptations can be made for motor impairments.
  • More difficult to administer than many other standard IQ tests.
  • Age equivalent scores are only available if you give both verbal and nonverbal portions of a domain and for the abbreviated battery.
  • No Canadian normative data.

• Ages 3:0 – 18:11
• Benefits:
  • Comprehensive measure of intellectual functioning designed to minimize verbal instructions and responses and limit “cultural content”.
  • Many subtests span the age range: Atlantis, Face Recognition, Number Recall, Gestalt Closure, Rover, Expressive Vocab, Verbal Knowledge, Rebus, Triangles, Word Order, Hand movements, Riddles.
  • In addition, out of age range norms are available for some ages (e.g.,. a 7 year old can be administered the 5 or 6 year old battery).
  • Extensive teaching is available.
  • Nonverbal scale available at each age point.
  • Most subtests have a sample item plus two teaching items (for children at the youngest age).
• Potential drawbacks/considerations:
  • Most nonverbal subtests require pointing. Some can be adapted with use of a grid (to label response options) but other subtests are not easily adapted in this way.
  • No Canadian normative data.

• Ages 3-94
• 4 core intelligence subtests (2 verbal, 2 nonverbal), 2 processing speed (verbal/nonverbal), optional verbal + nonverbal memory subtests
• Benefits:
  • Short administration time.
  • Minimizes need for motor skills.
• Potential drawbacks/considerations:
  • Supplemental subtests are different by age.
  • No Canadian normative data.

• Ages 2 +
• 10 core intelligence tests
• Benefits:
  • Low floor.
  • 3 subtest Brief Intellectual Ability score.
  • Co-normed with Woodcock Johnson's tests of Oral Language and Achievement.
  • Braille & Large Print versions available through American Printing House for the Blind.
• Potential drawbacks/considerations:
  • No Canadian normative data.

Nonverbal scales of intelligence

• Age range - 4:0-21:11
• Ages 4:0-7:11: Matrices, Coding, Object Assembly, Recognition
• Ages 8:0-21:11: Matrices, Coding, Spatial Span, Picture Arrangement
• Benefits:
  • Primarily pictorial/gestural instructions. Can be entirely nonverbal, but verbal instructions are provided.
  • Translations of verbal instructions (and prompts) are provided in 6 languages.
  • Completely nonverbal response format available.
  • There are Canadian norms available.
  • 2 subtest abbreviated scale option.
• Potential drawbacks/considerations:
  • Only 1 of the 4 scales spans the age range, meaning that for the other subtests, there is the issue of floor effects.
  • As an abbreviated measure, it has limited coverage of cognitive abilities.
  • Only 2 subtests (Matrices, Recognition) are easily adapted for those with serious motor disability.

• Ages 3 to 75
• 4 Cognitive subtests, 4 attention/memory/processing speed subtests
• Benefits:
  • Completely nonverbal assessment. All instructions are conveyed via picture, gesture, and demonstration. There are no oral responses required.
  • All subtests span the age range.
  • The cognitive subtests are untimed and do not require careful placement of cards/blocks so that children with mild motor impairments may be fully capable of completing the tasks.
• Potential drawbacks/considerations:
  • Takes time to learn how to administer the Leiter correctly. There is a training DVD available.
  • The examinee responds by moving small cards or blocks to indicate a response. Some children with severe motor impairments will not be able to do this.
  • In our clinic, we have had the experience that the Leiter-3 sometimes over-estimates a child’s true capabilities. Therefore, we recommend the Leiter should always be administered in conjunction with another IQ test.
  • No Canadian normative data available.

• Age 5:0-21:11
• 6 subtests: Symbolic Memory, Nonsymbolic Quantity, Analogic Reasoning, Spatial Memory, Numerical Series, and Cube Design.
• Benefits:
  • Entirely nonverbal administration and response format.
  • Has a 2 subtest brief IQ score available.
  • Attempts to limit cultural content.
• Potential drawbacks/considerations:
  • 3 of the 6 subtests require the child to manipulate task materials.
  • One subtest (Cube Design) is timed, with no option for an untimed administration. This subtest is not appropriate for those with severe motor impairments.
  • All other subtests require pointing to the correct response or moving tiles. This could be adapted to place letters/numbers below the responses for those who cannot point.
  • Some subtests are reliant on the child understanding written numbers and having a basic understanding of numbers (e.g., counting by 5s).

• Ages 6:0-89-11
• 6 subtests: Pictorial Analogies, Geometric Analogies, Pictorial Categories, Geometric Categories, Pictorial Sequences, Geometric Sequences.
• Benefits:
  • Can be entirely nonverbal administration, but verbal instructions are also provided.
  • Response format does not require any verbal output.
  • No manipulation of objects required.
  • Completely untimed.
• Potential drawbacks/considerations:
  • All subtests require pointing to the correct response. This could be adapted to place letters/numbers below the responses for those who cannot point.
  • No measurement of short term or working memory.

Single domain nonverbal tests

• Raven's Progressive Matrices (Various). Child/Adult.
• Naglieri Nonverbal Ability Test (2003). Age 5:0-17:11.
• Test of Nonverbal Intelligence–4th Ed. (2010). Age 6:0-89.

Developmental Measures

• Ages: 1 to 42 months (3 years, 6 months)
• Three scales administered with child interaction – cognitive, motor, language. Two scales conducted with parent questionnaires – social-emotional, adaptive behavior.
• Cognitive scale benefits:
  • Play-based test with natural type interactions.
  • Administration manual discusses accommodations/modifications.
  • Allows for some items to be scored based on parent report.
• Cognitive scale potential drawbacks/considerations:
  • Takes some time to learn to administer.
  • Starting from 13 months – requires the child to follow verbal instructions.
  • Requires some motor coordination from child (cannot modify some items for lack of hand use).
  • No Canadian normative data.

• Tests 5 global developmental domains and 13 subdomains: Adaptive behaviour, personal and social skills, motor skills, communication skills, and cognitive.
• Ages 0 – 7:11
• Benefits:
  • Wide age range for a developmental measure
  • Play-based test with natural type interactions.
• Potential drawbacks/considerations:
  • Challenging to learn and to administer
  • No Canadian normative data

• Birth to 68 months
• Benefits:
  • Play-based test with natural type interactions.
• Potential drawbacks/considerations:
  • Challenging to learn and to administer
  • No Canadian normative data
  • Older normative data

Recommendations

• SB-5 two subtest abbreviated IQ
• WNV two subtest abbreviated IQ
• Peabody Picture Vocabulary Test (PPVT) as estimate of IQ

Socio-emotional functioning interview

• What are the child’s likes and dislikes? What motivates them? Do certain experiences cause the child distress (e.g., changes in routine/caregivers, sensory overload)? What calms and comforts, is there a calming routine?
• Document issues with pain and ask about pain on the day of the assessment. Is the child able to communicate when and where they are in pain or uncomfortable?
• Interaction with peers (e.g., watches from a distance, waits to be approached, makes social overtures, has favored peers).
• What activities does the child do for pleasure? Are there ways to increase independence with leisure activities?

Safety issues/Behaviour interview

• Ability to judge personal safety (choking risk, stranger safety, wandering off, falling, unbuckling seat belt, etc.).
• Aggression towards self (self-injurious behaviour).
• Aggression towards others.
• Are there behaviours that are getting in the way of social functioning or learning?

Questionnaires

• “Says ‘I hate myself’” (does not talk)
• “Is organized” (the person who is nonverbal with quadriplegia may never have had the opportunity to try organizing materials)
• “Is a picky eater” (tube fed)
• “Avoids eye contact” (cannot see unless close up)
• “Listens to directions” (not able to follow commands)
• “Cleans up after self” (very limited use of hands)
• The same problems can be found in everyday executive functioning and autism questionnaires in this population!

Developmental assessments in older children

Limitations of age equivalent scores

• AE scores are an ordinal, not a ratio or an interval scale of measurement. They cannot be added, subtracted, or averaged. Being ordinal, a 3 month difference at age 4 can be very different than a 3 month difference at age 14.
• AEs do not take into account the range of normal performance. A child age 8:0 with an AE of 6:10 on WISC-5 Vocabulary may appear to be impaired based on the AE, but this is equivalent to a Standard Score of 8 (Average).
• AEs are not comparable across subtests (even on the same test). For example, you may see an AE score on the WIAT Word Reading subtest which is lower than the AE score on WIAT Numerical Operations subtest, even though Word Reading has a higher standard score compared to Numerical Operations.
• A 14 year old who scores at the 12 month old level on the Bayley-4 has a very different developmental experience than a typical 12 month old infant. It is unlikely that they function like a typical 12 month old child.

So what to do? Be aware of the limitation of AE scores. Use AEs when they are useful, but interpret with caution and only in the context of a broader assessment of the child.

Creative approaches to non-standardized assessment

• Child Guided Assessment by Jan van Dijk was originally designed for working with children who are Deafblind. This approach encourages the examiner to look at the processes through which the child learns, rather than evaluate discrete skills. The foundation of the assessment relies on the assessor establishing a relationship with the child. The child's interests and abilities determine what materials are used to promote the child’s engagement. The focus of the report/feedback is on identifying strengths and next steps in development. Child-guided strategies are “conversational.” Establishing an interactive routine is important. To do this, the assessor may imitate what the child is doing, then add new information. Communicative signals are elicited by stopping the routine and waiting for a signal from the child indicating a desire for continuation. Excellent video examples of this approach are available in the Resources for Further Education section below. 
• Sensori-motor learning by Millie Smith is designed to help learners move through hierarchical states/stages. This model recognizes that some children spend periods of time in what Smith calls "extended states" where they are sleepy or agitated. The goal would be to help them achieve and maintain focus on objects to promote learning. There are a series of objects available which help stimulate the child's various senses to see what they respond to. The next goal would be to help the child explore objects through their available senses. This would then move to understanding the function of objects and then learning to label objects. The goal is developing “Coherence” – the feeling that you understand what is going on in your environment.
• Active learning by Lili Nielsen is an approach for assessment and curriculum for children with multiple, severe disabilities. The Functional Scheme Assessment provides a structure to evaluate functioning across areas in order to develop an appropriate learning plan.

Communication

• Is the child able to communicate essential needs such as hunger, thirst, and pain?
• Is the child able to make choices when provided with 2 or more options? For example, would they consistently "choose" what is clearly the preferred choice (e.g., favorite TV show or favorite food)?
• Can they reliably respond yes and no, and in what mode?
• Do they understand or use any gestures (e.g., point to indicate desire, arms up to request "up")?
• Do they have finger/hand use sufficient for basic sign language use? Try to teach a simple sign (e.g., “more” in relation to requesting food).
• Does the child recognize any visual communication symbols such as symbols or signs (e.g., recognize McDonalds arches, sign for bus stop).
• Can they discriminate between different drawings or photos of objects? If they cannot do either, they may need real objects  to make choices (basketball to symbolize the gym).
• Can the child follow a one step instruction in a routine situation (e.g., “put your arms up” when dressing)? Can they follow a one step instruction when outside of a familiar routine (e.g., saying "put your arms up" during the assessment)? Do they need a visual prompt or can they follow a request with a verbal prompt only? In order to directly assess this, try incorporating commands into play or natural conversation. Be careful to observe what cues the child uses such as watching your eye movements or reading gestures. For example, you could ask, "Please put your napkin in the garbage."

General cognitive functions

• Can you elicit object permanence? Do they look for an object placed out of sight or dropped on the floor?
• Can the child understand cause/effect reasoning. Simple cause and effect reasoning would be something like - press a button to make a toy pop up, flip on a light switch and watch the light turn on.
• Does the child understand the function of common objects? For example, puts spoon in mouth, puts hat on head.
• Do you observe imitation/attempted imitation? For example, introduce a novel toy and show how it works. Are they able to reproduce this? Put a toy on your head, do they copy you?
• What kind of problem solving can the child demonstrate? For example - puts together a 2 piece puzzle, gets something out of a container, stacks cups, takes something out of a bag.
• Play skills: level of play provides insight into developmental level. A broad developmental trajectory would be mouthing, banging, throwing/dropping, shaking, functional play (play with a toy as it is intended),  parallel play, make believe play, cooperative play. However, be aware that children with severe motor or sensory disorders have had a different developmental experience than typical children. They may be less interested in, or less experienced with play.

• Is the child able to show habituation to repeated/familiar stimuli?
• What do they show memory for? Familiar people, places, objects? Get examples from everyday life. Do they react differently to familiar vs unfamiliar people? Having a favorite toy would be an example of memory for an object.
• Can the child predict what will happen if you repeat the same action multiple times? For example, do they know what to expect next in their familiar daily routines? If they go to the bus stop, do they get excited because they know they will be getting on the bus? Do they react to a mismatch to expectations? One fun way to test this is to put an object like a doll on your head and pretend to "sneeze" with a slow lead up to a big "achoo" where the doll flies off your head. Does the child start to predict this will happen and get excited?
• You can use things from a backpack that the child recognizes: present the items, remove, hide them etc.
• Learning from experience (trying something new). For example, find something new and teach it, and see if they remember it later. Many children have difficulty putting together two small triangles to make a large triangle on the Stanford Binet-5 puzzle. Teach them, then present it again later. Follow up - Will they apply their learning to new situations?
• Can the child hold information in mind briefly ("short term memory")? For example, hide a toy of interest or food under a cup. Increase the difficulty level by using multiple cups, move the toy/food to a new cup (visible displacement - “look I’m moving it here”), or switch the location by moving cups while toy/food is hidden (hidden displacement). There is a series like this on the Bayley-III.

Early academic assessment - reading. Is the child able to:

• Recognize any signs and symbols in the community (e.g., McDonalds; boys vs girls washroom)?
• Listen attentively to a short story?
• Recognize that a book is held a certain way.
• Recognize that words on the page are associated with spoken words.
• Recognize rhymes (do they enjoy rhyming songs, word plays?).
• Provide rhymes for words, e.g., fly, star.
• Recognize letters (i.e., which one is the “A”?). For many children, most likely they would recognize the first letter of their name.
• Name letters (presented one by one vs. in the context of a word or sentence).
• Name letter sounds.
• Recognize own first name written (provide choice of 3, can they point to it?) May want to try with printing three/four names on individual pieces of paper and ask them to pick up their name.
• Recognize sight words (may use enlarged version or whiteboard).

Early academic assessment – writing. Is the child able to:

• Hold a writing utensil (can they use a pencil/pen or do they need a marker?).
• Scribble purposefully.
• Connect dots; trace shapes.
• Copy shapes from model (line, circle, triangle) - may want to try doing the Beery VMI.
• Trace letters (e.g., of their first name).
• Copy first name from a model.
• Write letters or words to dictation.
• Speak clearly enough to use speech-to-text technology?

Early academic assessment - math. Is the child able to:

• Match by shape or colour.
• Recognize (point to) shapes/colours, name shapes/colours.
• Understand patterns using real objects XOXO pattern? (2 step, 3 step).
• Understand printed patterns XOXO..?
• Understand concepts such as more/less, up/down, empty/full, longest/shortest, same/different.
• Recognize written numbers.
• Able to answer questions about number concepts (e.g., how many brothers do you have? If we were setting the table for everyone in your family, how many plates would you need?).
• Count aloud; Count concrete objects aloud with 1:1 correspondence moving one at a time; concrete objects without moving them; count objects drawn on paper.
• Identify which group has a certain number of items.
• Understand concept of “1 more” (concrete, abstract).

Creative assessment requires creative tools! Here are some ideas:

• 2 or 3 large plastic cups to hide object under (e.g., from SB-5).
• 3 piece puzzle (e.g., triangle, square, circle from the SB-5 to assess visual spatial skills and problem solving).
• Toy cookie making set (to assess play skills, numeracy, ability to follow directions, social skills).
• Toys that assess cause and effect reasoning (press a button, something happens) especially those that light up or make sound.
• Large portable white board & marker (to assess letter recognition, name recognition, simple math).
• Shapes of different colors (to assess color/shape recognition and pattern recognition, “let’s put away all the yellow ones!”).
• A few items to assess recognition (e.g., spoon, pencil, ball, cup).
• Soft, squishy, easy to catch ball (to assess play skills, following directions, coordination).
• Snacks/treats and favorite objects brought from child’s home to use as motivation.
• Printed pictures/photos of objects/actions.
• Toys that promote creative play (e.g., dolls, figures, house cars).
• Objects/toys that involve sensory stimulation (make noise, have lights/shiny things, vibrate).
• Wiki sticks, thick crayons, triangular pencil, heavy black pen, thick lined paper.
• Balls of different textures, bounciness, weight and shape (e.g., white Styrofoam cube).
• Large magnetic letters plus magnet board.
• Developmental assessment kits (e.g., Bayley-4) have a lot of good items to use.

Adaptive functioning & Intellectual Disability

A diagnosis of Intellectual Disability according to the Diagnostic & Statistical Manual of Mental Disorders, Version 5 (DSM-5) requires that the child must have one or more domains of adaptive functioning impaired (Conceptual, Social, or Practical). The DSM-5 recognizes that scores are not the only consideration in evaluating adaptive functioning: “Adaptive functioning is assessed using both clinical evaluation and individualized, culturally appropriate, psychometrically sound measures… Additional sources of information include educational, developmental, medical, and mental health evaluations. Scores from standardized measures and interview sources must be interpreted using clinical judgment" (DSM-5, p.37). Furthermore, a DSM diagnosis of intellectual disability requires a relationship between the cognitive and adaptive deficits: “To meet diagnostic criteria for intellectual disability, the deficits in adaptive functioning must be directly related to the intellectual impairments described in Criterion A” (DSM-5, p.38).

However, standardized measures of adaptive functioning (e.g., ABAS, VABS) are not designed to differentiate between limitations in functioning arising from cognitive impairments from those arising from the impact of motor or sensory impairments.  What do we need to consider when evaluating adaptive functioning in children with multiple, severe disabilities?

• When evaluating young children with complex disabilities, it is wise to be cautious about diagnosing intellectual disability. Due to their very different developmental experiences, we need to be cautious in predicting their developmental trajectory.  For example, a child who is blind will need to learn special skills to identify coins and keep track of different denominations of money. Thus, they are likely to learn this skill at an older age than a sighted child. A child with severe motor impairments will not have had the same opportunities to learn and practice independence skills compared to their peers. Overall, when we see children in their teenage years, we can be more confident in making a diagnosis when it is appropriate.
• Adaptive functioning is best evaluated through interview format (e.g., VABS interview). If adaptive functioning is done in an interview format, you will better be able to understand which supports are in place due to motor or sensory impairments. Further, an adaptive functioning interview is helpful as it can be depressing and frustrating for parents to fill out forms where questions do not apply to their children, and where they have to fill out "zero after zero".
• Many questions on adaptive functioning forms will be inappropriate for children with motor or sensory impairments (e.g., “carries dishes to the sink” for those without the physical ability to lift dishes; "uses spoon without spilling" in a child who is tube fed, "stays on sidewalk" in a child who is pushed in a wheelchair). Guidance from the measures themselves suggest that if a child is not capable of doing something due to a physical condition, the item must be scored as “0” but that you should take this into account in your interpretation.
• Do allow for a child’s use of sign language, braille, or adaptive equipment to communicate (if used independently and unprompted). This includes listening to audiobooks and screen readers for those with visual impairments (VABS-3 Manual, p.45). The ABAS manual does not discuss this topic, but a similar approach between the tests would be appropriate.
• If you are finding the question of a possible intellectual disability to be a tricky one in a particular child, it will be important to do a detailed examination of individual items on adaptive functioning measures.  For children with severe motor impairments, some subdomains of adaptive functioning are very low due to the motor impairments (e.g., for a child who can not dress or toilet independently). If that is the case, it is helpful to look particularly at the level of independence in the social and leisure domains, or the communication domain if language is not severely impaired. It is essential that you look at the scores in the context of the child's experiences, opportunities, and current functioning. Observations and interviews are essential compliments to adaptive functioning forms.
• Be very cautious about interpreting age equivalents which may be calculated as part of adaptive functioning measures, particularly for children with sensory and motor impairments where you often see a lot of intra-subtest variability. See the section on age equivalents for more information on this topic.
• For discussion of evaluating the level of intellectual disability (mild, moderate, severe, profound, please see the next section - here.)

Development and assessment of vision in children

Visual conditions

• Problems with visual acuity, or sharpness of vision, may be present. Children who have visual acuity of 20/70 or poorer (with correction) qualify for the designation of “visual impairment" for special education purposes. For context, 20/200 (with correction) is considered “legally blind.” Children with visual acuity difficulties need material brought closer or enlarged. Children with acuity of 20/80 in general need information presented 4 times larger, or 4 times closer, than someone with 20/20 vision. 
• Strabismus is a condition where the eyes look in two different directions. The misaligned eye may look inward (esotropia), or outward (exotropia). Untreated, it can lead to amblyopia (sometimes called "lazy eye") and severe visual impairment in the affected eye.
• Cortical Visual Impairment (CVI) can result from damage to the occipital lobe or pathways between the eye and the occipital lobe. Children with CVI have an abnormal response or reduced response to visual input. CVI tends to improve with development. Children with CVI benefit from reduced visual clutter, and use of high contrast materials.
• Visual field loss can occur due to damage to the visual pathways in the brain. This can include specific field cuts (e.g., upper left field cut), or a reduced field of vision (e.g., loss of peripheral vision in both eyes). Hemianopia (also called hemianopsia) is the loss of half of the field of vision and can result from brain damage to the optic tract or occipital lobe. This can impact one or both eyes. Commonly, you will see "homonymous hemianopia." More details on assessment in children with homonymous hemianopia can be found in the next chapter.
• Difficulty with control of eye movements can impact functional use of vision.
• Problems with depth perception “stereopsis” are common in children with multiple, severe disabilities, but this should not impact typical psycho-educational testing.

General set up, optimizing vision & adaptations

• For children with visual impairments, it is often mentally draining to engage in visually-demanding tasks. Furthermore, the ability to see over the course of a day varies with level of fatigue, attention, familiarity, and lighting conditions. Eye movement issues, esotropia, exotropia, nystagmus, may become more impairing as the child fatigues. For this reason, it is helpful to alternate visual and verbal tasks and to provide lots of breaks.
• Pay attention to lighting, glare, and shadows. Some children need low light, while others need bright light. It can be helpful to have a table lamp available instead of (or in addition to) overhead lights. Watch for glare off of materials. Baseball caps can be good for glare and light sensitivity. Watch for shadows on the work area (a slant board can help with this).
• For visual items, consider placing the material on a book stand to bring the material closer to the child. You could also prop it up on a pile of boxes or books (see photo). The material should be at eye level of the child. This is to bring the material closer to the eye without producing neck strain.  Use caution when turning the pages so that you do not hit the child in the face.
• I like to start off by telling children that I am not trying to test their eyesight. If they have difficulty seeing ANYTHING during the assessment, it is important that they let me know. However, some children cannot or will not tell you if they are having difficulty seeing. If you have concerns about the child's ability to see details correctly, it is important to check with the child. When the discontinue is met, go back to an item where they made an error, and ask the child to describe exactly what they see. Ask the child to describe what they see rather than ask, "can you see this?". Pay attention to possible problems with color vision, mislabeling, missing details, etc. When tests are challenging for the child to see (when they can see but it is effortful), consider whether these tests are necessary to administer. Realize that they may not be a measuring what the test was designed to measure. For example, the WISC Processing Speed tests may not be a good measure of mental processing speed if the child has difficulty seeing the shapes. However, a score on these tests can give you a measure of how fast a child is likely to finish visually challenging written worksheets in the classroom compared to their peers.
• Observe how the child scans the page, do they scan in an organized manner; are they missing parts of the page? Some children with visual difficulties have difficulty with visual attention and visual search strategies. They may need support/reminders to attend to all aspects of the page ("look here, look here").
• Many children with visual impairments (particularly children with cortical visual impairment) benefit from increasing contrast. Consider using a black contrast mat ("desk blotter") to increase the contrast between test materials and the table. This also helps to focus visual attention on the testing materials. Pay attention to contrast on other test materials and how this may impact the assessment. For example, an early item on WPPSI Block Design asks the child to look at a picture of white blocks on a white background. Also, the Stanford Binet three-hole puzzle has no contrast in the puzzle pieces space. You could consider using a black "inset" in the puzzle to increase the contrast.
• When a task is "visually crowded" (e.g., the last page of the Visual subtest on the Beery VMI) consider isolating individual items by covering up irrelevant parts.
• For children with visual impairments, it is still important to assess visual learning and reasoning. For some children with visual impairments, vision may still be their strongest learning channel. However, if a child with visual impairments has difficulty on tests with high visual demands, we must consider the results a minimum estimate of their functioning.
• In addition to the typical areas of functioning, be sure to assess listening comprehension as this is an important skill for children with visual impairments who rely heavily on their listening skills.
• Using an enlarger, such as a magnifier, increases the working memory demands of the task as the child has to integrate multiple "parts" into a whole. Rather than being able to see and "take in" the whole of the picture, they must look at each part separately and then mentally integrate the parts. This inherently makes most visual tasks more challenging and this should be taken into account when interpreting your findings. Similarly, children who see only through a small visual field  (or who have spots of loss such as in scotoma) will need to work harder to integrate the things that they see.
• For children with visual impairment, it is important to be aware of the impact of sensory loss on development. Children with limited vision have reduced access to incidental learning. Be aware of how sensory (and motor) impairments may have limited an individual's exposure to certain concepts/pictures. For example, someone who is blind may not have had the experience of using something like chalk, an item with which most North American children would be familiar. Thus, asking how chalk and a marker are alike would present an unfair challenge.
• Children with visual field loss may show specific errors on testing related to their visual condition. For example, on WISC Picture Span, the child is asked to memorize a series of drawings of objects. Examination of the child's pattern of errors may show that a child with left field loss does not recall the item on the far left.

Academic testing

• Be aware that for braille learners, the expected progression of numeracy, reading, and writing, are not the same as the progression of the same skills in sighted peers.
• Be aware that reading, for individuals with a visual impairment, is likely to be slower. Reading enlarged materials takes more time. Reading small text takes more effort, and therefore more time. If a child with visual impairments has no difficulty with accuracy and reading comprehension, slow reading speed should not be considered a learning disability, but rather should be considered secondary to the visual impairment. Even experienced braille readers are typically slower than print readers. They will require extra reading time for tests due to their visual impairment.
• If needed, enlarge reading materials ahead of time of. Be sure that the copies have high contrast (you can adjust the contrast to the highest possible on the photocopier). With photocopies, make sure you present only one page at a time, so that there is no interference from text showing through from the page underneath.
• Right (compared to left) homonymous hemianopia has a stronger impact on reading as the person is not able to preview the upcoming letters, particularly impacting reading beyond the single word  stage and causing a decrease in reading speed. Left homonymous hemianopia can also impact reading by causing difficulty finding the next line of text and causing word reading errors as the first letters of the word may be missed.
• To support children who have low vision when writing during an assessment, it is appropriate to provide the child with whatever adaptations they normally use for writing. You may want to use paper with thick black lines (free printable pdfs are available online). There is also paper with raised black lines available for purchase. Give the person a dark thin pen or marker to write with to increase contrast.

Mild and unilateral (one sided) hearing loss

Assessment with someone who is Speechreading (“lip reading”)[footnote]Cromwell, J. (2005). Deafness and the art of psychometric testing. The Psychologist, 18,12, 738–740.[/footnote]

• Speak at a normal rate and with normal articulation.
• Keep your hands very still while talking.
• If you want to show something while talking, silently show first, then explain, and possibly show a second time.
• Never speak while not facing the person.

Assessment with an American Sign Language (ASL) interpreter

• If you are new to working with an ASL interpreter in an assessment setting, you should seek out consultation.
• When working with an ASL interpreter, allow more time for the assessment.
• Meet with an interpreter for 10-15 minutes before starting the assessment so you can talk about the process of the assessment. It is helpful to mention that you want to know the child’s level of language, therefore you want to know if they are using incorrect grammar, or if signs are signed incorrectly.
• Introduce the interpreter to the child and explain their role. Children may not be used to having interpreters.
• According to the professional code of sign language interpreters, they will interpret everything that occurs in the room (sounds, private conversations, phone calls).
• Generally, it is best to sit next to the sign language interpreter, opposite the child. Thus, the client can easily shift from looking at you to looking at the interpreter. Make sure there is no distracting background (e.g., venetian blinds) that could make it taxing to see the interpreter's hands.
• Address the client directly, and maintain eye contact with the client rather than with the interpreter.
• In general, wait to begin speaking until the interpreter is finished signing.
• Do not give visual instructions (pointing, demonstrating) at the same time as you are talking (or the interpreter is signing).
• Allow a brief silent time for reading if you hand out written material. Wait until the Deaf person looks up before you start to speak again.
• The process of reading or writing printed English for someone who communicates via ASL is called transliteration. The interpreter who is assisting with transliteration is having to pair the printed English word with their vocabulary of ASL signs. You may wish to ask the interpreter if it is best for you to read the text aloud or have them read it themselves (e.g., on a consent form).

Specific testing tips for the child who uses ASL

• It is important to understand that ASL is another language. Sentence structure is Object/Subject/Verb commonly (In spoken English, Subject/Verb/Object is most common). Further, verbs are tough to translate into a single ASL sign. The verb is usually communicated together with the sign for the subject or the sign for the object. There are signs for most nouns, but specific signs are often fingerspelled (spelled letter by letter). Thus for spelling tests this is an important clarification -  some spoken words may be difficult to translate into a single sign.
• With a test of word reading, try to get children to provide a single sign if one exists (the interpreter can tell you).
• For paragraph reading, it is likely best to choose a test which allows for silent reading (e.g., WIAT) rather than reading aloud (e.g., GORT).
• When giving a measure of adaptive functioning, have parents think about child’s communication in ASL or spoken language. The child should get "credit" for accomplishing something using either sign or spoken language. However, as with spoken language, independence of behaviour is important. For example, if the child is prompted (reminded) to use the sign for "thank you", that is not independent behaviour.

Introduction to neuromotor disorders

• Hypertonia - increased resistance of the muscle to movement. It may be caused by spasticity, dystonia, rigidity, or a combination of the two.
• Spasticity - resistance of the muscle is variable depending on the velocity of movement.
• Rigidity - frequently occurs in Parkinson's Disease in adults, but rarely occurs in children.
• Dystonia - a movement disorder in which involuntary muscle contractions cause twisting and repetitive movements, abnormal postures, or both. Dystonia frequently co-occurs with athetosis, problems with manual dexterity, problems with oromotor function, and abnormalities of eye movement.

Beyond the WISC: Psychological assessment of cognitive functioning in special populations

Jennifer Engle, Ph.D., ABPdN, Registered Psychologist

BC CHILDREN'S HOSPITAL, VANCOUVER CANADA

• The individual with HH may miss information on the affected side. They may bump into things,  have difficulty with stairs, or miss self-care on one side of body. In physical education class or on the playground, the child may not see children running or a ball approaching. They would not see a car approaching from their blind side.
• Driving can be dangerous.
• Children may adapt to field loss by moving their eyes or head to maximize their vision. 

• During the assessment, place yourself on the child’s “good side.”
• Place your materials slightly off centre to take advantage of the child’s intact visual field.
• Watch how the child scans pages to ensure they are looking at all options.  Remind the child to scan the whole page, using your finger to point to each part if needed. Make sure you are giving consistent reminders and not ONLY when the child makes a mistake.
• Observe: Do they lose their place when reading? Miss the ends or beginnings of words?

• It is important that the child is made aware of their condition for safety, particularly street safety. The individual must be taught to actively scan their blind side.  It would also be appropriate to walk down the hallway with the wall to the affected side. Orientation and Mobility Instruction within the school and community is suggested.
• Teaching compensatory strategies for reading is important. For children with right HH, this would include teaching children to scan to the end of each word, and to the end of each line. For children with left HH, this would include strategies such as using a ruler to keep place, and a line down the left side of the page to help orient to the start of the text. Some children would benefit from smaller text (so that more text is within their central vision), or text written diagonally. Students should have support from the Vision teacher at school to implement these strategies and supports.
• In the classroom, children should be seated with their intact visual fields facing the teacher and the classroom (blind side to the wall).
• Children should be approached from the side with intact vision.
• It can be helpful in the classroom to leave furniture in place throughout the year.
• Children must be allowed extra time to read.

In advance of your assessment, once you have learned about the child, make an initial plan for direct assessment. It is always best to not make any presumptions about what the child can do. That is, presume that the child in front of you will be able to demonstrate their skills and abilities when given appropriate accommodations for their motor and sensory impairments. When we approach a child in this way, they are most likely to show us the full measure of their ability. Use Plan A (standardized assessment tools) whenever possible and as a first choice in most cases. Be ready to flexibly move between plans during your assessment as you learn about the child. Details on Plans A, B, & C are available in the upcoming chapters.

Plan A: Standardized assessment tools: Standardized IQ tests are designed to compare children to a normative group of their same aged peers. For children with severe disabilities, their scores may be near the "floor" of the test. Thus, the IQ test will not necessarily identify the personal strengths and challenges of children with severe disabilities. However, IQ tests have a role to play, primarily as they are often required in order to support the child's access to appropriate supports and services at school or in the community. Plan A assessments with children with multiple, severe disabilities involve carefully evaluating the test requirements and matching those to the child's capabilities. The following sections will discuss various tests. Plan A assessments may include accommodations which do not change the underlying concept being measured.

Plan B: Out of age range measures: Sometimes it is appropriate to choose a measure which is developmentally appropriate but not age-appropriate for the child. For example, this would include using a measure of early childhood development (e.g., Bayley-4) in an older child with severe disabilities. When using out of age range measures, raw scores can be translated into age equivalent scores which can sometimes be helpful as a component of your broader assessment. The limitations of age equivalent scores are discussed along with the use of out of age range measures in a separate chapter.

Plan C: Non-standardized assessment/observation: Taking a different approach to assessment may be necessary when a child is not capable of participation in standardized measures, even those designed for younger children. Moreover, non-standardized assessment can be a useful addition to your regular assessment tools (Plans A and B), particularly for identifying strengths and next steps in development.

Often, some combination of the above is the most appropriate.