Ariati Rakic, Ph.D. Clinical Neuropsychologist

A NEUROPSYCHOLOGICAL ASSESSMENT is the most in-depth and comprehensive form of evaluation that is specifically aimed at exploring the behavioral manifestations of brain dysfunctions across various neurocognitive domains. This assessment is a crucial tool in specifying whether an individual has actually suffered a brain injury, especially when the effects of the injury are subtle and may be mistaken by other factors such as stress, depression, lack of motivation, undesirable “personality flaws”.  While imaging studies such as CAT-Scan or MRI’s may not detect slight structural abnormalities in the brain when the insult is minor or diffuse, neuropsychological testing will show ways in which the individual is able or not able to perform certain tasks that are dependent on healthy brain activity, and can, therefore, diagnose brain dysfunction in the absence of identifiable structural brain abnormalities. Thus, a thorough Neuropsychological Assessment will allow for early intervention and can answer simple but very crucial real-life questions such as:

• Can my parent continue to live independently without supervision?
• Is my spouse able to continue to take care of our finances?
• What medical conditions are contributing to the cognitive changes?
• What medications could be helpful?
• Are there any psychological/emotional factors contributing to the cognitive decline?
• What would be the best academic environment for my child’s specific learning style?
• Will my child be able to have an independent and productive life despite of his/her disability?
• Will my child do best in a community college rather than a 4-year university program?
• Is there anything that I can do at home that would be helpful to my child? 
• Has my child reached their highest potential or is there still room for further improvement?

The evaluation will be able to answer these real-life questions by providing specific information about the functioning of the following cognitive realms and how the deficits interfere with daily activities:

• Attention and Concentration which includes working memory, capacity for registration and mental manipulation of simple and complex bits of information, focused and sustained attention.
• Executive Functioning which includes processing speed, abstract thinking, mental shifting, organization, planning, sequencing, inhibition and impulse control.
• Memory and learning which includes immediate and delayed recall, recognition, storage and consolidation of new information into long-term memory, learning rate, storage capacity.
• Language which includes oral and written expression, auditory and reading comprehension, word retrieval, and verbal fluency.
• Sensory-Motor functioning which includes gross and fine motor skills, balance and postural stability, eye-hand coordination.
• Visual Spatial Abilities which includes figure-ground differentiation, visual scanning, attention to essential visual detail, visual analysis and synthesis.
• Auditory Processing which includes auditory functioning under various compromised auditory environments at different frequencies.

In addition, to providing relevant data on the “status” of these mental functions, a Neuropsychological Assessment provides an objective measure of the individual’s global intellectual potential or intelligence (IQ), and how their functioning in the various neurocognitive domains described above differ from the estimate of their true potential.  An understanding of the individual’s psychological and emotional well-being and the extent, to which unresolved issues or untreated clinical symptoms may contribute to the cognitive impairment, is also derived from this evaluation. 

A Neuropsychological Assessment will often involve not only the administration and interpretation of standardized psychometric measures, but also a thorough clinical interview to attain an in-depth understanding of the problems at hand, consultation with other relevant professionals and/or family members, observation of the individual in his/her natural environment such as school, nursing home etc., and a careful review of school, psychiatric, and medical records. The outcome of the evaluation is often very helpful in providing diagnostic clarification, assisting in educational and vocational planning, making disability and forensic determination, and establishing the guidelines for the development of an effective and comprehensive individualized Cognitive Rehabilitation Program.  This type of assessment is often recommended for: 1) baseline testing before a treatment or intervention is implemented, 2) to follow the progression of cognitive development especially during significant transition times when a new level of demands are necessary and services may need to be redefined, 3) cases in which a brain-based impairment in cognitive and behavioral functioning is suspected and is believed to be due to: 

• Traumatic Brain Injury
• Vascular Conditions such as CVA’s and TIA’s
• Brain Tumor, Aneurysm
• Neurodegenerative Disorders such as Alzheimer’s and Parkinson’s Disease
• Seizure Disorder or Epilepsy
• Hydrocephalus
• Central Nervous System Infections/Inflammation such as Meningitis, Encephalopathy, Multiple Sclerosis
• Toxic Exposure
• Chronic Substance Abuse such as Korsakoff’’s Syndrome
• Metabolic or Endocrine conditions such as Diabetes Mellitus, Kidney or Liver Disorders
• Genetic Disorders such as Fragile X
• Environmental Conditions such as in-utero exposure to illicit drugs, Fetal Alcohol Syndrome
• Neurodevelopmental Conditions such as ADHD, Pervasive Developmental Disorders

Symptoms and behavioral presentations that may warrant a visit to your Primary Care Physician and a referral for a Neuropsychological Assessment include:

• Memory Loss (i.e. forgetting conversations, forgetting names of familiar people, frequently losing or “misplacing” belongings around the house).
• Attention and Concentration (i.e. difficulty focusing on goal-directed tasks, being easily distractible, unable to filter out interfering stimuli, difficulty sustaining attention overtime, or dividing attention between multiple sources of information).
• Poor Organization and Planning (i.e. not knowing how to prioritize, poor time management, poor sequencing ability, knowing how to do parts of a task but being unable to bring it to completion).
• Difficulty Multitasking (i.e. unable to do several tasks at once such as answering the phone while trying to finish an email).
• Difficulties With Language (i.e. difficulties recalling the words for familiar objects, decreased fluency in speech, using the wrong word).
• Problems With Visual Spatial Skills (i.e. unable to read maps, difficulty finding objects in a busy visual field, having difficulty making sense of what you see while driving).
• Problems With Writing or Reading (i.e. not being able to read as well as before, not being able to read what you have written).
• Changes In Thinking and Increased Confusion (i.e. having illogical thoughts, increased suspiciousness, not recognizing familiar places, not remembering day or time)
• Changes in Impulse Control (i.e. doing or saying things you wouldn’t normally do, increased irritability or impatience, increased social disinhibition).

A PEDIATRIC NEUROPSYCHOLOGICAL ASSESSMENT is a broad-based and in-depth evaluation of a child’s brain functioning that is highly specialized.  It includes all the components of a thorough adult neuropsychological assessment but it also integrates specific knowledge of brain development, specific vulnerabilities during crucial stages of fetal growth, as well as understanding of normal childhood behavior and development.  Because neurodevelopmental disorders have early onset, the “event” may affect multiple brain and neurobehavioral systems that will require a framework that includes consideration of brain-behavior relationships, how a child’s nervous system interacts with his/her environment, and how these interactions manifest and change over time.  Early insults can stimulate alternative neural pathways that can assume the function of the affected area.  However, the development of these alternative pathways can affect not only the target function but also the “compensating” structures since they have to take on more “responsibilities” that may subsequently result in “crowding” in the neural pathway, thus affecting overall efficiency.

A Pediatric Neuropsychological Assessment provides clear and specific information regarding a child’s functioning compared to his/her average age mates, and may be particularly valuable when problem-areas have been identified in the past but the child has failed to respond to the recommended interventions.  In addition, children with neurodevelopmental disorders or conditions that involve early insults or abnormality in the developing central nervous system including premature birth or toxic exposure, often require a thorough pediatric neuropsychological assessment at various points in their lives, so as to better determine their changing needs and abilities over time.  When a child has difficulty with thinking and performing tasks that are age appropriate, has problems with learning or memory, displays uncontrollable emotions or unusual behaviors, a neuropsychological assessment may be valuable in bringing the reasons for the problematic presentation to the forefront. 

Neurological diagnoses can be associated with genetic (Fragile X, Turner syndrome, neurofibromatosis, Down syndrome, Klinefeler syndrome, phenylketonuria, juvenile Huntington’s, Sickle cell disease, etc), environmental (Fetal Alcohol Syndrome, traumas, infections, toxic exposure and teratogens), medical (seizures, metabolic or endocrine problems, premature birth, brain tumor), multiple factors (Tourette’s Syndrome, Cerebral palsy, Spina Bifida), fetal infections (toxoplasmosis, varicella zoster, parvovirus, rubella, cytomegalovirus).  For many of the above mentioned factors the frequency and duration of exposure and timing in relation to fetal growth or critical periods of rapid brain development play a crucial role in the severity of the presentation.  Oftentimes, a condition that may present with mild symptoms in the mother can have serious repercussions to the developing fetus.  Other times, an insult that was apparently benign, can have a more significant impact at a later stage, as the nervous system grows and the “loss” of function assumes greater consequences in a person’s life.

Young children whose brain has been compromised are often “developmentally off track” and more vulnerable to difficulties with regulation of behavior, attention and stamina.  The information derived from a Pediatric Neuropsychological Assessment will provide caregivers (parents, teachers, guardians) with a better understanding of their child’s developmental pattern, strengths and limitations that will result in the adults being more empowered and confident as to what to do to help and set appropriate expectations.  When warranted and with parental consent, I will participate in an IEP meeting so as to advocate for the affected child’s educational needs and put in place the appropriate interventions to be implemented at the school setting.

A MEMORY CLINIC EVALUATION is geared specifically to meet the diagnostic needs of older individuals age 55 and above who are presenting with cognitive changes particularly in the form of memory loss.  The evaluation involves a clinical interview with the individual and family members, a thorough review of medical records, consultation with other providers involved in the patient’s health care, and the administration of psychometric measures that evaluates all facets of memory functioning so as to better determine the nature of the “breakdown” in the memory process (registration, encoding, consolidation, storage or retrieval).  The testing also includes the evaluation of other cognitive realms, such as visual, sensory-motor, language and executive functioning; areas of impairment that often come hand-in-hand with memory loss.

The psychometric measures included in the Memory Clinic Evaluation were selected for their sensitivity and helpfulness in detecting and differentiating cognitive changes that are part of normal aging versus the early signs of a disease process.  All of us will experience a natural decline in our mental acuity.  However, when memory problems are consistently interfering with daily life such as when a patient is asking the same questions multiple times, becoming disoriented when in a new location, experiencing difficulties managing the finances, needing constant reminders to do chores or take medications; then an evaluation may be warranted to determine the extent  and the causes for the memory loss.  The Memory Clinic Evaluation was specifically developed to identify cognitive deterioration due to medical conditions that are often associated with the geriatric population including Neurodegenerative Diseases such a Alzheimer’s, Parkinson’s Disease, Fronto-Temporal Dementia; Vascular Conditions such as heart disease, stroke, hypertension, COPD, chronic articulation problems; and Metabolic/Endocrine Conditions such as diabetes, thyroid, chronic liver and kidney disorders.

An accurate diagnosis and identification of the causes for the cognitive changes is essential in determining the most appropriate and effective interventions.  This is particularly relevant when early detection of certain neurological disorders can lead to successful stabilization of the condition, or when the underlying cause of the mental deterioration  is associated with a medical state that is treatable (embolism, tumor, infection, metabolic/endocrine imbalances, toxic states, drug-drug interactions, etc.) with cognitive impairments that can be potentially reversible. Early intervention and participation in an effective Cognitive Rehabilitation Program can play a crucial role in prolonging independent functioning and delay the need for more restrictive placement in Assisted Living, Group Homes, or Skilled Nursing Care facilities.  This vital service seems to be particularly relevant since recent studies have shown that brain plasticity was found to be likely even in the elderly population (Kopytova et al., 2004) and cognitive interventions were found to help older individuals to improve their cognitive yield such as in episodic memory, reasoning and processing speed (Ball et al., 2002).

A LEARNING DISABILITY EVALUATION seeks to identify the presence of a cognitive deficit or “disability” that has a detrimental impact on a student’s ability to learn and attain a level of academic achievement that is equal to his/her intellectual potential or “intelligence”.   However, this evaluation is limited in scope, and does not involve the in-depth and comprehensive study characteristic of a Neuropsychological Assessment.  Consequently, it provides more limited information regarding the “root” causes for the learning difficulties or the interactive effects that various cognitive deficits or “inefficiencies” may have on the students’ overall cognitive functioning.  This evaluation may not be sufficient or appropriate if previous educational evaluations have already been conducted, and educational interventions, remedial programs, or accommodations have been implemented with little beneficial impact on the students’ academic performance. In these cases, a comprehensive Neuropsychological Assessment would be recommended.  

A Learning Disability Evaluation, includes a clinical interview, careful review of school records, consultation with teachers or other school representatives, and the administration of a measure of intellectual potential (WISC-IV, WAIS-IV), academic achievement (WIAT-II, WJ-III), attention and concentration (CPT-II, WCST), visual functioning (RCFT, TVAS, VMI) and/or auditory functioning (SCAN-C, SCAN-A II).  This evaluation would suffice for most students’ who are believed to be impacted by a Specific Learning Disorder such as dyslexia, or an Attention Disorder Hyperactivity Disorder (ADHD) without any other complicating factors.  Oftentimes, students who have already been previously diagnosed with a learning disability may opt to do this evaluation merely to establish their eligibility for services and/or school accommodations under  ADA or IDEA regulations such as additional time during standardized entrance examination (SAT, GMAT, GRE, MCAT), use of a separate room or noise-cancelling device, use of visual aids or calculators, provision of paper-and-pencil rather than computerized version of a test, or evaluation through multiple-choice rather than composition.

A DEVELOPMENTAL ASSESSMENT is designed to determine a child or a dependent adult’s level of intellectual (intelligence) and adaptive (ability to perform daily self-care activities typical for the age group) functioning.  This evaluation often involves individuals who present with notable developmental delays and suspicion of mental retardation or limited intellectual potential. Therefore, the assessment is often conducted to determine eligibility for benefits and services through the Regional Center or other publically funded agencies.  Children who have suffered significant birth trauma, hypoxia, or are believed to be in the autistic spectrum may be evaluated under this classification. When rather than determining a diagnostic category (i.e. Intellectual Disability or Pervasive Developmental Disorder), the evaluation is intended to identify the specific underlying cognitive processes that are contributing to the delayed functioning and/or problematic behavior presentation, a Neuropsychological Assessment would be a more appropriate alternative.  Similarly, a more comprehensive assessment should be pursued when parents or guardians are interested in determining whether neurocognitive retraining could bring positive changes in their children’s cognitive functioning.  A developmental neuropsychological perspective provides information that adds to the understanding of the child even when limited intellectual capacity has been previously identified, that can lead to important intervention strategies that can bring gains in adaptive functioning and improve the child and/or family’s quality of life.

COGNITIVE REHABILITATION OR NEUROCOGNITIVE RETRAINING is an area of specialization that focuses on restoring the functions of the brain that have been identified in the neuropsychological assessment as being impaired or inefficient.  The aim of the rehabilitation program is to “retrain” or help the brain develop the ability to execute mental functions that have been disrupted or undeveloped due to injury or abnormal developmental processes.  A mixture of various hands-on, mental, and computer-based activities are implemented at different times during the training program in order to achieve the desired level of competence and efficiency. Through this individualized program children and adults who have suffered a traumatic brain injury from an auto accident, falls, blast injury in war zones, neurodegenerative or neurodevelopmental disorders, and an array of medical conditions such as brain tumor, seizures, liver failure, encephalopathy, metabolic disorders, neurotoxin exposure, etc. can experience notable improvements in functioning which may bring meaningful changes in quality of life.

Often times more basic skills have to be developed or strengthened before integrating more complex or higher-order skills into the system otherwise the weak “infra-structure” is unable to withstand the demands that are placed upon it and will quickly collapse.  Therefore, a careful study of each patient’s specific pattern of cognitive strengths and weaknesses is a fundamental component for the development of the most effective individualized brain retraining program. Because a Neuropsychological Assessment is the most comprehensive tool to achieve such understanding of brain functioning, I see this evaluation as an integral part of the Cognitive Rehabilitation Program.

Neurocognitive retraining is based on the premise of brain plasticity or the ability of this vital organ to change in response to renewed stimulation and it is viewed by many as a lifelong characteristic of the human brain, with the possibility of reorganization existing for years after an injury or a developmental mishap.   Brain plasticity has become a more intriguing topic of research since advanced imaging studies have afforded us with first hand images of the changes that occur in the brain when exposed to new stimuli or alternative ways of responding.  Anecdotal stories as well as studies have shown that after an injury, other parts of the brain can learn to take over the function of the injured areas and renewed brain activity can be regained in the affected sites.  A child’s developing brain is particularly capable of this plasticity and may benefit more readily from the cognitive rehabilitation efforts.  Hence, it becomes particularly relevant to gain a thorough understanding of a child’s cognitive issues as soon as difficulties reaching normal developmental milestones are noted.  How an injury or disruption in the normal developmental process affects brain functioning varies from person to person according, for instance, to the individual’s premorbid (before the injury) abilities, personality characteristics, temperament, severity of the injury, gestational stage when the brain insult occurred etc.  In addition to assisting in the restoration and development of new skill sets Cognitive Rehabilitation also incorporates adaptive and compensatory strategies which involves helping the individual 1) learn how to do things differently and 2) implement helpful modifications in his/her environment so as to reduce the detrimental effects of the identified deficits. With this comprehensive approach that includes remediation, retraining and implementation of compensatory strategies the Cognitive Rehabilitation Program can make a vital contribution in helping the individual return to his/her pre-injury capacity or attain a level of optimal adaptive functioning that has never been achieved before.   Hence, Cognitive Rehabilitation brings not only substantial savings in medical case management cost (Cherek and Taylor, 1995) and the restoration of cognitive abilities impacted by a variety of medical conditions but it also has a therapeutic value with the resulting increase in the individual’s sense of confidence, competence and self-esteem.

Cogmed Working Memory Training is a computer intervention that has been shown to improve functioning in individuals with attention and working memory problems.  This training program can be implemented at home and uses different exercises over a period of five weeks to train working memory in 25 training sessions.  The intense quality of the program requires the training sessions to occur five days a week for a period of 15 to 45 minutes depending on the user's age (preschoolers, children, adolescents, adults, geriatrics).  Contrary to many other programs available in the market, the improvements associated with Cogmed Working Memory Training have been consistently demonstrated through published, peer-reviewed and controlled clinical studies.  About 80% of people who complete the program experience positive effects, such as a significant improvement in their ability to concentrate, exercise better impulse control, and use complex reasoning skills.  The improvements following completion of the training program have been shown to be substantial and long lasting, both in research and clinically.  Most importantly, the changes in working memory capacity generalize to behaviors that impact the quality of our adaptive functioning at home, school or workplace.  For instance, if a child is suddenly reading a little faster and remembering more of what is read; and subsequently the more material is remembered successfully the better reading comprehension is achieved-this is an example of stronger working memory in action.  In a successful scenario, reading will likely be more fun and the child may be more willing and interested in performing this activity with greater frequency or for longer periods of time.

Working memory, which can also be described as active attention, is an essential cognitive function that allows us to hold information in our minds for a brief period of time, typically a few seconds, just long enough to use the information in our thinking.  It is the engine that quickly processes the flow of information that surrounds it, and is a good predictor for academic and professional success.  Depending on how well working memory may be functioning, we may be more or less effective in carrying out many developmentally important tasks and activities in daily life.  Working memory plays an important role in our ability to: a) remember instructions about what to do next (e.g keeping driving directions in our heads while following through), b) keep all parts of a number in memory (e.g keeping all digits in mind to do a calculation), c) read and remember what is read, d) keep information in memory so as to use for problem-solving, e) sequence a task or perform the various steps of a task in a specific order, f) attend to the task at hand without becoming distracted by irrelevant stimuli, g) plan, organize and structure our daily lives.

Although results may vary and the effects in each individual can never be guaranteed, research and clinical data consistently show an 80% success rate for this program-meaning that 8 out of 10 users who complete this program experience measurable effects in daily life.  Changes can be observable immediately following completion of the Cogmed Training, but often more substantial gains have been reported after some time has elapsed (3-4 weeks, and over longer periods as well).  Parents and/or teachers have reported the following:

• The child communicates better
• The child is more focused
• The child acts more "mature"
• The child takes more initiative on his/her own (e.g  self-initiate chores including homework without nagging or reminders)
• The child concentrates and sustains attention for longer periods of time
• The child performs better on academic tasks
• The child shows greater interest in school work
• The child is more organized (e.g maintains assignment book, turns in homework)
• The child has improved frustration tolerance, thinks before acting, has fewer "meltdowns", is calmer
• The child shows better reading comprehension, retention and retrieval, with resulting improvement in test performance
• The child is able to master math facts more easily
• The child shows more self-confidence, more sense of responsibility and improved social interaction

Cogmed Working Memory Training is not intended to be a substitute for a consultation with a health care provider or for pharmacological intervention that a doctor may prescribe.  However, Cogmed has analyzed training effects for children who are on medication (methylphenidate) compared to children without medication, and found that both groups benefit equally from the training.

If you wuld like more information about Cogmed Working Memory Training, please go to their website at: www.cogmed.com.

NEUROFEEDBACK IS AN ALTERNATIVE METHOD of intervention to address brain dysfunctions and cognitive deficits that is non-invasive and often associated with substantially less adverse effects than the use of psychoactive agents such as anti-depressive or stimulant medications.   

Neurofeedback is a form of brain training that utilizes biofeedback principles to “teach” the brain to produce the appropriate brainwaves necessary to elicit the most effective level of functioning.  Hence, this method of intervention can help:

•  Eliminate the feeling of “brain fog” and sense of overwhelm.

• Improve memory function as well as other cognitive abilities such as attention, organization, working memory, and mental flexibility.

• Stabilize mood by reducing feelings of irritability, depression or anxiety.

• Reduce the experience of pain.

• Stabilize sleep patterns.

In the last several years, the field has undergone some significant new developments that have rendered this method of brain training even more appealing since some innovative systems such as LENS (Low Energy Neurofeedback System) have been able to “bypass” the need for the patient to consciously learn how to control their brainwaves.  Instead, feedback of brain function is applied directly to the brain in a language that is already very familiar to this vital organ, minute electronic impulses that are thousands of times weaker than the signal produced by cells phones, hence posing no harm or danger to the patient.  In fact, one of the most well-known of these innovative systems, LENS, has been deemed by the FDA as having equivalent safety status as conventional neurofeedback.  

However, alternative approaches such as neurofeedback or neurobiomodulation to yield the best results, a quantitative EEG brain map (QEEG) should be completed prior to commencing these treatment modalities.  The QEEG provides valuable information for a careful analysis of the brain waves patterns and the “coherence” between the various brain regions, and compares the patient’s QEEG to their age group norms in order to identify areas of the brain showing abnormal brainwave characteristics.  

Initially, treatment will require a minimum of two neurofeedback training sessions per week lasting for about one hour each.  Overtime, the sessions can be reduced to once a week.  Other treatments may require the purchase of a device but the interventions can be completed at home. Once the desired improvements are accomplished by the interventions, the changes in brain functioning are stable and permanent.  We, at Optimal Minds Neuropsychology, are committed to helping our patients achieve a better level of functioning and sense of well-being, hence we are very enthusiastic about making this intervention available to our patients through a collaborative effort with Dr. Eileen Roberts and Dr. Nina Nehring at Brain Builders Neurotherapy.