I’d like to introduce Michael Koffman, Ph.D. who is a licensed clinical neuropsychologist and the Director of North Jersey Neuropsychology, LLC in Montclair, New Jersey. Dr. Koffman specializes in providing educational and neuropsychological assessment for children and adults with cognitive, learning, mood, and behavioral issues.
Hi, Dr. Koffman. Can you tell us why a comprehensive neuropsychological evaluation is an important tool for students who may have suspected learning issues?
Hi Christian. Thanks for having me. There are several reasons. The first is to determine whether the student is performing at grade level. We do this by measuring skills across each of the major academic domains – reading, writing and mathematics.
Beyond this, however, it is essential to pursue a more thorough appraisal of what other interfering factors may be involved. To this end, we also measure such areas as attention/concentration, executive functions, language, memory and processing speed, to name but a few. Because there are often emotional issues that go along with learning difficulties, it is critical to assess in this area as well.
How exactly does an evaluation guide educators and parents to remediate problems at home or in the classroom?
The evaluation helps determine specific levels in each of the above-noted realms. This helps to prioritize points of entry vis-à-vis intervention. What emerges from the data helps us better know what specifically the child may need a) academically (e.g., 504/IEP/Accommodations, including extended time), b) behaviorally, including focus (e.g., behavior management, parent counseling, medication), c) psychologically (e.g., psychotherapy, social skills training, etc.), d) fine motorically (e.g., occupational therapy), e) organizationally.
I’m going to concentrate on the diagnosis of ADHD for a moment because many students I work with struggle with symptoms of this disorder. Can you talk a bit about what ADHD looks like, why ADHD seems to be more prevalent than it was years ago, and how the ADHD brain differs from the non-ADHD brain from a neuropsychological perspective?
ADHD can take on several forms. The first is the Inattentive type. This typically manifests as weak initiation; difficulty engaging in tasks requiring sustained mental effort and that are less interesting; difficulty with follow-through; needing things repeated for them; high levels of distractibility; propensity toward carelessness, etc. The second is the Hyperactive-Impulsive type. This is where the student has excessive energy levels which they struggle to harness in settings where it is more necessary (e.g., classroom). They struggle to sit still, with modulating their actions and words and act more generally impulsively. There is also a third type of ADHD, the Combined type. ADHD, overall, tends to correlate with learning disabilities, executive dysfunction and can often include behavioral/emotional struggles as well.
I agree that ADHD is being diagnosed more than in the past, likely over-diagnosed. Part of this has to do with a better understanding of the condition and the toll it takes on kids who are not diagnosed and treated. By the same token, there are those who diagnose it without doing a full, systematic analysis of all the factors involved and a thorough historical review of the student. Unfortunately, it has also become far too easy to reach out to a physician with complaints of attention problems and walk out with a prescription.
In terms of the neuropsychology of an ADHD vs. non-ADHD brain: The common areas impacted (beyond of course focus itself) are memory and processing speed. However, because, as noted, ADHD overlaps with several other disorders (e.g., reading disabilities/dyslexia), it is critical to test a broad range of skills. In the case of dyslexia, for instance, beyond deficits in reading and writing, we not-uncommonly find others in mathematics and in the underlying language apparatus.
Despite these findings, some people still think ADHD is a reified, or “made up” disorder and that we overmedicate children with stimulants. This controversial topic is mentioned often in the media. What would you say to individuals and parents of children diagnosed with ADHD who believe that ADHD isn’t a real disorder or that stimulant medication is overused or unnecessary?
The diagnosis of ADHD is very real. We have ‘hard’ evidence of structural differences in these brains. There are clear differences in neuroimaging (e.g., PET scans, MRI’s, etc.). There are differences in the levels of certain neurotransmitters.
The risks for not taking ADHD seriously and not treating it are significant. In the short term, they include compromised school performance, feelings of diminished self-worth. More long-term there can be profound impact on the student’s future career options, their ability to maintain successful long-term relationship (e.g., higher divorce rates). These individuals are also at higher risk for impulsive behaviors leading to accidents, as well as future substance and/or alcohol abuse.
At the higher levels, the most effective form of intervention for the treatment of ADHD – in combination with behavioral strategies – is medication. I have provided below a few important links for parents and educators to review at their convenience:
American Academy of Pediatrics (keyword: ADHD)
National Institute of Mental Health (keyword: ADHD)
American Psychological Association (keyword: ADHD)
All that said, I do agree that ADHD is in fact being over-prescribed. There are those who pursue it to gain an unfair advantage in school (e.g., college), who have been misdiagnosed as ADHD (e.g., when the issue is, say, anxiety), or where behavioral, combined with other forms of treatment (e.g., tutoring, organizational training) would have been far more appropriate.
We hear a lot about this relatively new term “executive function” in relation to ADHD and other brain disorders. Can you tell us what is meant by “executive function” (EF) and offer an example of how deficits in EF commonly manifest in the educational setting?
Executive function involves such things as initiation, follow-through, planning, organization, time management and self-awareness about one’s skills in these areas. There are almost invariably problems in one or more of these areas in kids with ADHD (though also in many of those without). The most significant impact noted tends to be during homework time, where long-term assignments are concerned, and test preparation. I find that kids with these issues also often struggle on writing tasks requiring multiple competing demands (e.g., generating ideas, structuring, technical execution, proof reading, etc.).
Sometimes I hear from a frustrated teacher or parent that a student is unmotivated, or “lazy” because they don’t want to work on a long-term school project or complete homework. The adults assume that willpower is playing a role here because the student may have a high IQ and maintain good focus when they do something that interests them, such as working with their hands, playing a video game or reading an suspenseful book. Do you think laziness is playing a part here, or is there evidence that something deeper may be going on?
I always find it unfortunate when I hear the word ‘lazy’ applied to a child. True, there may be a motivational element, but there is usually a far more complicated clinical picture involved which has yet to be tapped into. This is in fact the reason for the comprehensive neuropsychological evaluation. It may well be that this child has an undetected learning disability, struggles with focus, has weak organizational skills, or other factors that are interfering with his/her ability to achieve. When we stop and look at the struggling student, it seems rather reasonable that s/he would increasingly resist doing work as a means to ease their frustration. I find, however, this only leads to more pressure being put on the child which, of course, only makes them want to pull away more.
Are there other misconceptions you’d like to demystify concerning students with learning challenges? What are the most common questions asked by your clients and their parents?
I think one of them you addressed above – i.e., that the child is just being ‘lazy’ and needs to ‘try harder.’ Another is that a ‘learning disability’ means that the student is not and WILL NEVER be able to. Not the case. It simply means below grade level at the present time. With the right form(s) of intervention, there is every reason to believe that the child can and will succeed.
Some of the students that I tutor struggle with anxiety issues in addition to their primary learning disability, ADHD, or neurodevelopmental disorder. In 2010, at the “Learning and the Brain” conference in Washington, DC, several clinicians and researchers warned of an alarming increase in the incidence of anxiety among students over the past decade or so. Are more students in your practice presenting with anxiety than you’ve observed in previous years? If so, what do you think are the reasons for this? Is there a biological link between anxiety and learning disorders, or do you think environmental stressors are playing a bigger part?
I think the demands placed on kids these days are enormous. Beyond a rigorous course load, they often engage in numerous extracurricular endeavors. For the older students, they often feel the pressure of needing to pursue additional tutoring (e.g., SAT tutoring) and ‘resume-building’ of some sort. This applies to all students. For those with LD’s or other learning challenges, the stress is only compounded. I do frequently see this presentation and it is alarming. Biology and genetics undeniably play roles as well.
I’d like to thank Dr. Koffman for his time and thoughtful responses. Dr. Koffman, would you like to provide your contact information so that people potentially seeking a neuropsychological evaluation can get in touch with you?
Thanks again for having me, Christian. My contact information is as follows:
North Jersey Neuropsychology, LLC
460 Bloomfield Avenue, Ste. 400
Montclair, NJ 07042
973-908-4860