Cindy Lopez: Welcome. My name is Cindy Lopez, the host of this CHC podcast, Voices of Compassion. We hope you find a little courage, feel connected and experience compassion every time you listen.

Are you wondering what a neuropsychological evaluation actually tells you and what to do with the results? In this episode CHC experts, Dr. Joaquin Burciaga and Dr. Whitney Geller break down how neuropsych testing actually helps clarify a child’s learning, attention, memory, language, and emotional regulation, so families can move from questions to a clear plan. You’ll discover what a neuropsych evaluation for kids really is and what it isn’t, how it differs from the psychoeducational testing done through schools and the signs that might suggest it is time to consider one – whether you’re navigating ADHD, autism, learning differences, or anxiety our experts also share practical guidance on how to cut through the jargon, focus on the summary and recommendations, and turn that thick report into actionable steps that actually help your child. So, whether you’re just starting to wonder if testing might provide answers or you’ve got a report sitting on your desk that feels overwhelming, this conversation will help you understand what these evaluations reveal and how to use them to advocate effectively for your child.

 Welcome Dr. Burciaga and Dr. Geller. So glad that you could spend some time with us today talking about this topic about neuropsych evaluations. And I’m wondering if you could just take a minute to tell our listeners a little bit more about yourselves.

Joaquin Burciaga, PhD: My name is Joaquin Burciaga. I’m a neuropsychologist at CHC. I’ve been a licensed psychologist now for 10 years and have been working with children for the past 10 years, but my past experiences include working with adults, older adults. So, I really have a broad experience of the lifespan of neuropsychological evaluation, and I’m now also a clinical program manager at CHC.

Cindy Lopez:  Thank you, Dr. Burciaga.

Whitney Geller, PhD: Please feel free to call me Whitney. So, I have been doing neuropsychological evaluations for over a decade now, and I have a lot of experience across the lifespan, but really found over the years that my heart lays with children and the work that I have really felt like is the most meaningful is my work with children. So, after doing a lot of lifespan work in fellowship, I decided to really specialize in pediatric neuropsychology, and that’s when I felt like I really was able to connect with my patients and start to build a good understanding of comprehensive medical conditions as well as things that are often seen in medical conditions and other places such as ADHD and autism and learning disorders.

Cindy Lopez: So, thank you again for joining us today, both of you. As we get into this conversation today, I think a lot of our listeners are probably wondering, like, what is a neuropsych evaluation? So, for our listeners, it is a neuropsychological evaluation. You might hear it referred to as neuropsych evaluation, and so we might use those terms interchangeably today as well. So, let’s talk about what it is first.

Joaquin Burciaga, PhD: Yeah, I mean, a neuropsychological evaluation, it’s a comprehensive assessment of how a child’s brain is functioning in everyday life. And what we’re doing when we’re doing the evaluation is looking at the relationship between the brain and behavior. So how a child thinks, how they learn, how they remember, regulate their emotions and navigate the world. And one important distinction between neuropsych or neuropsychological evaluations as we often call them for short, is that people think that neuropsych evaluation is like neuroimaging or a way to look into a child’s brain. And neuroimaging is limited in the sense that it can’t really tell us much about how much is going on with respect to cognitive functioning or everyday life. It gives us information about structure, but it doesn’t tell us how well a child can pay attention in class or process language or much less manage their frustrations. And so that’s where neuropsych evaluations are uniquely valuable.

Whitney Geller, PhD: Yeah, and I think Joaquin brought up an excellent point of, you know, there isn’t a brain scan that we can do to see how somebody functions day to day,

Joaquin Burciaga, PhD: It would be amazing if we could.

Whitney Geller, PhD: It would be wonderful if we could, it might put me out of a job, but hey if we could make it that easy that would be amazing because sometimes it is really hard to figure out what’s going on and specifically with neuropsychological evaluation, we’re looking at the brain behavior relationships. So, seeing how people do on certain tasks, tap into different cognitive function, which then maps onto specific brain areas. So, in that respect, we’re looking at the brain behavior relationship. But as we know from time and time again with our neuroimaging studies that structure and neurobiological function does not actually equate to day-to-day function.

Joaquin Burciaga, PhD: 100%.

Cindy Lopez: Some of our listeners probably know about a psychological evaluation or even a psychological educational evaluation. I’m wondering what the difference is between what we’re talking about and a neuropsychological evaluation and those kinds of things.

Whitney Geller, PhD: That’s actually an excellent question. I think one that comes up a lot, not just with people seeking evaluations, but even other psychologists and psychiatrists and MDs, it’s actually a really common question even for people that are in the field of psychology – is understanding the difference between a neuropsych eval and one of your more standard, either like psychiatric or psychoeducational, or we also call that psycho-ed evals. I think that one of the key differences that I usually think about in terms of whether I’m recommending seeing somebody who’s a neuropsychologist versus somebody who doesn’t have that extra expertise, is there a need to examine specific brain behavioral relationships that could allude to a more distinct brain difficulty. And what I mean by that is, so we think about medical conditions for instance, like epilepsy or when somebody has had cancer and has undergone chemotherapy or certain kind of hematological conditions, like sickle cell disease. And we think about those things have a really profound impact sometimes on what the brain is doing and how the brain is functioning. And it would be really important in a case like that, that we are able to come in with the expertise of understanding those brain behavior relationships. The caveat to that though is that I do very frequently see and have seen throughout my work with those populations that they also tend to present with a lot of the common features, for instance too, like ADHD. So, individuals with epilepsy or who’ve undergone chemotherapy may also present with attentional difficulties or learning difficulties that may appear very similar, but the underlying cause might be a little bit different.

Joaquin Burciaga, PhD: Yeah. And then to chime in there, so, you know, Whitney, you talked about the neuropsych evaluation, the psychoeducational evaluation is often more focused on academics, educational needs, school-based planning. And so when someone is coming in for a psychoeducational evaluation because they’re concerned their child might have a ADHD or a learning disorder, that’s a different evaluation than what we would do for a neuropsychological evaluation when we’re concerned about something like a seizure disorder or a traumatic brain injury or multiple sclerosis or various conditions.

Cindy Lopez: So, you kind of, alluded to this in both of your comments so far, but for our listeners, what’s the purpose of a neuropsych evaluation?

Joaquin Burciaga, PhD: The big purpose of the neuropsychological evaluation is to identify what the child’s strengths and weaknesses are across cognitive, academic, behavioral adaptive functioning, or adaptive domains. And when we’re looking at the evaluation, we’re looking at the full profile, not just like scores on attention or scores on executive functioning. And then we use that data to clarify a diagnosis, whether the questions are about ADHD, learning disorders, autism, anxiety, and the results help guide interventions and treatment planning.  

Whitney Geller, PhD: Yeah, I’ve actually had it come up a number of times where people will ask me, “My child needs a psychoeducational evaluation. Does the neuropsychological evaluation include that?” And my answer is yes. I typically think of a neuropsychological evaluation, at least in the pediatric setting as being a psychoeducational evaluation plus. Now, that being said, certain forms of testing aren’t always indicated. So, for instance, if there’s no history of learning difficulties and no indication that a learning disorder might be present, then a neuropsychological evaluation probably is not going to include educational assessment, whereas if somebody went to the school, so this comes up a lot with schools… So, schools do psychoeducational evaluations. If you go to the school district, they will do one, but it will typically only include academic assessments and an intellectual assessment, and then like some mood and behavioral questionnaires and like meeting with the kids, school observation. And it’s really focused on more of that intellectual academic aspect. When it’s a neuropsychological evaluation, we do that plus a lot more of like the nuanced exploration of cognitive strengths and weaknesses. And frankly, schools actually don’t have the legal ability to diagnose. So,  that’s another area that can get a little bit fuzzy. So, for instance, I’ve had patients that have had a psychoeducational evaluation through the school, but there’s something that the school has alluded to, like they see these things, but they can’t formally tell you, I think your child has autism or I think your child has ADHD,at which point they may be coming to somebody like us where the school has recommended further testing.

Cindy Lopez: Yeah. And as you’re talking, you kind of answered this, but what outcomes do you hope to achieve? I mean, you just mentioned one, which would be accurate diagnosis. Are there others?

Whitney Geller, PhD: I think that that’s kind of the jumping off point, right, is how do you treat something if you don’t know what’s going on? And I think that being able to pinpoint what is going on is the jumping off point for being able to treatment plan. So, a large amount of our work is figuring out what’s going on, but then the second piece of that is, well, what do you do now? And our job is to help point you in the right direction. So, I wouldn’t say always, but typically a neuropsychologist is more of like a short-term stop. So, it’s somebody who helps you figure out what’s going on and then make a plan for how to move forward, how to get treatment, how to treatment plan.  For instance, diagnosis can inform medication, diagnosis can inform the type of therapy you would need to do.  It can inform  academic accommodations or services and we are   the people that say, hey, this is what’s going on and here’s what you do about it. We’re not typically the people who are going to do ongoing therapy with you after. That being said, there are some neuropsychologists out there who will do cognitive rehabilitation, or some of us do therapy as well. And I would say that that’s probably more far and few.

Joaquin Burciaga, PhD: And beyond the diagnosis and recommendations, oftentimes parents are seeking help regarding advocacy tools, like, does my child need an IEP or a 504? Does my child need specific accommodations and treatment planning? So, sometimes I’d say like maybe half the time our evaluations are interdisciplinary evaluations where we have a speech language pathologist or an occupational therapist or an educational specialist involved. And so we try to tailor thoughtful treatment planning recommendations for parents regarding how to approach the services that their child might need. And try to provide a connection to the appropriate resources so families don’t feel like they’re navigating everything alone.

Whitney Geller, PhD: Yeah. And the wonderful thing about CHC is thata lot of places it’s like you have your one stop shop for your evaluation and then you have to go somewhere else.  Here we have the luxury of being able to say, hey, there’s definitely some language difficulties going on with your child, and we can help you with that. We can help you get started. So, while the neuropsychologist might only be involved in the short-term, CHC as a whole is able to provide some of that long-term support.

Cindy Lopez: Yeah, and speaking as an educator too, we do have schools at CHC that can also take into account some of those accommodations and actually be able to implement some of those accommodations for your students.

So, I’m guessing like lots of people hear the term neuropsych evaluation, but they don’t really understand what their child would experience in a neuropsych evaluation. Can you walk us through like what actually happens?

Joaquin Burciaga, PhD: Yeah, parents and kids often imagine something intimidating, but the process is actually very structured and child centered. It always starts with a comprehensive intake session, where we gather information regarding developmental history, medical history, school concerns, family observations and this is the critical piece because test scores never exist in a vacuum. We want to know everything that’s going on in the child’s life. And then next we do the in-person testing, which is done in our offices. Our offices are not sterile doctors offices; mine is full of Lego. Most kids come in and are totally surprised by the amount of toys I have in there. And the testing can occur over one or more days, depending on the child’s age and the needs. And testing usually involves a variety of tasks. We use a lot of iPads for some of our measures. And some of the tasks might feel like puzzles, some like homework, some like games. And we’re trying to observe not just what answers the child is giving us, but how they approach the task, how they respond to challenges and how they manage their effort and frustration. If the evaluation is done as a team, where we have other members of the team, we get together to talk about the results, to come up with our diagnoses and recommendations, and then we meet with the family to discuss the results. And it’s an interactive and collaborative feedback session where we walk families through the results in as plain language as possible, explain what the findings mean, answer questions with the goal being to provide clarity and not overwhelm families. Regardless, it’s can sometimes still feel like drinking from a fire hose with the amount of information we give parents, but we try our best to check in and avoid overwhelming folks.

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Cindy Lopez: So, what are some of the signs or struggles that a parent or caregiver might see that might prompt them to consider a neuropsych evaluation? Like, how do they know when it’s more than just kind of typical development, and how do they know when it’s just more than typical developmental differences.

Whitney Geller, PhD: Yeah, I think that that’s a good question. This one’s a little tricky because it’s hard to know, right? Like, it’s hard to know, especially I run into this all the time with parents that only have one child. That’s even harder. It’s like, how am I supposed to know when I only have my one kid? I think that the key defining thing for me when I recommend like seeking evaluation is something pervasive? Is it bleeding into other aspects of life, like is it impacting your child’s day-to-day function? Are they struggling in school? Are they struggling with friends? Are they struggling in any other aspect of their life? Is it something that’s pervasive and impairing, and especially when it’s something pervasive and impairing and chronic. So, you know, we all have struggles here and there. We all have bad days. Is it something that’s persistent though? Is it lasting for a long time – longer than would be expected? We all think about like the terrible twos, right? Toddlers going through that phase of the terrible twos, but what happens when you have your 6-year-old or 8-year-old, or 10-year-old, that feels like they’ve never quite outgrown that, right.

Cindy Lopez: So, I am imagining that people listening to this podcast who are thinking, okay, we did a neuropsych report, but it’s taken me months to really understand it or to, you know, to really process all of the information that was given to me. It could be more than 20 pages of data and scores and observations. So, from your perspective, what are the most important things that parents or caregivers should focus on, and what do you want them to truly understand about their child from the findings?

Whitney Geller, PhD: I think that like Joaquin was saying, that one of the most important things is doing the feedback session because our job is to help you understand what’s going to be in the report and what you’re going to get. And so that’s kind of like the first step is that feedback session to prepare you for what you’re going to be reading. I often joke with patients during feedback, I’m like, don’t even read the report, just read the summary and just read the diagnoses and read the recommendations. Seriously, you know your kid, you don’t need to read that whole background information. There’s all these scores in there, which the reason that we have all that in there is because this report is meant to travel to a lot of places. So, we always recommend take the report to the school, give the report to your medical providers or your psychiatrist or your therapist or your OT or your speech therapist. Like, there are people who are going to need to see the full report so they can understand the background and then also so that they can understand at this point in time, where is your child falling. The scores are not going to be super meaningful to you probably because they really are more of like a technical standpoint for treatment and for other providers.

Joaquin Burciaga, PhD: Yeah, I agree with you there, Whitney. The report is meant to travel, and so we walk this fine line of trying to write a report that can be consumed by people from different audiences, so teachers, doctors, other psychologists. And so sometimes we try to limit the amount of jargon that’s in there, but it’s sometimes just inevitable that we include it in there so that another neuropsychologist reading it in three years knows what we were talking about. And so it sounds like we know what we’re talking about, but yeah, same thing as Whitney, I often tell parents, you know, just read the summary and the diagnostic impressions and then of course the recommendations.

And again, also agreeing with Whitney, the feedback session being so important. I can’t tell you how many people I’ve seen or families I’ve seen that come in for an evaluation. Their child was evaluated earlier and they either didn’t have a good feedback session that really helped them understand the scores or they didn’t have one at all. And they said, you know, I got these scores, I don’t know what they mean. And the number of times I said, hold on, let’s just look at these together. And I look at the old reports with families together and explain what was found before and use that when I use that data when I talk about their current results. I think one other piece too is that there’s going to be tables, scores, a lot of technical details, what we want parents to take away is that the report is not like a list of deficits. It’s more like a narrative explaining how their child’s brain works and how we can best support them.

Cindy Lopez: Yeah. And I think that that’s an important thing to note, Joaquin, what you just said, it’s not intended to be a list of deficits. It’s intended to be kind of a roadmap to help you understand your child and understand what kinds of experiences and interventions, are going to be most helpful to your child especially as they go through school. You know, school takes up so much of their lives and how can they navigate that in a really beneficial way that works for them?

So, I think that along those lines, one thing that can sometimes surprise parents and caregivers is how much a neuropsych eval can reveal beyond academics, like emotional regulation, executive functioning, social cognition, there’s a host of things. Can you maybe share an example of when an evaluation uncovered something that was unexpected?

Joaquin Burciaga, PhD: Yeah, you know, one of the interesting things, as you said, Cindy, is that the evaluations can find so many different areas of strength and challenge. I think one of the common referrals that we have are around ADHD where parents are saying, you know, my child just can’t seem to focus in class and they’ve been really struggling for years. And doing a comprehensive evaluation, part of the evaluation also includes emotional functioning, so questionnaires, an interview with a child. And after completing the evaluation with this child, I actually found they had fantastic executive functioning. Their ability to sustain their attention was actually quite strong, but they were just incredibly anxious and they spent so much time ruminating about social status or you know, what their friends were thinking about them. But then also the amount of work that they had to do that the diagnosis was actually a diagnosis of a generalized anxiety disorder and not ADHD. And then sitting down with parents to talk about the results and how there is an overlap in how a child with ADHD and generalized anxiety, the symptoms can overlap, but how they’re different and helping parents understand them. It almost felt like a light bulb for them, but then they also started to feel a little bit of guilt about not being able to recognize or acknowledge the anxiety that was present. And so part of our work too is normalizing the experience where, you know, we can’t know everything because there is so much of an overlap and helping parents not be so hard on themselves. Whitney, do you have an example?

Whitney Geller, PhD: Yeah. So, one of my younger pediatric cases, he was roughly eight or nine years old. And it was actually a case for another clinician here where it had been kind of one of those standard psychoeducational evaluations with some concern for ADHD, but after they had met with the kid, they were really concerned, like socially what was going on with this kid because they almost kind of had an autism type feel where they just weren’t super socially responsive, maybe would get asked a question and would kind of just like sit there; almost that like, kind of non-responsiveness. And so they pulled me onto the case to do a specific autism assessment. So, they did really comprehensive, like cognitive, academic, intellectual assessment. And then I came in for the autism piece and did comprehensive autism workup. But, nothing about it really felt like there was a social deficit. The kid actually was very like socially responsive, but there was kind of this oddness to how they would respond. And so I did some more extensive like language testing, and it turned out this pour little guy, he could not process or understand what was being said to him. And then he was having like a lot of word finding difficulties, being able to form sentences. And it actually turned out to be a language disorder. And so, the treatment for ADHD is going to be very different than the treatment for a language disorder, right? And so then we were able to kind of pinpoint like, okay, so this isn’t autism, it’s not ADHD, it’s actually a language disorder. And we need to really target like some speech therapy with this kid. So, that was one of my younger pediatric cases.

Joaquin Burciaga, PhD: What you just said, you know, it goes back to one of the first things we were talking about, identification. What’s actually the problem? And for that kiddo, I’m sure the narrative changed from, won’t pay attention or can’t pay attention to this child needs language support and it just completely shifts the way that the child is perceived.

Whitney Geller, PhD: Absolutely. Absolutely. And I think that it also changes how people interact with the child. Like, if the issue is that you can’t pay attention, the way that we structure treatment is going to look very different than if the issue is you don’t understand what’s being said to you.

Cindy Lopez: It’s so interesting hearing you talk about these cases that you had and some of the things that came out of it. And Joaquin, what you noted, I think is just so important because the perception might have been attention, but it was really a language thing. And so, obviously it’s about how you treat that, but it’s also people’s perceptions of that.

Being an educator and having kids in my class, knowing that it’s not attentional, it totally would change how I interact with that student and how some of the accommodations I had put in place for that child. So, I think that’s really important. You think one thing going into it and you learn something else coming out of it. And speaking of that, how does having this neuropsych roadmap kind of change a child’s trajectory, we just talked about a little bit, is there anything that you might want to add?

Joaquin Burciaga, PhD: Yeah. Well, you know, one of the things that I’ve heard over the years from families who act on recommendations, they often report less stress or reduced stress, the child’s functioning is improving, and a better alignment between their expectations of their child and the support that the child is receiving. And the child or adolescent also feels more understood and the interventions can become more targeted and more effective. And as we talked about already a few times, accurate diagnosis matters because it’s much easier to treat something when you actually know what’s going on. And so in the case of Whitney, who often works with younger children and does autism evaluations, early intervention is especially powerful because the earlier we can identify challenges and then start to intervene, the better the long-term outcomes are. And so, you know, it can have a vast impact on the child’s trajectory if we identify autism when they’re three versus when they’re 15. There’s a lot more that can be done and in some cases medications may include specific therapies like for autism it might include something like applied behavioral analysis therapy or ABA therapy, social skill support. It could include medication like stimulant medications for ADHD when they’re clinically indicated, or anxiety medication, depression medication, and when medication is paired with the appropriate supports, outcomes are often significantly improved.

Cindy Lopez: Thank you so much, Whitney and Joaquin for joining us today to talk about neuropsych evaluations. I really appreciate you breaking that down and talking about the neuropsych evaluation, helping our listeners understand it. And how important it is for parents and caregivers. If they think there’s something going on with their child, it’s always worth taking a look at. I can’t tell you how many conversations I’ve had with parents over the years. As an educator saying, well, I think I’m worried about X, Y, Z, but maybe I’m seeing things that aren’t there, and I always tell parents like, you know your child really well and if there’s something that’s kind of niggling at you, it’s worth paying some attention to. So, I would say that to our listeners as well. If there is something going on, it’s always worth paying attention to.

Joaquin Burciaga, PhD: Yeah, even if there’s just kind of a concern that they don’t know what to do with, or if it’s even worth exploring further, CHC does offer free 30 minute consultations where they get to talk with a psychologist or a neuropsychologist and just talk about their concerns. And, you know, our job is not to steer you to an evaluation or to services at CHC. It’s really to make sure that you’re getting what you need, whether it’s with us or elsewhere. And so I’ve had conversations with parents where they come in with concerns and I actually tell them, you know, you should consider pursuing an evaluation through the school district or consider some other type of recommendation that didn’t always include an evaluation at CHC. And sometimes some of the concerns that parents have are just typical child behavior that don’t warrant an evaluation.

Cindy Lopez: Yeah. So, if you are interested in parent coaching or an evaluation or even therapy for your child, whatever treatment, speech and language or occupational therapy. We have all of those services at CHC and we’d be happy to help you, and I will share that contact information as we close. Whitney and Joaquin, as we wrap it up today, I’m wondering what is one thing you really hope that our listeners hear from you today?

Joaquin Burciaga, PhD: You know, one thing that I hope the parents hear is that a neuropsychological evaluation is not about labeling a child. It’s about understanding them and providing families with that roadmap that helps them move from confusion and frustration to clarity and some focus and direction. And my hope is that once they leave from CHC, that understanding can be life changing for them and their child. It can have some positive lasting impacts.

Whitney Geller, PhD: The evaluations you do are absolutely life changing. I second what Joaquin said as well. I think that it’s helpful. I think the most helpful thing is being able to figure out what’s going on and then making a plan from there and getting some professional guidance.

Cindy Lopez: If you need help, CHC is here for you. As we’ve mentioned, parent coaching, we have free resources. We have things like free parent support groups and an online resource library. And this podcast, you can go back and find other episodes of this podcast that might really be important for you at where you are right now in this stage with your child. And if you want to connect with us, you can email our care team at [email protected]. You can also call us at 650-688-3625. Thank you so much, Joaquin and Whitney for joining us today and to our listeners.

Joaquin Burciaga, PhD: Absolutely.

Whitney Geller, PhD: Thanks, Cindy.

Cindy Lopez: Visit us online at podcasts.chconline.org. Make sure to subscribe to Voices of Compassion so you never miss an episode, and we’d love it if you’d leave us a rating and review. Have a question? Send us an email or a voice memo at [email protected]. We’re here for you when you need us.