Home-Based Pediatric Teleneuropsychology: A validation study

[Formula: see text] Neuropsychological assessment in rare pediatric neurogenetic disorders: considerations for cross-cultural clinical research

Neuropsychological assessment in rare neurodevelopmental disorders has provided clinicians and researchers with a more comprehensive view of natural history as well as opportunities for additional endpoints in treatment trials. While challenges to protocol development have been addressed in the literature, cultural considerations have been overly broad resulting in limited utility when including mixed international samples. Using experiences over the past five years with the development of ten different protocols for neurogenetic rare diseases, this paper presents further considerations for protocol development that are culturally sensitive to international samples. Recommendations are offered across areas including participants from multiple countries; cognitive, sensory and motor impairments; psychometrics; and assessment logistics. A neuropsychological assessment selection checklist that guides researchers and clinicians through considerations and a standard operating procedure that provides guidance on thinking through the assessment process are offered.

Development of a self-administered online battery for remote assessment of executive functions and verbal memory: equivalence with face-to-face administration, preliminary norms, and acceptance

OBJECTIVES

Interest in teleneuropsychology services increased considerably after the COVID-19 pandemic. However, the utility of unsupervised administration of computerized tests remains largely unexplored. In the present study, we developed a brief computerized battery that assesses self-reported cognitive abilities and performances on executive functioning and verbal memory. We investigated the equivalence of the self-administration online (SAO) procedure and the face-to-face (FTF) administration. Preliminary normative data were developed and the acceptance of the SAO procedure was explored.

METHODS

A community sample of 169 Greek adults [94 women; mean age: 41.95 (SD = 13.40) years, mean years of education: 15.10 (SD = 2.65)] completed the SAO assessment. A subgroup of 40 participants was tested in a counterbalanced way both with SAO and FTF. Participants' performances were compared with paired sample t-tests and the agreement between the two methods was estimated with intraclass correlation coefficients (ICCs). Multiple linear regression analyses were applied to investigate the effect of demographic characteristics on SAO measures.

RESULTS

No difference between SAO and FTF scores was observed. ICCs indicated moderate to good agreement (.418-.848) for most measures. Age was positively associated with self-reported cognitive state and negatively with neuropsychological performances and the level of acceptance of the SAO procedure. Approximately 80% of participants reported satisfaction from the SAO assessment, 69% good compliance with the instructions, but less than 30% belief that the FTF assessment could be adequately replaced.

CONCLUSION

SAO testing is feasible and well accepted among Greek adults yielding equivalent results with FTF testing. Despite the wide satisfaction, though, notable reluctance was noted for the substitution of FTF with SAO procedures.

Chronotype, Time of Day, and Children's Cognitive Performance in Remote Neuropsychological Assessment

Research on the influence of chronotype and time of day (TOD) on cognitive performance, especially in children, is limited. We explored potential interactive effects, hypothesizing that performance differs when comparing preferred vs. non-preferred TOD. In total, 76 morning-type (MT = 37) or evening-type (ET = 39) children from the third and fourth grades (48.7% girls; M age = 8.05; SD age = 0.51), identified through the Children Chronotype Questionnaire, completed two 30-min neuropsychological assessment sessions via videoconference on the first (9:00) or last hour (16:00) of the school day. The protocol included neuropsychological tests targeting memory, language, and attention/executive domains. The results revealed an interactive effect of medium size between chronotype and TOD on a Rapid Alternating Stimulus (Naming) Task. MT and ET performed faster in asynchrony conditions (morning for ET; afternoon for MT). Additionally, ET outperformed MT in a Backward Digit Span Task, irrespective of TOD. TOD also influenced performance on an Alternating Verbal Fluency Task, with both MT and ET children performing better in the morning. These results underscore the importance of chronotype and TOD in children's cognitive performance, particularly in working memory and verbal fluency. Children assessed during non-preferred TOD exhibited better performance on some cognitive tasks, challenging the assumption that optimal times always yield superior results.

Remote assessment of the Penn computerised neurocognitive battery in individuals with 22q11.2 deletion syndrome

BACKGROUND

Neurocognitive functioning is an integral phenotype of 22q11.2 deletion syndrome relating to severity of psychopathology and outcomes. A neurocognitive battery that could be administered remotely to assess multiple cognitive domains would be especially beneficial to research on rare genetic variants, where in-person assessment can be unavailable or burdensome. The current study compares in-person and remote assessments of the Penn computerised neurocognitive battery (CNB).

METHODS

Participants (mean age = 17.82, SD = 6.94 years; 48% female) completed the CNB either in-person at a laboratory (n = 222) or remotely (n = 162).

RESULTS

Results show that accuracy of CNB performance was equivalent across the two testing locations, while slight differences in speed were detected in 3 of the 11 tasks.

CONCLUSIONS

These findings suggest that the CNB can be used in remote settings to assess multiple neurocognitive domains.

Diagnostic certainty during in-person and telehealth autism evaluations

Background

Many diagnostic evaluations abruptly shifted to telehealth during the COVID-19 pandemic; however, little is known about the impact on diagnosis patterns for children evaluated for autism spectrum disorder (ASD). The purpose of this clinical research study was to examine (1) the frequency of diagnoses evaluated beyond ASD; (2) the frequency of diagnoses made, including ASD; and (3) clinician diagnostic certainty for all diagnoses evaluated for children who received an evaluation due to primary concerns about ASD via telehealth during the pandemic compared to those evaluated in person before the pandemic at an ASD specialty clinic.

Methods

The sample included 2192 children, 1-17 years (M = 6.5 years; SD = 3.9), evaluated by a physician/psychologist at an ASD specialty center. A total of 649 children were evaluated in-person September 1, 2019-March 13, 2020 (pre-pandemic) and 1543 were evaluated via telehealth March 14, 2020-July 26, 2021 (during pandemic). Upon completion of each evaluation, clinicians provided a final diagnostic determination (i.e., "Yes," "No," "Possible," or "Not Assessed") for the following DSM-5 conditions: ASD, attention-deficit/hyperactivity disorder (ADHD), intellectual developmental disorder (IDD), anxiety (ANX), depression (DEP), and behavioral disorder (BD). "Possible" indicated lower certainty and the diagnosis was not provided. "Not Assessed" indicated the disorder was not evaluated.

Results

Diagnostic certainty for ASD and ADHD was lower and clinicians evaluated for and made diagnoses of IDD less often during evaluations that occurred via telehealth during the pandemic versus in person before the pandemic. DEP and BD were diagnosed more frequently, diagnostic certainty of DEP was lower, and no differences in the frequency of ANX diagnoses emerged during evaluations conducted via telehealth during the pandemic compared to those conducted in person before the pandemic.

Conclusions

Differences emerged in the frequency of diagnoses evaluated and made and diagnostic certainty for evaluations conducted via telehealth during the pandemic compared to in person before the pandemic, which likely impacted patients and reflect real-word challenges. Future work should examine whether these patterns are generalizable and the mechanisms that contribute to these differences.

Tele-Neuropsychology: From Science to Policy to Practice

OBJECTIVE

The primary aim of this paper is to accelerate the number of randomized experimental studies of the reliability and validity in-home tele-neuropsychological testing (tele-np-t).

METHOD

We conducted a critical review of the tele-neuropsychology literature. We discuss this research in the context of the United States' public and private healthcare payer systems, including the Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CPT) coding system's telehealth lists, and existing disparities in healthcare access.

RESULTS

The number of tele-np publications has been stagnant since the onset of the COVID-19 pandemic. There are less published experimental studies of tele-neuropsychology (tele-np), and particularly in-home tele-np-t, than other tele-np publications. There is strong foundational evidence of the acceptability, feasibility, and reliability of tele-np-t, but relatively few studies of the reliability and validity of in-home tele-np-t using randomization methodology.

CONCLUSIONS

More studies of the reliability and validity of in-home tele-np-t using randomization methodology are necessary to support inclusion of tele-np-t codes on the CMS and CPT telehealth lists, and subsequently, the integration and delivery of in-home tele-np-t services across providers and institutions. These actions are needed to maintain equitable reimbursement of in-home tele-np-t services and address the widespread disparities in healthcare access.

Cognitive pediatric tele-assessment: a scoping review

Cognitive tele-assessment (CTA) adoption has increased considerably recently, in parallel with the maturation of the digital technologies that enable it, and the push to move assessment to the online format during the COVID-19 pandemic in 2019. This mode of assessment stems from remote assessment applications that originated in general tele-medicine, where it was typically used for patient screening as part of an intervention. The development of remote tele-medicine was later adapted for CTA in adult populations in tele-neuropsychiatry and tele-psychology and is increasingly applied in experimental research in cognitive science research with adult and pediatric populations, and for remote academic assessment. Compared to in-person assessment, CTA offers advantages such as decreasing time and logistic costs and facilitating the assessment of remote or special needs populations. However, given the novelty of CTA, its technical, methodological, and ethical issues remain poorly understood, especially in cases where methods for assessment of adults are used in pediatric populations. In the current paper, we provide a scoping review on the evolution of remote tele-assessment from the years 2000 to 2021, to identify its main themes, methodologies, and applications, and then focus on the issues of assessment in pediatric populations. Finally, we present recommendations on how to address the challenges previously mentioned.

Social cognition and behavioral outcomes in congenital heart disease: profiles and neuropsychiatric comorbidities

Autism spectrum disorders are more prevalent in children with congenital heart disease (CHD) than in the general population. Children with CHD without diagnosed autism are also at increased risk for neurodevelopmental and psychiatric impairments. We characterized social and behavioral outcomes in children with CHD and examined neurodevelopmental and psychiatric comorbidities. Children without diagnosed autism who underwent infant open-heart surgery were eligible. Parent-reports assessed social communication, unusual behaviors, self-regulation, anxiety, and executive function (EF). Neuropsychological tests assessing theory of mind (ToM), working memory, and verbal comprehension were administered. Outcomes were compared to normative data. Linear regressions were estimated with parent-reported scores and ToM abilities as outcomes. Predictors were anxiety symptoms, parent-reported EF, and working memory scores. Covariates were age, parental education, ADHD diagnosis, and verbal comprehension. Clinically relevant comorbidities were identified (N children scoring ≥1SD below the norm). Fifty-six children (10.8 ± 1.8 years) participated virtually. Compared to norms, children with CHD had impaired ToM, more unusual behaviors (p = .002), and less self-regulation (p = .018), but better social communication (p = .014). "Autism-like" traits were positively associated with anxiety symptoms (ß(95% CI) = 0.28(0.08-0.49), p = .008) and worse working memory (ß(95% CI) = -0.36(-0.59-0.13), p = .003). Twenty-one out of 22 children who displayed clinically relevant social and behavioral scores also showed anxiety symptoms (n = 4), impaired EF (n = 7), or both (n = 10). Children with CHD without diagnosed autism have elevated unusual behaviors, lower self-regulation, and impaired ToM. There is a high risk of co-existing anxiety and impaired EF which may increase disease burden. Targeted therapeutic interventions are needed to reduce long-term psychosocial risks in these children.AbbreviationAttention deficit/hyperactivity disorder (ADHD), Autism Spectrum Rating Scale (ASRS), Behavior Rating Inventory of Executive Functions for school-aged children, 2nd Edition (BRIEF-2), cardiopulmonary bypass (CPB), congenital heart disease (CHD), Empathy/Systematizing Quotient Child Version (ESQ-C), Multidimensional Anxiety Scale for Children, 2nd Edition (MASC-2), Social Responsiveness Scale (School-age form), 2nd Edition (SRS-2), theory of mind (ToM), Theory of Mind Task Battery (ToM-TB), Wechsler Intelligence Scale for Children, 5th edition (WISC-V).

Clinical utility of teleneuropsychology among pediatric patients with broadly average and low intellectual functioning

The reliability of teleneuropsychology (teleNP) within pediatric populations, particularly those with low intellectual functioning (LIF; i.e., Intellectual Quotient <80), is largely unknown. This repeated-measures study compared performance on WISC-V and WAIS-IV subtests administered in-person before the COVID-19 pandemic and via teleNP during the pandemic in individuals with LIF versus broadly average (BA) intellectual functioning in a clinically referred pediatric cohort. Data were collected from a retrospective chart review of 35 pediatric patients who underwent in-person neuropsychological evaluation at an academic medical center before the pandemic (Mage = 10.10 years, SD = 2.93) and videoconference teleNP assessment during the pandemic (Mage = 13.47 years, SD = 2.88). Participants completed the Similarities, Matrix Reasoning, and Digit Span subtests from the WISC-V or WAIS-IV at both time points. After controlling for test-retest time interval, partial correlations showed relatively strong associations in test-retest performance across subtests in the whole sample and among the subset of LIF patients. Distribution of significant reliable change indices (RCI) between the LIF and BA groups were similar. Strong correlations were observed between performances on select Wechsler subtests administered in-person and via teleNP. Results lend initial support toward the utility of teleNP administration of these measures in children with a broad range of intellectual functioning.

Tele-neuropsychological Assessment of Children and Young People: A Systematic Review

The coronavirus pandemic identified a clinical need for pediatric tele-neuropsychology (TeleNP) assessment. However, due to limited research, clinicians have had little information to develop, adapt, or select reliable pediatric assessments for TeleNP. This preliminary systematic review aimed to examine the feasibility of pediatric TeleNP assessment alongside (1) patient/family acceptability, (2) reliability, and (3) the quality of the literature. Between May 2021 and November 2022, manual searches of PubMed, PsycINFO, and Google Scholar were conducted using terms related to "pediatric" and "tele-neuropsychology." After extracting relevant papers with samples aged 0-22 years, predefined exclusion criteria were applied. Quality assessment was completed using the AXIS appraisal tool (91% rater-agreement). Twenty-one studies were included in the review, with reported qualitative and quantitative data on the feasibility, reliability, and acceptability extracted. Across included studies, TeleNP was completed via telephone/video conference with participants either at home, in a local setting accompanied by an assistant, or in a different room but in the same building as the assessor. Pediatric TeleNP was generally reported to be feasible (e.g., minimal behavioral differences) and acceptable (e.g., positive feedback). Nineteen studies conducted some statistical analyses to assess reliability. Most observed no significant difference between in-person and TeleNP for most cognitive domains (i.e., IQ), with a minority finding variable reliability for some tests (e.g., attention, speech, visuo-spatial). Limited reporting of sex-assigned birth, racialized identity, and ethnicity reduced the quality and generalizability of the literature. To aid clinical interpretations, studies should assess underexamined cognitive domains (e.g., processing speed) with larger, more inclusive samples.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40817-023-00144-6.

The Evolving Need for Neuropsychology in Neurosurgical Settings: Challenges Facing Transformative Care

Clinical neuropsychology has been a valuable asset to neurologic surgery, contributing to lateralization and localization of pathologic brain tissue, identification of eloquent cortex, and evaluation of postoperative neuropsychological functioning. Moreover, neuropsychologists provide empirically driven interventions aimed at supporting preparation and/or recovery of neurosurgery patients. Nonetheless, several challenges may limit the reliability, validity, and generalizability of the assessment data obtained and reduce the usefulness of other neuropsychological services provided. Specifically, linguistic, cultural, educational, and other biases associated with demographic characteristics can lead to a narrowed view of an individual's life experiences, which must be confronted to fulfill the mission of ensuring that all patients have access to care that is appropriate to their needs. Instead of perceiving these challenges as insurmountable barriers, such issues can be viewed as opportunities to catalyze change and foster innovation for the future of neuropsychological care in neurosurgical settings. In addition to reviewing the possible mechanisms of these obstacles, the current article offers tangible solutions at both a macro level (e.g., discipline-wide transformations) and micro level (e.g., individualized patient-centric approaches). Outlined are practical techniques to potentially improve consensus and standardization of methods, advance and globalize research, expand representativeness of measures and practices to serve diverse individuals, and increase treatment adherence through engagement of patients and their families.

Remote neuropsychological assessment: Acceptability and feasibility of direct-to-home teleneuropsychology methodology during the COVID-19 pandemic

OBJECTIVE

To determine the acceptability and feasibility of telephone and video-conference calls to complete cognitive assessments during the COVID-19 pandemic.

METHOD

In rapid response to the pandemic, evidence-based adaptations were made to routine face-to-face (FTF) practice, delivering teleneuropsychology (TNP) within a National Health Service (NHS) Scotland neuropsychology service. Caldicott guardian approval was obtained to complete a six month study (April to October 2020) from the early stages of the first United Kingdom (UK) lockdown. Assessments were completed with patients in their own homes (direct-to-home) via remote connections. Neuropsychology clinicians, service-users and referring agents were approached for structured feedback and qualitative comment.

RESULTS

Data was captured for 212 referrals assessed by seven clinical psychologists; with responses from 70 (33%) service-users and 14 (58%) referring agents. 94% of referrals were assessed remotely and discharged. TNP reduced defaulted appointment discharge rates. Gender, socioeconomic deprivation and age did not affect access to information technology (IT) equipment.Clinicians agreed that remote assessment allowed them to complete initial interview (96%) and formulate (77%) cases appropriately. Service-users agreed they were comfortable with equipment (84%), the process was straightforward (74%), and would recommend TNP to others (68%). Referring agents were satisfied with the service provided (100%). Limitations included evidence-based remote test availability, technical issues and home distractions.

CONCLUSIONS

Study findings evidence the acceptability and efficiency of TNP; increasing service accessibility, while reducing infection risk, defaulted appointments and travel. The results advocate for a post-pandemic mixed model of service delivery encompassing both FTF and TNP approaches.

Telehealth services for cardiac neurodevelopmental care during the COVID-19 pandemic: a site survey from the Cardiac Neurodevelopmental Outcome Collaborative

OBJECTIVE

COVID-19 has markedly impacted the provision of neurodevelopmental care. In response, the Cardiac Neurodevelopmental Outcome Collaborative established a Task Force to assess the telehealth practices of cardiac neurodevelopmental programmes during COVID-19, including adaptation of services, test protocols and interventions, and perceived obstacles, disparities, successes, and training needs.

STUDY DESIGN

A 47-item online survey was sent to 42 Cardiac Neurodevelopmental Outcome Collaborative member sites across North America within a 3-week timeframe (22 July to 11 August 2020) to collect cross-sectional data on practices.

RESULTS

Of the 30 participating sites (71.4% response rate), all were providing at least some clinical services at the time of the survey and 24 sites (80%) reported using telehealth. All but one of these sites were offering new telehealth services in response to COVID-19, with the most striking change being the capacity to offer new intervention services for children and their caregivers. Only a third of sites were able to carry out standardised, performance-based, neurodevelopmental testing with children and adolescents using telehealth, and none had completed comparable testing with infants and toddlers. Barriers associated with language, child ability, and access to technology were identified as contributing to disparities in telehealth access.

CONCLUSIONS

Telehealth has enabled continuation of at least some cardiac neurodevelopmental services during COVID-19, despite the challenges experienced by providers, children, families, and health systems. The Cardiac Neurodevelopmental Outcome Collaborative provides a unique platform for sharing challenges and successes across sites, as we continue to shape an evidence-based, efficient, and consistent approach to the care of individuals with CHD.

Concurrent validity and reliability of at-home teleneuropsychological evaluations among people with and without HIV

OBJECTIVE

To determine the reliability of teleneuropsychological (TNP) compared to in-person assessments (IPA) in people with HIV (PWH) and without HIV (HIV-).

METHODS

Participants included 80 PWH (Mage = 58.7, SDage = 11.0) and 23 HIV- (Mage = 61.9, SDage = 16.7). Participants completed two comprehensive neuropsychological IPA before one TNP during the COVID-19 pandemic (March-December 2020). The neuropsychological tests included: Hopkins Verbal Learning Test-Revised (HVLT-R Total and Delayed Recall), Controlled Oral Word Association Test (COWAT; FAS-English or PMR-Spanish), Animal Fluency, Action (Verb) Fluency, Wechsler Adult Intelligence Scale 3rd Edition (WAIS-III) Symbol Search and Letter Number Sequencing, Stroop Color and Word Test, Paced Auditory Serial Addition Test (Channel 1), and Boston Naming Test. Total raw scores and sub-scores were used in analyses. In the total sample and by HIV status, test-retest reliability and performance-level differences were evaluated between the two consecutive IPA (i.e., IPA1 and IPA2), and mean in-person scores (IPA-M), and TNP.

RESULTS

There were statistically significant test-retest correlations between IPA1 and IPA2 (r or ρ = .603-.883, ps < .001), and between IPA-M and TNP (r or ρ = .622-.958, ps < .001). In the total sample, significantly lower test-retest scores were found between IPA-M and TNP on the COWAT (PMR), Stroop Color and Word Test, WAIS-III Letter Number Sequencing, and HVLT-R Total Recall (ps < .05). Results were similar in PWH only.

CONCLUSIONS

This study demonstrates reliability of TNP in PWH and HIV-. TNP assessments are a promising way to improve access to traditional neuropsychological services and maintain ongoing clinical research studies during the COVID-19 pandemic.

Innovations in Neuropsychology: Future Applications in Neurosurgical Patient Care

Over the last century, collaboration between clinical neuropsychologists and neurosurgeons has advanced the state of the science in both disciplines. These advances have provided the field of neuropsychology with many opportunities for innovation in the care of patients prior to, during, and following neurosurgical intervention. Beyond giving a general overview of how present-day advances in technology are being applied in the practice of neuropsychology within a neurological surgery department, this article outlines new developments that are currently unfolding. Improvements in remote platform, computer interface, "real-time" analytics, mobile devices, and immersive virtual reality have the capacity to increase the customization, precision, and accessibility of neuropsychological services. In doing so, such innovations have the potential to improve outcomes and ameliorate health care disparities.

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

OBJECTIVE

This study examined test score equivalency between traditional in-person assessment and teletesting among youth diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD).

METHOD

In all, 896 youth with ADHD, ages 5-21 years, were administered cognitive, academic achievement, and verbal fluency measures via either teletesting (n = 448) or traditional in-person assessment (n = 448). The teletesting and in-person groups were matched on age, sex, and insurance type (as a proxy for income).

RESULTS

Results indicated no significant differences in test scores obtained via in-person and teletesting evaluations across all examined measures.

CONCLUSION

Clinically referred youth with ADHD perform similarly on measures of cognitive functioning, academic achievement, and verbal fluency, regardless of whether these measures are administered in-person or via teletesting. While additional evidence for equivalent psychometric properties of neuropsychological instruments administered remotely is needed, this study offers support for the validity of remote administration among youth with ADHD.

A Systematic Review and a Latin American Clinical Model for Teleneuropsychological Assessment

OBJECTIVE

The objective of this study is to propose a TeleNP model for remote assessment and offer practical recommendations for clinical practice with patients in Mexico and Latin America, based on a systematic literature review and clinical experience.

METHOD

A systematic review of studies from 2011 to 2021 in English and Spanish used TeleNP, teleneuropsychology, telepsychology, online, assessment, teleneuropsicología, and evaluación for the search; the databases examined included PubMed, BiDi UNAM, ScienceDirect, Google Scholar, and Wiley One Library; the Oxford Centre for Evidence-Based Medicine system was used to grade the levels of evidence. The experience of the last two years of students and faculty in the Master's and Doctoral Programs in Psychology, Clinical Neuropsychology Residency Program, was also used as a basis for this guide.

RESULTS

We propose a clinical model for TeleNP assessment in Mexico and Latin America based on the review of 31 articles and the practice of professors and students of clinical neuropsychology.

CONCLUSION

The proposed model describes a procedure and adaptations for home-to-home clinical practice in the neuropsychological assessment of Mexican patients that could also be used in other Latin American countries. Its reliability remains to be assessed, but this model and the suggestions proposed could be used in future studies and clinical trials for Mexican and Latin American populations.

Equivalency of In-Person Versus Remote Assessment: WISC-V and KTEA-3 Performance in Clinically Referred Children and Adolescents

OBJECTIVE

Teletesting has the potential to reduce numerous barriers to patient care which have only become exacerbated during the COVID-19 pandemic. Although telehealth is commonly utilized throughout medicine and mental health practices, teletesting has remained limited within cognitive and academic evaluations. This may be largely due to concern for the validity of test administration via remote assessment. This cross-sectional study examined the equivalency of cognitive [Wechsler Intelligence Scales for Children - Fifth Edition (WISC-V)] and academic [Kaufman Test of Educational Achievement - Third Edition (KTEA-3)] subtests administered via either teletesting or traditional in-person testing within clinically referred youth.

METHOD

Chart review using a retrospective, cross-sectional design included a total of 893 children and adolescents, ranging from 4 to 17 years (Mean age = 10.2 years, SD = 2.9 years) who were administered at least one subtest from the aforementioned cognitive or academic assessments. Of these, 285 received teletesting, with the remaining (n = 608) receiving in-person assessment. A total of seven subtests (five from the WISC-V and two from the KTEA-3) were examined. A series of inverse probability of exposure weighted (IPEW) linear regression models examined differences between groups for each of the seven subtests after adjustment for numerous demographic, diagnostic, and parent-reported symptom variables.

RESULTS

Only two significant differences were found, such that WISC-V Visual Puzzles (p < .01) and KTEA-3 Math Concepts (p = .03) scores were slightly higher in the teletesting versus in-person groups. However, these differences were quite small in magnitude (WISC-V Visual Puzzles, d = .33, KTEA-3 Math Concepts, d = .18).

CONCLUSIONS

Findings indicate equivalency across methods of service delivery without clinically meaningful differences in scores among referred pediatric patients.

Executive Functions and Rapid Automatized Naming: A New Tele-Rehabilitation Approach in Children with Language and Learning Disorders

Executive function deficits are documented in many neurodevelopmental disorders and may contribute to clinical complexity or rehabilitation resilience. The present research was primarily aimed at presenting and evaluating the feasibility and effectiveness of a telerehabilitation program used during the pandemic period. MemoRAN (Anastasis), a computerised cognitive training to improve executive control during visual-verbal integration tasks was used in a sample of 42 children (5–11 years old) with specific learning or language disorders. The MemoRAN training was based on exercises of inhibition, cognitive flexibility and updating in working memory for three months, with a frequency of approximately three sessions per week. Afterwards, a comparison between a subgroup of children using Memo-RAN and an active control group, using a tele-rehabilitation program directed on reading was conducted. Effect size analysis in pre-post measurements suggests an average effect of MemoRAN in measurements that require control processes, such as accuracy in dictation, reading, inhibition and working memory testing. Comparison with the active control group and the clinical utility implications of these types of treatment will be discussed.

Neuropsychological intervention in attention and visuospatial skills in two patients with Williams syndrome with different types of genetic deletion

Williams Syndrome (WS) is a neurodevelopmental disorder with a distinctive physical, cognitive, and behavioral profile caused by a microdeletion in the q11.23 region of chromosome 7. The neuropsychological profile of WS is characterized by intellectual disability, hypersociability, and deficits, especially in attention and visuospatial skills. Our objective was to assess the effectiveness of a neuropsychological intervention program in attention and visuospatial skills in two patients with WS (aged 7 and 13 years old) with different types of deletion (1.5 and 1.8 Mb). Cognitive, behavioral, and adaptive abilities were evaluated through various neuropsychological tests and scales; the neuropsychological intervention program was subsequently applied, and we assessed its effectiveness. Both patients initially presented significant deficits in attention and visuospatial skills. After the program, we found improvements in attention and visuospatial skills. In addition, both patients had significant clinical advances and changes in adaptive behaviors (social and self-care). These findings suggest that this intervention program could improve attention processes, visuospatial skills, and some aspects of adaptive behavior in patients with WS, regardless of deletion size. Although the sample was small, limiting the generalizability of the results, we believe this program could be a helpful resource for professionals working with individuals with WS.

Continuing Care For Critically Ill Children Beyond Hospital Discharge: Current State of Follow-up

OBJECTIVES

Survivors of the PICU face long-term morbidities across health domains. In this study, we detail active PICU follow-up programs (PFUPs) and identify perceptions and barriers about development and maintenance of PFUPs.

METHODS

A web link to an adaptive survey was distributed through organizational listservs. Descriptive statistics characterized the sample and details of existing PFUPs. Likert responses regarding benefits and barriers were summarized.

RESULTS

One hundred eleven respondents represented 60 institutions located in the United States (n = 55), Canada (n = 3), Australia (n = 1), and the United Kingdom (n = 1). Details for 17 active programs were provided. Five programs included broad PICU populations, while the majority were neurocritical care (53%) focused. Despite strong agreement on the need to assess and treat morbidity across multiple health domains, 29% were physician only programs, and considerable variation existed in services provided by programs across settings. More than 80% of all respondents agreed PFUPs provide direct benefits and are essential to advancing knowledge on long-term PICU outcomes. Respondents identified "lack of support" as the most important barrier, particularly funding for providers and staff, and lack of clinical space, though successful programs overcome this challenge using a variety of funding resources.

CONCLUSIONS

Few systematic multidisciplinary PFUPs exist despite strong agreement about importance of this care and direct benefit to patients and families. We recommend stakeholders use our description of successful programs as a framework to develop multidisciplinary models to elevate continuity across inpatient and outpatient settings, improve patient care, and foster collaboration to advance knowledge.

Integrating Telehealth Into Neurodevelopmental Assessment: A Model From the Cardiac Neurodevelopmental Outcome Collaborative

Objective

In the wake of the COVID-19 pandemic, psychologists were pushed to look beyond traditional in-person models of neurodevelopmental assessment to maintain continuity of care. A wealth of data demonstrates that telehealth is efficacious for pediatric behavioral intervention; however, best practices for incorporating telehealth into neurodevelopmental assessment are yet to be developed. In this topical review, we propose a conceptual model to demonstrate how telehealth can be incorporated into various components of neurodevelopmental assessment.

Methods

Harnessing existing literature and expertise from a multidisciplinary task force comprised of clinicians, researchers, and patient/parent representatives from the subspecialty of cardiac neurodevelopmental care, a conceptual framework for telehealth neurodevelopmental assessment was developed. Considerations for health equity and access to care are discussed, as well as general guidelines for clinical implementation and gaps in existing literature.

Results

There are opportunities to integrate telehealth within each stage of neurodevelopmental assessment, from intake to testing, through to follow-up care. Further research is needed to determine whether telehealth mitigates or exacerbates disparities in access to care for vulnerable populations as well as to provide evidence of validity for a wider range of neurodevelopmental measures to be administered via telehealth.

Conclusions

While many practices are returning to traditional, face-to-face neurodevelopmental assessment services, psychologists have a unique opportunity to harness the momentum for telehealth care initiated during the pandemic to optimize the use of clinical resources, broaden service delivery, and increase access to care for pediatric neurodevelopmental assessment.

Feasibility and Acceptance of Direct-to-Home Tele-neuropsychology Services during the COVID-19 Pandemic

OBJECTIVE

Neuropsychological assessment via video conferencing has been proposed during the COVID-19 pandemic. Existing literature has demonstrated feasibility and acceptance of neuropsychological measures administered by videoconference, although few studies have examined feasibility and patient acceptance of TNP visits directly to patients' homes (DTH-TNP).

METHODS

We modified a previously published patient satisfaction survey for DTH-TNP and developed a clinician feasibility survey to examine experiences during DTH-TNP.

RESULTS

Seventy-two patients (age range: preschool-geriatric) evaluated by DTH-TNP for cognitive problems at an academic medical center responded to voluntary surveys between April 20, 2020, and August 19, 2020, and 100% indicated satisfaction. Fifty-nine percent of patients reported limitations (e.g., technological concern) during the appointment. 134 clinician surveys were collected and indicated that clinicians achieved the goal of their appointment in 90% of encounters.

CONCLUSIONS

These qualitative data suggest that patients and clinicians found DTH-TNP to be satisfactory during the COVID-19 pandemic, while also recognizing limitations of the practice. These results are limited in that voluntary surveys are subject to bias. They support the growing body of literature suggesting that DTH-TNP provides a valuable service, though additional research to establish reliability and validity is needed.

Neuropsychology consultation to identify learning disorders in children and adolescents: a proposal based on lessons learned during the COVID-19 pandemic

Learning disorders are common neurodevelopmental conditions, occurring both idiopathically and in the context of other medical conditions. They are frequently comorbid with other neurodevelopmental and psychiatric conditions. Delayed identification and treatment have been associated with significant negative psychosocial consequences. The need for pediatric neuropsychologists to efficiently screen for learning disorders is likely to increase in the months and years following the COVID-19 pandemic, which has severely disrupted access to educational services, especially for children who also face racial and economic disparities. In this paper, we describe a consultation model that can be used to screen for learning disorders and can be completed using both in-person and telemedicine visits. Implementation may result in earlier intervention for struggling children, increase access to neuropsychological services without increasing wait times for comprehensive evaluations, and provide opportunities for collaborations with other health professionals (e.g., pediatricians, therapists, psychiatrists, and neurologists).

Tele-assessment of cognitive functions in children: a systematic review

Cognitive Tele-Assessment approach (CTA) has been widely used in adults for clinical, research, and screening purposes. In the last decades, it has been considered a useful tool for evaluating child development in both clinical and educational settings and new instruments for CTA in children have been developed. In comparison to In Person Assessment (IPA), CTA can have several advantages, such as increasing accessibility, cutting waiting lists, reducing time and travel costs, and assisting with infection control by minimizing face-to-face contact in times of pandemic. Nevertheless, several issues related to the feasibility and reliability of using CTA to evaluate cognitive development are still open. The present systematic review has a twofold aim: 1. to describe the cognitive functions that are most frequently measured by CTA in children, the procedures used, and the characteristics of the samples investigated; 2. to investigate the agreement between CTA and IPA scores in children.In the present systematic review, 23 studies using CTA in children, with typical or atypical development, have been selected and analyzed. Results support the similarities in performance scores between IPA and CTA and good compliance by children and their families in participating in CTA. Nonetheless, most studies suggest that several methodological precautions must be taken to manage technical and procedural characteristics that may represent challenges for CTA of children. Suggestions for a correct use of CTA, factors affecting the validity of the results and directions for future research are discussed.

Investigating Clinician Experiences of Teleneuropsychology Service Implementation within Rural Inpatient Rehabilitation Settings: A Mixed Method Approach

OBJECTIVE

The aim of this study was to understand clinicians' experiences of teleneuropsychology service implementation within rural inpatient rehabilitation settings and the variability of those experiences across rural settings and clinical disciplines.

METHOD

Clinicians (n = 56 from four rehabilitation settings) who were involved in a hub-and-spoke teleneuropsychology service completed surveys throughout service implementation. A purposive sample of 16 clinicians then completed semi-structured interviews at the conclusion of the service implementation period. Quantitative data were analyzed descriptively and qualitative data were analyzed using thematic analysis, prior to the results being converged.

RESULTS

Four themes characterizing clinicians' experiences were identified. Pre- and early-implementation considerations included factors such as early collaboration and consultation, which were identified as important for service integration into rural settings. Facilitators/barriers included factors such as technology usability, which positively or negatively influenced service implementation. Benefits and outcomes included perceptions on the impact of the service, such as improved equity and quality of care in rural settings. Finally, future applications encapsulated what the clinicians envisaged for the future of teleneuropsychology services, such as hybrid teleneuropsychology/in-person services. Some differences were identified in clinicians' experiences across rural settings and disciplines, including preferences for technology infrastructure and satisfaction with teleneuropsychology sessions.

CONCLUSIONS

Most clinicians reported positive experiences and acceptability of the teleneuropsychology service. Facilitators and barriers, which can guide the successful establishment of future teleneuropsychology services, were identified. These findings may be used to contribute to improving equity and quality of care for people living with neuropsychological impairments, especially those living in rural areas.

Feasibility of administering the WAIS-IV using a home-based telehealth videoconferencing model

Use of telehealth to deliver neuropsychological services has proven to be a feasible approach, however, there is limited research which has examined the reliability of home-based assessment models using a comprehensive intelligence test. The aim of this study was to examine the reliability and feasibility of a home-based videoconferencing administration of the Wechsler Adult Intelligence Scales-4^th Edition (WAIS-IV).

Thirty healthy participants (aged 18-40 years) completed the WAIS-IV both in-person and via home-based videoconferencing utilizing a randomized counter-balanced methodology to attempt to control for an order effect. Paper record forms for Coding/Symbol Search and Blocks were sent and returned via tamper proof courier packs. Participants completed an online survey of their experiences of TNP following completion of their assessments. Group mean comparisons, intra class correlation coefficients (ICCs) and Bland-Altman measures of bias were calculated.

Findings from both modalities were highly concordant across all WAIS-IV subtests and indices, with all ICCs rated as "excellent," (≥0.9). There were no significant mean group differences and no evidence of proportional bias. The majority of participants were very satisfied with the use of videoconferencing as an application for cognitive assessment and high levels of participant compliance were observed.

In this non-clinical cohort home-based videoconference administration of the WAIS-IV was feasible, reliable and acceptable. TNP may offer an alternative for those consumers where there are challenges in accessing a face-to-face service delivery model, thereby improving equity, and enabling continuation of service delivery. Future research is needed with a larger and more ethnically diverse clinical population.

Pediatric mTBI during the COVID-19 pandemic: considerations for evaluation and management

The COVID-19 pandemic has changed healthcare utilization patterns and clinical practice, including pediatric mTBI evaluation and management. Providers treating pediatric mTBI, including neuropsychologists, have a unique role in evaluating and managing an already complex injury in the context of the COVID-19 pandemic with limited empirically based guidelines. In the present paper, we review usual, evidence-based pediatric mTBI care, highlight changes experienced by healthcare providers since the onset of the pandemic, and provide possible considerations and solutions. Three primary challenges to usual care are discussed, including changes to post-injury evaluation, management, and treatment of persistent symptoms. Changing patterns of healthcare utilization have created unique differences in mTBI identification and evaluation, including shifting injury frequency and mechanism, reluctance to seek healthcare, and increasing access to telemedicine. Typical injury management has been compromised by limited access to usual systems/activities (i.e., school, sports, social/leisure activities). Patients may be at higher risk for prolonged recovery due to pre-injury baseline elevations in acute and chronic stressors and reduced access to rehabilitative services targeting persistent symptoms. Considerations and solutions for addressing each of the three challenges are discussed. Neuropsychologists and other pediatric healthcare providers will need to continue to flexibly adapt to the changing needs of youth recovering from mTBI through the duration of the pandemic and beyond. Consistent with pre-pandemic consensus statements, neuropsychologists remain uniquely qualified to evaluate and manage mTBI and provide an increasingly integral role as members of multidisciplinary teams in the context of the global pandemic.Abbreviations: AAP: American Academy of Pediatrics; CDC: Centers for Disease Control and Prevention; COVID-19: coronavirus disease 19; ED: emergency department; mTBI: Mild traumatic brain injury.

The impact of COVID-19 related educational disruption on children and adolescents: An interim data summary and commentary on ten considerations for neuropsychological practice

OBJECTIVE

The coronavirus 19 (COVID-19) pandemic resulted in educational disruption of historic breadth and duration. The authors describe early studies and interim standardized assessment reports to highlight effects of educational disruption and present critical questions for neuropsychologists.

METHOD

A summary of pre-pandemic and interim literature was compiled, including analyses of national and local assessment data and preliminary studies on academic gains related to remote learning, educational and school services disruption, chronic absenteeism, and child and adolescent mental and physical health during 2020-2021. Ten major themes were identified in the early reports on impacts of educational disruption.

RESULTS

Preliminary information indicates prolonged educational disruption has resulted in attenuated learning gains, most remarkably for those already at risk for educational disparities: students of color, students with disabilities, English learners, and students from low-income households. There have also been increased mental and physical health challenges for some youth during the pandemic. Other literature highlights challenges such as diagnosis of learning disabilities, reliance on normative data and development of academic recovery programs.

CONCLUSION

The effects of prolonged educational disruption and psychological stressors on learning and mental health should be considered in the neuropsychological evaluation of children and adolescents, especially marginalized students. Normative data collected prior to the pandemic may be insufficient for interpretation of scores, and evaluation and treatment may be delayed due to backlog and increased demand. Clinical practice considerations are presented.

The development and implementation of teleneuropsychology in an academic lifespan neuropsychology center: Lessons learned from the COVID-19 pandemic

INTRODUCTION

Teleneuropsychology (TNP) became a critical means for providing care during the COVID-19 pandemic and may continue as an option for delivery of neuropsychological services. To understand how patient characteristics impact clinician decisions and service models, this study examines practice patterns within a lifespan outpatient neuropsychology center before, during and post-pandemic.

METHODS

Patient volume, demographics, and characteristics were compared across four, 3-month time intervals in 2019-2020. Two baseline intervals when the center was physically open (PO) were compared to one interval when the center was physically closed (PC) (all evaluations were conducted via direct-to-home TNP) and a fourth interval when the center was physically reopened (RO) and evaluations were conducted in one of the three modalities: in-person, virtual only or hybrid (both virtual/in-person).

RESULTS

A total of 1,459 total neuropsychological evaluations were conducted with a 64.6% reduction during PC. At RO, the number of evaluations returned to pre-COVID baseline during which in-person (72.4%) evaluations were conducted at a higher rate than hybrid (7.1%) or virtual only (20.4%). Across the lifespan, mean number of appointments to complete evaluations was significantly greater during PC (p< .001) than at other time intervals, and during RO, hybrid evaluations required significantly more appointments (p < .001) than in-person and virtual. The majority of evaluations were conducted with adult patients (71.4%). For adult patients, neurodegenerative/memory disorders received TNP evaluations at a higher rate during PC and RO. Pediatric patients were significantly older during PC (p < .001); neurodevelopmental referrals received more hybrid and virtual evaluations.

CONCLUSIONS

Results indicate that patient characteristics, especially age and referral categories, impact the feasibility of TNP. Data from the RO period suggest that in-person evaluations not surprisingly remain the mainstay; however, for adult patients, and especially older adults with neurodegenerative/memory disorders, TNP may provide an important option for delivery of neuropsychological evaluations.

Cross-cultural considerations for teleneuropsychology with Asian patients

OBJECTIVE

Recent teleneuropsychology (TeleNP) models provide some degree of guidance in the application of telecommunication technologies toward the practice of neuropsychology. However, there remains a paucity of peer-reviewed data on TeleNP practices with culturally diverse patients, including Asian patients. This manuscript describes the challenges related to TeleNP practices with Asian patients and offers practical recommendations to complement existing TeleNP guidelines.

METHOD

Based on extant literature on multicultural applications of neuropsychology, weprovide recommendations for TeleNP services with Asian patients that pertain to specific components of a TeleNP evaluation, such as a) pre-evaluation preparation, b) determining the appropriateness of the referral, c) determining language proficiency, d) working with interpreters, e) informed consent and confidentiality issues, f) conducting a culturally sensitive clinical interview, g) behavioral observations and communication, h) test selection, and i) interpreting data and writing reports.

CONCLUSIONS

Our recommendations for TeleNP services with Asian patients highlight the need for flexibility to accommodate cultural differences and commitment to the complex nature of working with patients requiring interpretation services, while also recognizing the importance of preserving the validity of neuropsychological methods. Moving forward, it is imperative that the field of neuropsychology increases the training and accessibility of neuropsychologists who are knowledgeable in providing TeleNP services to Asian patients, and promotes research on the validation of TeleNP for Asian and other ethnic minority groups.

How We Work Now: Preliminary Review of a Pediatric Neuropsychology Hybrid Model in the Era of COVID-19 and Beyond

Objective

Although telehealth has become a central component of medical care in response to the coronavirus disease 2019 (COVID-19) pandemic, comprehensive pediatric neuropsychological assessment over virtual platforms lacks empirical efficacy. This paper presents: a) the results of a quality improvement project examining the feasibility of in-person evaluation in the context of safety measures that alter test standardization, b) the impact such changes had upon neuropsychological test scores, and c) how using a hybrid model of clinical service delivery affected access to care.

Method

We compared demographic and outcome variables between patients seen during the pandemic (N = 87) to a group of patients seen in our service immediately prior to COVID-19 (N = 87). A subset of those patients were case-matched for age and diagnosis (N = 39 per group). Children seen for neuropsychological re-evaluation during the pandemic (N = 10) were examined using pairwise comparison.

Results

Groups did not differ on age, sex, or FSIQ. Despite changes to standardized administration, no group differences were found for any selected neuropsychological test variables in the larger sample or subsamples. In fact, all variables were moderately to highly correlated in the re-evaluation subgroup. The hybrid model expedited feedback sessions and increased face-to-face (telehealth) feedbacks.

Conclusions

A hybrid model incorporating modified in-person testing and intake and feedback encounters via telehealth may be a feasible and effective way to provide pediatric neuropsychological services. These preliminary findings suggest such novel aspects of neuropsychological evaluation could represent an improvement over pre-COVID models, especially in rural settings.

Transforming pediatric neuropsychology through video-based teleneuropsychology: an innovative private practice model pre-COVID-19

Objective

In pediatric neuropsychology multiple barriers such as long wait times until an appointment, insurance coverage, and limited providers who are bilingual/bicultural or who sub-specialize in pediatric neuropsychology, often slow families from receiving diagnoses and interventions in a timely and affordable manner. This paper focuses on increasing accessibility through the development of a video-based, pediatric teleneuropsychology (TeleNP) practice model that was developed in a private practice 2 years before the COVID-19 pandemic.

Method

‘Design thinking’ methodology to problem-solving was utilized to innovate the traditional neuropsychology practice model in under-served areas who may have limited financial and healthcare resources. The practice model approach to include a virtual diagnostic clinic with increased patient and provider efficiency was created to enhance accessibility for patients and sustainability for providers.

Results

Video-based TeleNP screenings were conducted for 67 children with developmental (i.e., attention deficit hyperactivity disorder, autism spectrum disorder) and language disorders, as well as concussion and psychiatric diagnoses. Additional comorbidities were identified in 65.6% of children. Follow-up data approximately 2 months later revealed 98.5% of children were receiving new interventions as a result of the video-based TeleNP assessment.

Conclusion

Video-based TeleNP benefits the consumer as it can reduce wait times, decrease family financial burden (i.e., travel and parent time off work), expedite referrals for interventions, and provide geographically under-served populations access to providers who are linguistically and culturally responsive. For providers, this model revealed improvements with direct implications for cost-saving, thereby facilitating long-term economic sustainability within a private practice healthcare marketplace.

A Teleneuropsychology Consultation Service Model for Children with Neurodevelopmental and Acquired Disorders Residing in Rural State Regions

OBJECTIVE

Accessing neuropsychological services, which are often centralized in urban regions, poses unique challenges to children and families in rural regions. In 2017, urban neuropsychologists and a pediatrician practicing in a rural region of New Mexico started to develop a teleneuropsychology (TeleNP) consultation service model to efficiently triage and determine a clinical course of action. This pilot project, aimed at expanding clinical access to specialized pediatric services in rural areas, evolved over the course of 2 years prior to the coronavirus disease 2019 pandemic.

METHOD

Providers earned the trust of the local community, gained understanding of pertinent sociocultural factors, and acquired knowledge of the clinical and educational concerns for the children residing in the rural community. The application of a culturally informed approach that highlights the importance of community participation and collaboration steered the decision to implement a TeleNP consultation model. By widening access to neuropsychology, this service helped to determine whether neuropsychological testing procedures were medically indicated.

RESULTS

We summarize the distinct processes that needed to occur at each location to support the implementation of telemedicine. We propose a clinical service decision tree with specific criteria to help guide providers on how to triage cases in order to increase access to specialized healthcare.

CONCLUSION

The success of implementing a TeleNP consultation service hinges upon ongoing care coordination between providers, clerical staff, patients, and families with clear goals and expectations, maintenance of legal and ethical standards, and development of specific administrative and clinical processes supporting the use of TeleNP.