Discussion question: Should we recommend neuro-psychs for an initial diagnosis?

[Kathy in MD]

Years ago I recieved the impression that neuro-psychs did a thorough an exam as my developmental pediatrician. This would include a physical, observation, blood work to check for nutritional deficencies and heavy metal poisoning and possible allergy testing.

 

However lately I've received the impression that neuro-psychs do nothing but administer "academic" tests and skip much of the "medical" work my ds's dev. ped did. KRenee recently confirmed this.

 

Is this others' observations? Or are there "cadillac" neuro-psychs that do a complete physical and others who don't? If so, what do we tell parents to look for in a neuro-psych? If they don't, should we ever recommend that a neuro-psych be seen first for an initial diagnosis?

 

Personally I don't like that an initial screening for possible LD's doesn't include a physical, blood work and allergy testing. All too often something revealed by a thorough physical can add to LD problems.

[Ottakee]

Well, our neuropsych. was a PhD Doctor, not w MEDICAL doctor. While she was very knowledgable about meds, medical issues, etc. she could not herself order any medical tests. Our psychiatrist did order the EEG, MRI, blood work, etc. and our neurologist did even more in that area--but neither of them did the extensive learning tests that the neuropsych did.

 

We saw a developmental ped a few weeks ago for the first time and honestly, at this point she said she couldnt' do any more than we have already done. I dont' know what she would have done though had we started with her years ago.

 

For us, we needed the psychiatrist, the neurologist and the neuropsychologist to get the big picture of what is going on.

[Kathy in MD]

Well, our neuropsych. was a PhD Doctor, not w MEDICAL doctor. While she was very knowledgable about meds, medical issues, etc. she could not herself order any medical tests. Our psychiatrist did order the EEG, MRI, blood work, etc. and our neurologist did even more in that area--but neither of them did the extensive learning tests that the neuropsych did.

 

We saw a developmental ped a few weeks ago for the first time and honestly, at this point she said she couldnt' do any more than we have already done. I dont' know what she would have done though had we started with her years ago.

 

For us, we needed the psychiatrist, the neurologist and the neuropsychologist to get the big picture of what is going on.

 

 

that you also see the neurologist and psychiatrist? What I'm afraid I'm seeing is that people see the neuro-psych first and are never refered to others for blood work and other medical exams. Instead they're referred to therapists right away and skip the medical exams because the exams are never recomended. Yet food allergies, nutritional deficencies and other problems can have a major infuence on LD's.

 

OTOH, my ds's dev. ped did much of the physical exam and refered us to other MD's for other specialties (ENT because of snoring, etc), therapists, a psychatrist and even an neuro-psych. But our dev. ped was helpful because we saw her first in our journey for remediation. In fact, we stopped seeing her for years before we finished all the therapies. I can understand that midway or towards the end of remediation a dev. ped typically would not be that helpful.

 

As I read your post, it dawned on me that years ago we recommended seeing a pediatric neurologist first instead of a neuro-psych. (If my memory's correct :confused: )

[Claire]

That's a good point. Unfortunately, because doctors vary so much in how they practice their specialties, I don't think there's any one best route to getting all the information that is useful.

 

I was under the impression that neuro-psych evals done by a team in a children's hospital setting would include the physical, blood tests, etc. I thought they also did the OT eval, speech/language eval, IQ and achievement testing. Thought the only things routinely left out were evals for APD and developmental vision problems. But, so few people go this route, I seldom see posts about it and none in recent years. I think that most neuro-psychs will order OT and speech testing if they think there is a need, but I never thought about the basic physical exam components.

 

I've always figured a DAN! doctor would do more thorough physical testing than other doctors. I don't know if they refer to neuro-psychs though.

[Ottakee]

Trying to remember here. I can't remember which one we saw first---neuro-psych or psychiatrist. They worked together in the same office so it was close together. The psychiatrist referred us to the neurologist when the EEG was abnormal.

 

I honestly did a lot of research on my own and asked for some of the tests, etc. The psychiatrist though did uncover the anemia, bladder infection, and hypo-thyroid with the tests she ran early on though. Then again, I think that our psychiatrist is rare in that she does the EEG, lots of blood work, likes natural supplements, etc.

 

I think the developmental ped. we saw recently would have been helpful early on--she seemed willing to look at lots of pieces to the puzzle. Hard to say though how much she would have done back then.

 

It was through a friend that I heard of another neurologist that was great with kids with speech issues. It took months to get into him but we did figure out that 12dd's stuttering is related to seizures. He also did a muscle biopsy and found her mitochondrial disorders, etc.

 

For us, it has been a whole team approach---psychiatrist, neuropsychologist, neurologist, mitochondrial specialist, endocrinologist, etc.

 

In many children's hospitals they have a team that will see the kids which would include many different specialists.

[Kathy in MD]

Usually that happens because the professionals see a synergy in working with other disciplines when caring for their patients. But how many "stand alone" neuro-psychs do this? That's what I'm wondering.

 

You also had another advantage. You had enough background to know to request certain tests. How many newbies have that background? I didn't. I was just lucky to find a dev ped who did look at many pieces and would use complimentary medicine whenever possible.

 

So how do we guide the newbies like I once was? What should we recommend? Each child is different and won't need the same tests so we can't say make sure your doctors do the following tests, A, B and C. Yet I feel we need to direct parents to make sure that the physical as well as the educational testing is at least considered. What thoughts do you have?

[Kathy in MD]

Interesting, our Dev. Ped. did no medical tests at all. She did a couple little things with dd, basically a cursory check for Autism, and then talked to me. No medical anything.

 

We did a full physical with our reg. ped, but nothing like mri or eeg. I would love the academic testing of a nuro. psyc but never heard of them doing the physical stuff.

 

Our dev. ped did a physical exam and asked for a few, special blood tests to be run. The food sensitivity testing she had us do was limited based on his symptoms - dairy and wheat and we didn't have to do wheat. She didn't order an MRI or an EEG, but she did recommend that we see an ENT because in her questions about sleeping she found out ds snored. I've never heard anyone else on these boards needing that type of eval.

 

So the problem is, we want to direct people to get good, complete evaluations to get them started quickly in the right direction. But that means we can't say everyone needs the following tests. Should we just recommend that everyone make sure that a physical exam is part of the initial work-up? Should we put together a list of items to ask the doctors to consider? Or what should we do?

[Kathy in MD]

That's a good point. Unfortunately, because doctors vary so much in how they practice their specialties, I don't think there's any one best route to getting all the information that is useful.

 

That's the problem in a nutshell! And we don't want to force all doctors into the same mold, because we would lose the innovations that have led to better treatments. So how do we best advise people? You mentioned the teams in children hospitals doing complete work-ups. That might be a good suggestion. We could expand that recommendation to large, multi-discipline private clinics as well. My ds's dev ped has formed such a clinic.

 

I've always figured a DAN! doctor would do more thorough physical testing than other doctors. I don't know if they refer to neuro-psychs though.

 

Well, our dev ped, who is now a DAN! doctor did refer us to a neuro-psych. So at least one does :D

[NCW]

I have no suggestions for the right route, but I can tell you there's no way I could have gotten an insurance referral to get a complete work-up in a hospital. I would also never have been able to convince my dh it was necessary.

 

I have not had good luck with the pediatricians we've had available to us. I had to insist on allergy testing, finally just saying I wouldn't give him the medicine they kept prescribing until we had some tests to show he needed it. We've actually never seen a neuro-psych MD or a psychiatrist - so perhaps we're missing part of the picture. I'd love to see the results of a blood test for heavy metals, etc.

 

Anyway, what I'm trying to say is that recommending someone go in for a huge eval at a hospital may be just what one parent needs to hear, and far too daunting for others. I think giving the option for checking out pediatricians or neuro-psych doctors, telling them to make sure a physical eval with bloodwork is involved, as a place to start could be a good idea.

 

Don't know if this was helpful or not...

 

NCW

[kRenee]

In my case I knew my ds had SPD and we are already in vision therapy but instead of jumping into OT I waited until I could get an appointment with a nuero-psych. So, when I get her report and it says I should do vision therapy and OT for SPD I don't feel like I got value for my $1500. On top of that I am realizing that OT should be started sooner rather than later, so I feel that I wasted valuable time getting the psych eval first.

 

So, I wish I had gone with an OT evaluation first. I think a neuro-psych eval is approriate at some point in time, but can't you always do it later in the process? The only time I see it as being appropriate as a first step is if you have no idea what is going on with your child and have no idea how to help him/her.

 

I think a person should plan on getting an OT eval, vision eval, see a Dev. pediatrician for bloodwork, etc, and see a neuro-psych. But depending upon the child's age and what you already know, the first step may differ.

[Claire]

I think a person should plan on getting an OT eval, vision eval, see a Dev. pediatrician for bloodwork, etc, and see a neuro-psych. But depending upon the child's age and what you already know, the first step may differ.

 

I agree with this, and would just add that a speech/language eval is also a good idea early on.

 

OT and speech/language would be the first two evals I would get.

[Laurie4b]

Honestly, I think it depends both on the individual symptoms and on the individual practioner. To some extent, it also depends on the child's age.

 

Outside of DAN! doctors, I'm not sure that many medical doctors are going to recommend the allergy testing, nutrition stuff, etc. Mel Levine, who is arguably the country's best known developmental pediatrician does not recommend any alternative therapies that I am aware of. I think you just hit the jackpot with your particular physician. On the other hand, I've been hestiant to visit some of the DAN doctors around here. The closest one is an ENT. I know physicians can practice outside of their specialty, but I'm not crazy about that lack of background.

 

Neuropyschologists are not physicians and so can't order the medical tests. They do learning, psychological, and neurological testing. We got a very comprehensive neuropsych exam and it was very helpful. The neuropsych's can also recommend accomodations for SAT testing, etc.

 

For a child who is exhibiting a wide range of problems that have a probably sensory component, or a motor component, I don't think you can go wrong with an OT eval (by an experienced OT) early in the process. OT will likely be a recommendation of any comprehensive eval anyway, and they do TREATMENT as well as evaluation. IF you ask them, an OT might also be willing to steer you in the direction of any further eval to pursue, though they won't make any diagnoses outside their area. (eg they won't tell you that your child appears to be on the autism spectrum; they will tell you that your child has sensory processing disorder or is dyspraxic, etc.) I'm not sure they would always tell you on their own. The good thing about OT early on is that the treatment can be going on at the same time that you pursue other testing options. It's often the foundational piece that other professions want worked on before or during their treatment (For instance, in our area, there is a practice where OT's and ST's work together).

 

If there are any language issues (reading problems plus late talking, difficulty understanding, difficulty expressing self, odd use of language, etc.) then a speech and language evaluation is one of the basic entry points as well. Again, like OT, the ST involves an evaluation, but then TREATMENT.

 

On the other hand, for a child with good social skills, good language, who is a decent athlete and artist but is struggling with reading, I would recommend certain reading approaches first (if the child is under 8) . If the child is older, I'd recommend the new approaches for 3-6 months only and then on to testing that evaluates various aspects of reading if the child has not signficantly closed the gap with peers in that time. By the time that a child is older, a parent really needs to know what she is dealing with, imo, rather than experimenting and running into deadends. The kind of testing that I think is necessary can be done by most tutors. If more is needed, then you can get more, but sometimes more is overkill.

 

Our course was vision therapy eval, then OT eval, OT, remediation for dyslexia, back to OT as hormone drip started, neuropsychologist, and back to vision therapy. The plan is to do cognitive skills training after vision therapy, and then, if still necessary, to pursue meds for ADHD.

 

So, to sum up, I don't think there is any one "best" recommendation for every situation. I do think there are "best" recommendations for particular situations.