Measuring Up: The Role of Neuropsychological Testing with Peryl Agishtein, PhD

In this episode, neuropsychologist Peryl Agishtein explains when neuropsychological testing IS and IS NOT needed, as well as an overview of these tests, including how they help us understand why a child may be struggling academically, socially or behaviorally.
Dr. Peryl Agishtein completed her Ph.D. in clinical neuropsychology at the Graduate Center of CUNY. After training in a number of inpatient and outpatient settings and completing postdoctoral work at Columbia University Medical Center/ NYP, she was the founding director of a neuropsychological testing department at Achieve in upstate NY. She’s continued to practice neuropsychology in hospitals and in private practice, as well as several therapy specialties. She currently supervises testing divisions in several clinics and private practices. She also gives seminars educating clinicians in the best practices for psychodiagnosis. Dr. Agishtein divides her time between Israel and the US, focusing on couples and CBT therapy in Israel and managing a neuropsychology testing practice in the US. She is also the co-founder of a mental health AI startup that aims to improve access to quality neuropsych assessments.

Website: www.LifespanNeuropsych.com
Contact info: DrAgishtein.Info@gmail.com

Office of Dr. Peryl Agishtein, Ph.D.
Lifespan Neuropsychology
www.LifespanNeuropsych.com
720-727-7924 (US)

Cover art by Charlotte Feldman
Please note that while I am a pediatrician, I am not your child's pediatrician. This podcast is for informational purposes only and does not constitute medical advice. For any medical concerns or decisions, please reach out to your child’s health care professional.

Transcript

0:11

Welcome to Kids Matter. I'm Dr. Elisa Minkin. As a pediatrician, mom and grandma, I understand how challenging it can be to help our kids grow into their best selves. We are so much more powerful together. Here I will be sharing the knowledge and wisdom of a wide range of people who understand and care deeply about children. I'm hoping for your input as well because kids really do matter. They are our future. Welcome back to the Kids Matter Podcast. I'm really honored and really excited to be here today with Dr. Perel Agostine. Dr. Agostine completed her PhD in clinical neuropsychology at the graduate center of CUNY. After training in a number of inpatient and outpatient settings, and completing post-doctoral work at Columbia University Medical Center, New York Presbyterian, she was the founding director of a neuropsychological testing department at ACHIEVE in Upstate New York. She's continued to practice neuropsychology in hospitals and in private practice, as well as several therapy specialties. She currently supervises testing divisions in several clinics and private practices. She also gives seminars educating clinicians in the best practices for psychodiagnosis. Dr. Agostine divides her time between Israel and the US, focusing on couples and CBT therapy in Israel, and managing a neuropsychology testing practice in the US. She's also the co-founder of a mental health AI startup that aims to improve access to quality neuropsych assessments. Is that your Lifespan Neuropsych? No. Lifespan Neuropsych is my private practice. What's the new- This is a new- Yeah NeuroScribe AI. It's, we're just entering beta testing, and we're extremely excited about it. Oh, so it's not ready to be linked to my podcast. We'll have to keep our eyes open. Uh- NeuroScribe AI. Not quite ready yet. We, we haven't yet published the website. We're, we're literally starting beta testing June 1st, so- It's really exciting so we'll, we'll pu- have a link to put up soon. Yeah. Amazing. So welcome, Dr. Agostine, to the podcast. Thank you. Thank you so much. Thank you. So- I'm so happy we're making this happen I, I am, because as we discussed before, this is my second podcast, and we were gonna do this years ago, so it's really overdue in both of our minds. Yeah. And we made it happen ASAP this time. Yeah. So thank you for doing this with me, and, you know, as a pediatrician, neuropsychological testing does come up frequently. And so I'd like you to start, I'd like you to start with telling us about, what's the typical scenario, right? Go get an evaluation. Tell me more about that, please. Okay. That's exactly where I wanna start, because that's where people come to me at. So, so I'm, you know, screening calls and getting phone calls for people who were told by their school usually, "You need an evaluation." This is the typical kind of scenario for pediatric evaluations, and there are evaluations for adults as well. Okay, so the typical scenario that comes to my office is this: A kid's in third grade, maybe fourth grade. They might have been struggling a little bit all along, and now they're starting to struggle some more. The struggles in school could be behavioral, they could be social, they could be academic, they could be reading, they could be math, and the school tells the parents, "You need an evaluation." And the parents might ask them, you know, for more detail. They might say, "What kind of evaluation?" The parents might tell them, "Go to..." You know, they might, the, the, the school might not even be clear on exactly what kind of evaluation. They might tell them, "I think you could use a neuropsych evaluation, a neuropsychological evaluation." They might just tell them, you know, "Go to, go see a psychologist," or, "Go see a psychiatrist." And those are the cases that end up on my desk. And when I call them back to s- you know, to try to understand if they actually need a neuropsych evaluation, what I'm hearing from them is usually the school told us to get an evaluation, and we're not really sure why. Um, yeah. I wanna, I wanna, I wanna come in as the pediatrician perspective. Yes. Okay? 'Cause I have a couple things to say about this. Typically, what parents are told is, "Go to someone." It could be a neurologist. Yeah. Yes. And I think there's a lot of confusion about who does testing, and also there's always the issue of the school doing testing versus private testing. Yeah. Yeah. And so I really want you to explain the difference. First of all, what is neuropsychological- Yeah versus psychological testing? Right. Who does it? What's the difference between school testing and outside testing? Perfect. That's exactly what I want to go into. Yeah. So, so I'll tell you the honest truth. Around 50% of the people who end up on my, on my desk, you know, who ends up, you know, requesting intro calls or free consults through my assistant, don't need neuropsych testing. I tend to turn away around literally 50% of the people who I'm talking to. I end up saying, "You don't need this. Here's where you need to go." And that's why I'm doing this podcast, 'cause I, I... Not c- just 'cause I want to save myself time, but because I feel like there's really ignorance around this, not just among parents, but also among educators, and even in the mental health profession. I actually just spoke to some, you know, a social worker at a referral agency who said to me, "Don't tell anyone this, but I don't really know what the different kind of evaluations are." And this is somebody who works in a referral agency whose job is to send people to the right professionals. So there's really a lot of ignorance around this, and that's fine. That makes sense. It's not, it's, you know, sort of obscure terms, but that's why I'm here. I want to go through what the different terms are. So, um, let's start with, like, the basic thing. Right? What, what's the whole point of an evaluation? Let's start with the basic question. The point of this evaluation is to really understand what's causing your child's struggles. If a child comes into school, and first grade they're not learning how to read, and second grade they're really not reading at all, it's usually more clear what's going on, and then, like, what kind of evaluation is needed is very clear, right? Or if a child, um, uh, comes in with al- with an already diagnosed developmental disability, like for example, they have some kind of genetic disposition towards, um, some kind of intellectual disability, then it's very clear. You don't need an evaluation necessarily. But where evaluations come into play is when it's really not clear why this child is struggling. So that's what we call the etiology of the disorder, right? The, the, the what's causing the disorder, what's causing the challenge. Right. I wanna go again from my pediatrician's perspective. I think we're gonna go back and forth- Yeah because you see one piece and I see the other piece. Yeah. And so I always encourage people to go to their pediatrician first and talk to them, not just go- 100% from the school to a neuropsychologist. 100%, yes. Because we usually do know this. Yes. Like, this is our, you know- Yes our jam. Um- Right and so I'm sure you see different scenarios, but the first thing I encourage is if there's any academic concerns, or even potentially behavioral or emotional concerns, I will say please go to your school district. If you're in private school, you can still go to your local school district. Mm-hmm, mm-hmm. If you're in public school, go to your school district- Mm-hmm and get an evaluation. It depends on the age, right? If you're- Yeah below three, it's early intervention, above three to five is child, child, uh, CPSC or preschool, and then CSE, Child, um, Committee- Yeah for Special Education is five and up. And ask for that evaluation, and they usually do a psychological. How is a psychological different from a neuropsych? Okay. So act- Okay, so let's go through that. So actually school, schools tend to do not just psychological, but also psycho-educational. So there's a couple of different things that we're looking at when we're, when we're looking at a child with challenges and we're saying, "Let's understand where these challenges are coming from." We're trying to evaluate different areas. So the first area that we're trying to evaluate is, let's call it psychological, right? And that's the mental health area. And that's the question that says, is this a child who's really struggling with anxiety, for example, or maybe they're depressed. So depression, one of the symptoms of depression, is lack of motivation. The child isn't learning 'cause they're not motivated to learn, right? By the way, inattention, that's also a symptom of depression that's less, less well-known, right? So this is a child who's struggling with attention and motivation. You can't get him to go to school, but this is not oppositional behavior, and this is not ADHD, and this is not executive functioning, it's just depression, right? So that's the psychological piece of the evaluation where we wanna see, is the challenge coming from some kinds of psychological disorder? By the way, it could be subclinical. It doesn't have to be, like, full-blown anxiety or full-blown testing anxiety or full-blown school refusal, right? It could just be some kind of subclinical behaviors that don't quite meet the criteria for a diagnosis, but it's a really anxious kid who's- and that, that's really affecting their functioning at school. That's the psychological piece of the evaluation. The second piece of it, let's call it, um, academic or educational. Right? So that piece is looking at how is the child's ability to learn. And for that, we, we tend to look at their scores on achievement tests. So we look at how's their reading, how's their writing, how's their math. We compare it to other kids either their age or their grade, and we really try to see, like, okay, you think he's a little weak in reading, but you know what? Actually, he's sort of average. It's not actually a, a, you know, something that could be linked to a learning disability, right? That's the academic piece. Um, another piece of the evaluation that we can look at is social-emotional functioning. That sometimes goes hand-in-hand with psychological functioning, sometimes it doesn't. Sometimes you're looking at that separately, and that could be, you know, how's their social language, how's their ability to have theory of mind and understand other people's point of view. How is their, you know, general emotion regulation, those kind of, those kind of skills, that kind of, you know, a piece of the puzzle. And then the fourth piece is really the neuropsychological piece. We can also call it, like, the cognitive piece, and that includes all of the, all of the, um, the aspects of your mind that help you think and process things. So that would include things like, uh, attention Ability to learn over time, visual-spatial functioning, um, executive functioning, which can include things like impulsivity, impulse control, ability to switch between different tasks. Intellectual functioning, as in, like, the person's IQ, is usually going to be included in either the psychological functioning- Mm-hmm or the neuropsych functioning. So there is overlap here, but those are all the different pieces of what you wanna look for. Different evaluations are going to be looking at different parts of, of this whole picture that makes up the person, right? So the neuropsychological evaluation is actually the last piece of the puzzle. It's the last resort. You're not doing a neuropsych evaluation if it's very straightforward. Right. We'll talk about who you can go to if it's very straightforward. Let's do that. Neuropsych evaluation... Yeah. No, I wanna go there- but let me just let's start with the most complicated, and then we'll, and then we'll- Work backwards. Okay work up. Exactly. So the neuropsych evaluation includes all of that. It's the longest evaluation. It's the most time intensive. It's very expensive because it's a lot of hours of time. So if it's a pediatric evaluation for, you know, a average complexity, you're probably sitting with the child between 6 to 10 hours- Mm and doing face-to-face testing, right? You're also sitting with the parents one to two hours beforehand to do an intake, and then you're meeting with the parents for feedback, and the majority of your time, or maybe not the majority, but a big chunk of time is spent scoring all those tests that you did and writing up a full report so that everybody understands exactly what's, what's going on. You know, putting all the pieces together. You're also talking to parents. You're talking to the school district. You're talking to the therapist. You might be talking to the pediatrician. Um, so that's everything that's going into the neuropsych evaluation. That's when you have the most complicated cases. It's really not clear what's going on. You know, maybe the s- the school thinks it could be ADHD, or it could be anxiety, or it could be a learning disorder, right? Those are the kind of cases that are ending up on the desk of a neuropsychologist, and that's when I say, "Yeah, you know what? She could use a neuropsych evaluation. It won't be a waste of your time and money. Bring her in." Right? First, before you get to the neuropsych evaluation, you're starting at a much, you know- Higher level stepped up kind of level of care. Yeah. It's big guns. It's big guns. Don't pull out the big guns until you need to. Exactly. Exactly. So first of all, yes, you know, going to a pediatrician if there's any kind of complaints around, um, social-emotional functioning, for example, you go to your pediatrician, um, to rule out, you know, to sort of get further guidance. That's like, that is kind of a step one, but bring in the pediatrician perspective please. I, I have to, first of all, hug all pediatricians now. I have this moment where I have to hug them now because it's really hard to be a pediatrician today. We're seeing so much anxiety, so much depression, so much issues, and we have so little time. Yeah. And so I'm gonna put out a plea to parents listening to this to ask for a separate visit. Do not come in at their well visit and say, "Oh, by the way, wave my hand on the door, my kid might have blah, blah, blah." Oh, what an important point. Ask for a separate visit. Thank you. And it, and if your pediatrician doesn't have the capacity to do that separate visit, then you're gonna have to go elsewhere. You should certainly start there, but you, this cannot... I always say it's not like strep is to amoxicillin as depression is to Zoloft or ADHD is to a stimulant. It's just not so straightforward. That is so great. That is so great that you're saying that. Thank you for bringing that in. Of course, that's true. Yeah, because these are, because these are, are better, you know, are, are more complicated questions than does the child have strep, 100%. Um, so I would add to that, and, and I wanna hear your perspective, I would add to that that you can also, you know, you know, sort of an analog to the pediatrician would be a slightly more intensive level of care would be to make an appointment with either a developmental pediatrician or a neurologist. Um, what do you think of, of those options? So it depends on the scenario. I think neurologists are appropriate for kids who may have autism. Right. Um, they can see kids with ADHD. It really depends. Yeah. The quality will depend. The concern I have for ADHD- Yeah is we have no test for ADHD. I will have parents coming to me saying, "I need to be sent for testing for ADHD." Yeah. There is no such thing. And by that you mean there's no definitive, uh, bl- "Take this blood test and we will see if you have ADHD swimming in your blood," or take this even, you know, um- Neuropsych. Even neuropsych testing- Right can supplement. Uh, no, 100%. Yes. There, the, in other words, there's no definitive, you know, strep culture and you have ADHD. Right. And especially in a short, in a short visit. And parents, you know- right often will say, "I don't want my child medicated," and they may feel, "Well, we've had-" Right, right "a 15-minute visit with the pediatrician." Right. They've done these Vanderbilt, you know, scales- Oh, and s- right that take five minutes. Right. And those are meant to supplement a comprehensive, you know, history and physical, potential other referrals. It's not so straightforward. No. No, it isn- right. No, so let me, let me just be clear. I don't mean go to a pediatrician to get diagnosed with ADHD or ASD. Go to a p- go to a pediatrician first to be, to rule out any medical causes of what's going on, right? So do all the blood work to see if maybe low iron is contributing to low motivation, or if poor vitamin D might be going on, right? There's so many, there's so many biological factors that can contribute to a child's challenges in school, and you can speak to that more than I can. Um- They, they can, but we as pediatricians are under pressure to actually be the ones taking care of these kids. Okay, and then, and then the other piece that I would say- It's problematic, in my opinion what a pediatrician for is actually... No, I, I agree with you. I think it would be to refer out to, to the next level of care. In other words, I think the pediatrician should rule out medical causes and give you, and give you referrals, and tell you exactly who to go to, 'cause you, you are the gatekeeper. You know exactly who the next person to pass them onto is. So that might be a developmental pediatrician who will spend, you know, a good hour, hour and a half maybe going into a lot more detail. It might be a neurologist if you suspect ADHD or ASD. It might be a psychiatrist if you suspect A- ADHD, for example. That that's, you know, that's where I'm going with that. So I think the first level of care is the pediatrician, and then you get to the evaluations, and the evaluations are going to be done first level of care by a psychiatrist, neurologist, or developmental pediatrician. And what they can do is they can do a really thorough, usually a really thorough either psychological assessment if it's a psychiatrist, or, and/or a, a psychiatric evaluation where they're looking at both, you know, all the biological factors that could be at play here. They're do- also doing medication management if they're a psychiatrist, certainly. Um, and, and then the psychological piece of the evaluation is they're able to tell you, does the child have ADHD? Does the child have anxiety? Does the child have depression? They're basically going through this, uh, or, you know, I'm listing the most commonly known diagnoses, of course, and the most common childhood symptoms, but of course there's more on the table than that. But those are a lot of the really common, uh, differentials and possible disorders that could be contributing to a child's challenges. So that's that level of care. If you had- And just, I just, I'm sorry, I just wanna add that in today's day, the reality is pediatricians- Yeah are caring for these children, and it, there's not enough access to those- I get that to those specialists. So it's, it's, in the ideal world, you would have- Right someone who has the time- Yeah to do this, but this is the reality. Yeah. You know? So we don't want the, the perfect to be the enemy of the as good as we're gonna get. Right. And I think that parents have to be the best advocate- Yeah for their child, saying, "Have we considered this? Have we considered that?" You know, or, "I do need to see a higher level specialist with my child." Thanks for bringing in that real world medical experience- Always real world, yeah. That's not my forte. I'm talking about the- Always real world okay, so the next level of care, the next kind of evaluation I would say would be a full psychodiagnostic evaluation, and again, that's something that a psychiatrist and/or a developmental pediatrician might be doing, but not necessarily. A psychologist can do that, and what that looks like is really looking at, um, all the possible diagnoses in the mental health bible, which is the DSM-5. So all those different kinds of anxieties, childhood depression, different presentation for childhood depression. It could be irritability that really actually is depression, for example. Um, that's a full psychological or psychodiagnostic evaluation. Um, the psycho-academic evaluation or psycho-educational evaluation is when you suspect a learning disability, so you're looking at their intellectual functioning relative to their academic functioning, and you're checking if there's a real gap there, and it's the gap that we're interested, right? If you have a really bright child but their reading is just average, that's already gonna be possibly- Right a reading disability. Um, and then the, the highest level of care, as we said, is the neuropsych evaluation, which is gonna look at all of that. It's gonna look at the possible learning disabilities, looking at all the psycho-academic stuff, looking at achievement plus intellectual functioning. It's also gonna look at psychological components, and then it will also look at all the cognitive components that might be underlying this. It does get at the full etiology. It gets at the full causes of the challenges bottom up- so instead of just telling you, yes, it looks like they have a learning disability, it will tell you they have a learning disability and it's because they have, you know, a really poor ability to differentiate between different sounds, or really, you know, they, they c- they have really poor verbal fluency. They can't get out, they can't identify the labels and get out the words fast enough. So the neuropsych piece is a more thorough piece. You don't always need it, right? So, yeah. Yeah. So I wanna point out again, real life, coming to real life here- Yeah, yeah that when you have ADHD, it's very commonly associated. It's not you don't have ADHD, you may also have learning disabilities, also have anxiety. Yeah. There's so many other things, and I think one of the problems is, again, if you have a short office visit with the clinician- Yeah whatever they are- Yeah and they just say, "ADHD, boom"- Yeah um, to keep in mind as the parent advocate that you can have- Yeah these other things, and that the school district's evaluation, I just wanna make it really clear, i- in, in the real world is, is limited, okay? Yeah. It's very limited. Yeah, yeah. And you, you need to not expect it to be a comp- the same as a comprehensive neuropsych. Right. So, so let's talk about the school evaluation for a minute, because- Yeah there's so many pros and cons there. I, I tend to, when I, when I tell, those 50% of my phone calls who I tell, who I, who I send away, I'm either sending them usually to a psychiatrist or to the school district. And here's the scenario, right? If somebody comes in and they tell me their kid is struggling in school, they're fine socially, their mood seems pretty fine, I don't think they have massive attention problems, they're really struggling to read. My first question is, "Did you get an evaluation through the school district?" And that's because we have this fantastic law, right, in, in, in most states as far as I know, certainly in the tri-state area, but I believe it's all the states, that if you ask, if you tell the school dist- If you reque- You as a parent have this power to request an evaluation, and they have to fulfill that request. So what they're gonna be doing is for sure a psycho-educational evaluation. Depending on the school district, they might do a little more, right? Usually school districts have school psychologists doing the testing. A school psychologist is a master's level clinician u- usually, not a doctoral level clinician, and they're not trained in doing neuropsych evaluations. They're not necessarily trained in doing, the full gamut of the social-emotional evaluations, for example. Um, but they certainly will be doing intellectual functioning and also academic functioning, and that alone is usually gonna be enough to tell you the child does or doesn't have a learning disability, and here are the services that we need to offer based on that. So yes- But there's- Yes, but there's caveats here. Again, real world experience- Yeah. Lot of caveats pediatrician here. Yeah. Yeah. I'm, I'm- And that- I'm ready to go for the caveat. Yeah what parents will hear with a brighter child is, "Oh, your child doesn't need testing because- Yeah they're meeting their, their metrics. They're passing." Okay. Okay? Doesn't matter they're underachieving. Yeah. It does matter. That's number one, and this is where parent advocacy again comes into play. Yes. Yeah. And the other thing I hear is not labeling learning disabilities because they haven't done response to intervention. I think they've done away with the discrepancy model, and they start with response to intervention, and basically your kid has to fail- Yeah before they get the help. Well, they actually- Yeah. Yeah. Well, they actually, in general they won't, they won't actually diagnose it. Right. They have a funny approach to diagnosing, and that's based on different legal issues, and it's based on different professional qualifications, but they wanna start diagnose it. It's not a diagnosis that you can take elsewhere. They will say they qualify for these services. So here are the caveats. I agree with you. Those are all caveats. I'll tell you from my experience as a neuropsychologist, my caveats are that who am I seeing? I, I am seeing the kids who did go through the school district- Right and it wasn't enough, right? Right. So sometimes that's because there's something else going on that the school district isn't going to catch, right? If this is a child with ASC or with ADHD, all the, all the real, you know, um, the real more organic neurological disorders, even like the anxiety or depression, they're not necessarily gonna pick up on that. Right. That's not what they're trained to do. Right. They are trained to do intellectual functioning really well and academic functioning really well. If you're lucky, some school districts will have, you know, more of an interdisciplinary team. They might have the speech therapist evaluate them also. They might also have an occupational therapist evaluate them. The school psychologist working in that school district might be a doctoral level school psychologist who will do a more thorough job. But- You sort of have to get lucky for that, right? The other scenario that comes to me, like you mentioned, is the really bright kid who actually scores within, you know, maybe they're low average on reading, but the school districts aren't, this is a little bit, you know, uh, unkind to say, but they're not so motivated to provide services Right? Or, you know, let me say it in a kinder way. I know what you mean. They're stretched thin. They're stretched thin. And their main goal- School districts are stretched very thin. Yeah is, is to take care of the kids that aren't meeting the metrics. If your kid's meeting the metrics- right it's not their problem. Right, and that, and that's what has to be their main goal. Yeah. And at the same time, you have to be your child's advocate. Exactly. So if you have a really bright kid whose, you know, IQ is, you know, in the 90th percentile, and her reading is in the fifth percentile, that's a problem, right? Right. That's a real problem. Possibly even in the 25th or the 30th percentile, the discrepancy matters. I was just going to say, I've had cases where the- Yeah, sorry. I've had cases where the kid actually is totally in the fifth percentile for reading, but that is with four years of the parent getting tons of private tutoring and sitting with them every night, and they're still breaking their teeth. And they're getting it, 'cause the parent has, you know, sort of put their guts into this kid. But this is a kid who should be scoring in the 99th percentile for reading effortlessly, and she's scoring in the 50th with tons of intervention. And the school district is refusing to give her services because she doesn't meet criteria, you know, according to their metrics. Right. But this is- So that they have, yeah sometimes they will say things. Sometimes they will say things, 'cause like you said, they're just not motivated. But you still have the right. Your child has the right to a free, appropriate public education in the least restrictive environment. That is your child's legal right. And unfortunately, there are times when you just have to be that squeaky wheel. Yeah, so that's- And that's, and this is about, right? Yeah. I'm mostly reaching out to parents here going- Yeah "Listen to this. This is what you need to know to fight for your child." That's exactly right. Yeah, that's exactly right. And then, and, and those parents have come to me, and we've done evaluations. By the way, they've come to me, you know, in my private practice, they've also come to me in why, you know, I, my last, my last, um, job out of my private practice was working in a, in an outpatient clinic attached to St. Charles Hospital out on Long Island. So these evaluations are fully covered by insurance, really high-quality evaluations. You did have to wait. There was a very long waiting list to get them. Um, but again, they're getting a full neuropsych evaluation. They're waiting a little bit longer than they would have to wait in a private practice. And they're then taking that evaluation back to the school district and saying, "Based on this, you really do need to give us more services. You need to give us, you know, real treatment for dyslexia," for example. We really need to talk about the next step after the district, 'cause you'd start- Yeah, yeah with the district evaluation. And- Okay if it's okay, I'll say it, 'cause I know this too. Which is that if your child was evaluated and you look at that evaluation and you say, "Mm-mm, this is not doing it." Yeah. They're telling you your child's not eligible. It's just not nailing the problem, that your kid is bright, but they're, you know, the discrepancy isn't big enough or whatever. You can ask for an independent evaluation at district expense, and that's very different than going privately. Because obviously anybody could go privately and have somebody hired to say what they want. You're entitled, that free appropriate is a Chevrolet, not a Cadillac. You're not entitled to- hire somebody to fight for what you want. It has to be appropriate, and so there's a process of requesting an independent evaluation at district expense. One of the things they will say is, "Well, here's our list of acceptable people," and you need to know that, no, you can propose someone, they just have to meet their acceptability criteria, right? And then you must request it properly. I've had it where I know someone who asked for a psychological when she meant a neuropsych. Oh. Because they'll tell you the budget is X, like 1,000 for a psych- Yeah, yeah and 5,500 for a neuropsych. Right, right. Ask for the right one, do it in writing, do it politely. Yeah. Oh, thank you for adding that in- 'cause that's, that's exactly what parents need to hear, and, and I'm at the other end of it, so I'm not as familiar with that piece, uh, you know, the, the parent advocacy. One more thing I wanna make parents aware of is the fact that there are people out there whose job is, either as a volunteer or for payment, to be a parent advocate in the school district, and sometimes that's what you need to do. Sometimes you need to really, you know, what... It's har- it's hard to navigate all the ins and outs and nooks and crannies of this, and if you're not, um, you know, if you don't have somebody on your side within the school district or within the school who's sort of holding your hand through it, I do encourage parents sometimes to, to engage a parent advocate who can help them deal with the school districts, who can even attend IEP meetings, um, to help get their child services. You're looking a little skeptical, though. I'm looking a little skeptical. Thank you for saying that. My eyes kind of twitching here. 'Cause remember, I, I am a, an, a veteran autism mom. You know, my daughter's 32 now. I've been through many, many meetings, and I've also attended- Yeah meetings as a pediatrician. Um, there are parent advocates that are part of the CSE team. I don't believe they're truly on your side. I have never gotten help- Okay from the district. But I wasn't refer- Yeah. Okay, I'm thinking more of the private ones. Okay. You can hire a private one, but let's just be really frank about equity here. Yeah. They cost money. Yeah. There are sometimes services which provide them, but they're few and far between, and we just really need to be, be very open and honest here about equity. Private neuropsych evaluations cost money. The process of getting an independent evaluation very often requires the parent to upfront the money and get it back. It means you have to have that money. It's not always the case, right? You should always try to get the district to pay for it upfront, but for people who can't afford it, it's really a barrier. It really is. Yeah. Yeah. Yeah. Yeah. Yeah, thank you for pointing that out. Um, one other resource, I'm scared that you're gonna be cynical about this one also, but, um- the, w- you know, and I'm, I hope I'm getting the name correct, but SEPTA, like, um, the- SEPTA, the special ed PTA. Yeah. Thank you. That's better. That's better. Okay. So you can speak to that better than I can maybe, 'cause you can speak to that. It's, it's, it's, special ed PTA is a chance to network with other moms, some of who may be super, super savvy. Um, it's always worth reaching out to other parents, but remember, your child is your unique child, and they're good at their unique children. Right. So there's, there's a limit. There's a limit. It's a great, it's a great thing to mention. You know, you can definitely also go online. You can find out whether there's resources that, that will cover, especially if you have Medicaid, there may be organizations specifically for people who have Medicaid or have, financial limitations to even out the playing field at least a little bit. Um, neuropsych evals are, if you're doing them privately if the district doesn't agree to an IEE, first of all, you should be aware that if you come in there with your own evaluation, they don't have to honor it. They have to look at it, but they don't have to honor it. Right. Right. Be very careful about going privately if you want the district to honor it. But it is, but, but I f- I find that they usually do tend to honor it. I find that they, that, that if it's a really well-done neuropsych evaluation that speaks very clearly to what the diagnosis is and what the recommendations are, um, it's not been my experience that they have, that they fight the fact that they need to honor it. Whether or not they do it in practice could depend on resources. Right, and whether they actually have somebody who's trained in, for example, Orton-Gillingham, which is the way to treat dyslexia well, right? Exactly. So what, but, but they do, they do agree when they see that diagnosis coming from a neuropsychologist, "Okay, yes, this is something that we, we need, we do need to provide these services. We, we need to get on this." And I just- And I just wanna summarize- I'm sorry. Yeah, I, I looked at it, I just wanted to make sure that it's clear, like, what the different kind of evaluations are- Yes and then talk about- Okay maybe what the purpose of the evaluation is. What's the parent getting out of it? Why should I, you know, spend all this money and time doing an evaluation in the first place? Does it really matter, right? So again, so we have these different pieces of functioning that makes up a person. We have the psychological functioning. We have the social-emotional functioning. We have intellectual functioning, that's the IQ. We have the academic functioning, and we have, like, the cognitive neuropsych piece, and all those come together in how a, a child or a person is functioning. And if you look at that whole picture, that's what's going to tell you why is this child struggling. Why, why is this kid having these challenges? And- Depending on how, on, in how many areas they're struggling maybe, or depending on how many p- how complex the case is, you could get away with just doing the psychiatric evaluation. You could get away with the developmental pediatrician. You m- you know, th- you could just get away with having a really great pediatrician with a really, you know, directed kind of appointment who can tell you exactly what's going on. Um, and the schools themselves could catch it. Um, again, the neuropsych evaluation is, like, the last step. It's when you see that you really don't have clarity, the case is complicated enough that you really just wanna go straight to the neuropsychologist and look at all the pieces together, one professional doing it all, and, and they'll be able to put the piece, the pictures together for you, give you, you know, g- give you the next steps. So that, that speaks Right? Is that clear? Did I- That's clear. Excellent. And I wanna really talk about autism before we go further Go for it. What is the role of neuropsych testing in autism? That's such a great question. Um, I would, I would say that, um... Okay, so, so autism, again, like the, like, like the ADHD kind of family of disorders, you don't give a blood test for it. It's a diagnosis that needs to be by a qualified professional, and the qualified professional is somebody who really needs to spend a lot of time, um, evaluating the child and also getting the history, right? Because you're looking out for, two different families of symptoms. One has to do more with, um, uh, you know, the social-emotional functioning. How is this child's emotion regulation? How is their, how are their social skills? The other one has to do more with, like, repetitive kind of behaviors, um, you know, or, uh, I'm, I'm blanking on the actual name of what that family of symptoms is, but it, it includes things like, you know, sensory issues and bodily issues, but also, um, uh, the, you know, stimming, things like that. Right. And I'm not- Restricted repetitive behaviors, RRBs. Thank you. You're welcome. Thank you for that, for that title. Um, and a good clinician really needs to see evidence of both of those, and sometimes it's fairly obvious. Sometimes it's even very obvious- Right if somebody comes in with really low-functioning autism, right? With somebody who has really severe autism, it's really, really obvious, and sometimes it's a lot less obvious. Sometimes it's much more subtle. So you have, you- autism is a spectrum, and because of that, you have people who are really, you know, non-verbal, really low-functioning, and then you have people who are super high-functioning, really bright. They might have friends, they might be very likable, they might be really functioning well in certain areas, and at the same time they're still really struggling in other areas because of this high-functioning ASD that they have. So I'm, I'm, I don't think a neuropsychologist has to be the one to diagnose them, but I do think whoever diagnoses them has to use some of the gold standard measures of autism that we have out there. The gold standard measure of autism is the ADOS. Mm-hmm. And what that looks like is, um, is really an experiential kind of measure, where the clinician has certain tasks that they perform with the person being evaluated, whether it's a child or an adult, and then they rate how they performed on all those tasks. And it's, it's, you know, a long evaluation. It's, uh, certainly more than an hour long, depending on who's doing it. Um, you have to get specialized training in just that measure. Not every neuropsychologist is trained to do the ADOS. Not every clinician or psychiatrist is trained to do the ADOS, so you have to get specialized training in that measure. And, and on top of that, you also have to really interview the parents and get a history of how they were as a child, get a development- ment- developmental history. So I don't think that a neuropsychologist needs to be the one to do the evaluation. I think what you need to know is that the person you're seeing has experience evaluating ASD specifically. Again, yeah Yeah, so I'm gonna just put my two cents in here. First of all, it's a pediatrician pain point that we can see these autistic kids, and we can't diagnose them because there is a barrier to services that requires this comprehensive evaluation, no matter how obvious it is. Yeah. Yeah. That's, that's super, super frustrating, um, because it should be a clinical diagnosis, and if it's very obvious that they meet the criteria for social communication disorder and the restrict- restrictive, repetitive, all those kind of things- Right, right we can see it, we can document it- Right and it should be done. And back in the past, I was actually able to do that. Okay. But because of the rise in autism and the demand, it's become an intentional barrier to try to limit, right? Yeah. Yeah, yeah. So that's, that's really problematic, and I'm just gonna say a few things. Um, different areas have different resources. I know on Long Island where I am, if you get them in early intervention and sometimes in the preschool period, you can have the autism evaluation done by your school district or by your early intervention, and I highly recommend that because it's very expensive if it's out of pocket very hard to get through your insurance. And why would you need the label? Labels belong on cereal boxes but also for services. That's what I say. That's a good line. To get those services that- I like, steal that line. That's a good line that, that, but steal it. That, that barrier is stupidly there for. You know, it's like the little boy with the finger and the dike. All right? Mm-hmm. So that's, that's one thing I wanted to say. The other thing I will say is that once they've missed that window of earlier diagnosis, and this will happen more with the higher functioning so-called- right kids, it can actually be harder to diagnose, and it really does require something sophisticated like the ADOS. Yeah. That's where I see a neuropsychologist coming into play because it is- Yeah really hard to get a developmental pediatrician. Not all the developmental pediatricians are prepared to do the ADOS. They may be, you know, especially if you're getting it on your insurance- 100%, 100%. Yeah not at the time. Same thing for psychiatrists and psychologists. It may be really, really hard. So a neuropsychologist or a psychologist who's very experienced in autism is the person that I send to. And by the way, you know who really gets missed? The girls. 100%. 100%, yeah. That's the, the vast majority of kids I'm seeing in seventh to eighth grade with- with autism are girls, yeah. The boys who I'm seeing with autism are much younger, more like, first grade, second grade, and often they actually were already, you know, were caught even earlier than that. Yeah, 100%. By the way, the ADOS is not the only gold standard of measurement. It's, it's the most time-consuming one, and it is the one that's really accepted everywhere. You're confident if you do that, that this will be accepted. The CARS is also very well-accepted. It's also- really great research base and, um, and, and it is usually accepted for services. On the other hand, you really need to be a good clinician to give it. You need to be someone who's really trained in it. It's you- I've seen people actually hand the cards to the parents and say, "Can you fill this out?" Pretty horrifying. Yeah, so, so I, I think that, um, I think that what you're saying really speaks to the reasons to get an evaluation in the first place. You're talking about getting services. You're talking about getting a diagnosis. I mean, the overall picture is that you wanna lo- know how to help this child, right? And, and, and here's the thing. You could actually know what your child's symptoms are really well. You can understand your child really, really well, but if you don't know what's causing those symptoms, no matter what you do, you're not gonna necessarily know how to help them. I'll give you a scenario, true story, that just happened to me. I had a mom call me and ask me if I'm, you know, gonna be available to do neuro psych testing anytime soon. Um, as, as I'm in Israel, I go into the States twice a year. I, I am going in in July, but I'm like, "I'm not coming in so soon. Let me help you find someone who can do it sooner. It sounds like it's pretty urgent." So I, I look for people in her area. She's not local to me. I, you know, I reached out. I networked a little, but I got her a couple of good names. Um, uh, and I follow up with her 'cause I'm a nice person. I tell her a week or so later, I'm like, "Hey, did- what happened? Did you end up connecting with any of them?" And she says to me, "Actually, you know what I did? I typed all my child's symptoms into ChatGPT." It told me exactly what to do for her. I've been doing those things. She's really been improving, in parentheses, except for a few detentions from school. Wow. And I thi- I think that's good, right? Like, do you think that's okay? And it took me a minute to think about how to respond to that. I'm like, h- like, you know, well, my- maybe that is fine, maybe that is sufficient. And then I, uh, then I'm like, hang on a second. You don't know why your child is having those symptoms still, right? So let's say your child is struggling with friends, and you think, "Okay, fine. Like, she's struggling with friends, so let me figure out, let me, let me do structured play dates," for example, right? If you have a child who's struggling with friends, they might only need that little bit of push, like structured play dates, right? They might only be a little bit shy. They might also have real significant social deficits, right? For example, they might have a lack of theory of mind. They might not know what's going on inside the other person's brain, right? They might not understand empathy. They might not understand how to t- take the other person's perspective, in which case you need to work on those skills. Those are skills you can give your child, right? A g- an excellent speech therapist, an excellent... Even some OTs could work on that, right? Certainly a rehab specialist can work on that. You should be working on those skills. You shouldn't just do structured play dates for that particular child. Um, so I found that, you know, sort of like a laughable scenario that happened recently, and I was a little, uh, you know, put out that I had wasted my time like that networking for her. But I also felt like it was a very real kind of scenario that's happening today- Yes where people are, are sort of, you know, re- I, I'm sure you see this all the time in the pediatric world, that people are sort of, um, skipping the professionals, and sometimes that's really okay. Sometimes it's really, really okay. I am so happy to tell you, you know, okay, your, your kid has this, and now- Right and now go on, on Claude, and they'll generate for you a whole wonderful treatment plan, and here is the sum- my summary, and you don't need my recommendations. You can ask Claude to generate that. Yeah, it could be. It could be co- you know, I don't think it'll do as good of a job. But a Coby will be able to do that, right? But the real reason you're getting an evaluation is in order to understand exactly what's underlying your child's struggles, and that can be goals, 'cause once you understand where their struggle is coming from, you understand how to treat it. You also understand what services you need, but you also understand how to treat it. Right. I love that. And, you know, at the beginning we talked about how you were working on an AI program, and I think AI has such potential, but it's also being- it- we're expecting too much of it. Yes, we do. It's just kind of advanced Google right now. Like, it should never- Yeah replace. There's no such thing as Doctor Google instead of a real doctor. Yeah. Right. And there's no such thing as AI doctor. I- no matter what they say- right, right it'll never replace the human being. You may be able to save time and get information. You may be able to come to your doctor with what you've learned- Yes and save us both time. I love that, you know? Yes. Okay. But to take it away- Right and expect that you've- Yes figured it out by googling it don't try this at home. Part of it is that you don't even know what to ask about. Right. Right? You don't even know what- what's important. When you go to a neuropsychologist and you go to a pediatrician, they will ask you totally unrelated questions, and you'll be like, "Hey, how'd you know that was a problem?" Because we're a professional and we know exactly what's included in that diagnosis. Um, I- we wanted to talk about equity, I think, and access. So let's talk about that for a minute, because I think there is this perception that neuropsych evaluations are just inaccessible. They're so expensive, and you probably can speak to this better than I can. I'm- I'm living in Israel. My prices are still stuck, you know, a few years ago. Wow. But I- I- I'm hearing from people that the prices for neuropsych evaluations privately are really skyrocketing. Yeah. Um, I know that $3,000 is considered cheap now, and I think a few years ago that was- No, $2,000. No, $5,000 nobody's paying it. Absolutely. And I think a few years ago. Okay. So, so that's pretty, pretty crazy. I- I n- I think it does depend on where you are exactly. I think, for example, if you're in the city, you're gonna be charging a lot more than if you're, you know, you know, maybe in- in, y- you know, Midtown New Jersey or wherever it is. Um, I do wanna encourage people to look for other high-quality neuropsych options. Mm-hmm. So first of all, a lot of hospitals have outpatient clinics c- clinics attached that do neuropsych testing, and it's the same neuropsychologist who might be working in their own private practice who are spending part of their time in this hospital. They might be getting good training there. They might be enjoying the collegial atmosphere. They might be, um, work- getting to work in the inpatient and the outpatient unit, so that's part of it. But they're often working in their private practice and in this outpatient clinic. I've worked in more than one of those hospitals. Excellent, excellent quality care. For example Columbia University Medical Center, where I did some of my postdoctoral and predoctoral work, they have an amazing pediatric neuropsych department, um, that takes insurance fully- Again, the, the downside is that you're going to have a long waiting list. Like, so the s- the cheaper it is, the longer the waiting list. And sometimes it's gonna be done by interns. But often, even if it's done by interns, it's really supervised, you know, and, and overseen every step of the way by, by one of these high quality professionals, and that's a really good option if somebody can't afford to pay privately. And honestly, paying privately is a huge expense. It is a huge expense. Right. Um, so, so clinics attached to hospitals, training clinics attached to graduate programs, that's gonna be maybe a little bit lower quality care because that's, um... because that, you know, your, your testing is definitely being done by interns or by people who are, who are learning to become neuropsychologists. And at the same time, again, they're getting excellent supervision. They're doing a really thorough job. You could get a really good evaluation done like that for, usually for, like, sliding scale fees, so usually, like, $1,000 or less than $1,000. Um, so for example, um, uh, I know in Queens College has a, a training clinic like that attached. I know Pace University has a really excellent testing clinic attached to it in, you know, over in Manhattan. There's a lot of, a lot of those options. Then another option is community mental health clinics. So some of them, uh, don't have any testing departments. Some of them do. So for example, um, I actually supervise in a few different testing departments that are located within community mental health clinics, sometimes within federally funded community mental health clinics. And again, a long waiting list, um, and, and sometimes the people doing it are post-docs or even interns. Sometimes the people doing it are just clinicians there who are really good at what they do, um, and they're taking insurance fully. So there are those kind of options out there. Um- When you say long waiting lists, I'm sorry. When you say long waiting lists, how long do you mean? Usually six to 12 months. Yeah, because our developmental pediatrician- Right wait now is, like, three years. Wow. It's really a problem to the tune- That, that- It's really a problem that's, uh, that's not doable. You can't make- Right. And even 12 months might, might just be too long. Right. Yeah. Yeah. And I'm just gonna reiterate- Yeah the independent evaluation at district expense- Yes or asking directly, say, if you're thinking of autism, for that ADOS- Yeah you may be surprised to find that your early intervention or your child's or preschool or even sometimes your s- your older kids will do it if you ask for it. That's a fantastic, that's a fantastic option. One thing I recommend to parents, by the way, when they first call me and, and I tell them, "Okay, go to a psychiatrist," they probably, it's probably straightforward ADHD, so just go to a psychiatrist, they can diagnose that. But I will tell them, "And at the same time, get on the waiting list for, you know, the pediatric testing over at Columbia in case you realize that you really need a full neuropsych evaluation." So when you're on the waiting list, you can always cancel, but, you know, if, if you already went through the process with a psychiatrist, did a medication trial, you realize that you needed more information, you only have to wait three months instead of waiting nine months at that point. Um, I, this, this te- this testing startup that we have right now is, the, the dream of it is to increase accessibility, reduce wait time, and reduce prices. And what we're doing is we're basically building this portal for neuropsychologists and for other mental health professionals to use to write the evaluations for them based entirely on their clinical feedback. Uh-huh. So what we're cutting out of that is instead of taking six hours to write a report, it's gonna take two hours to write a report or one hour to write a report. And the idea of that is that, you know, instead of seeing one patient a week or two patients a week, a clinician should be able to see three patients a week, and they're, they're, they're spending so much less time on it that hopefully they'll, they'll be able to, you know, reduce the prices. Um, because right now the, the reason why, what, part of the reason why prices are so expensive is because it is taking so many hours of manpower for our clinicians to do a report. Um, so yeah, we're, we're trying to make it more accessible. You know, I, I also, I've, I've started testing departments within clinics because I wanna make it more accessible to people. Like, that's, that's a big passion of mine. I think that this is not a luxury item, a neuropsych evaluation. It isn't. Right. It shouldn't be. It shouldn't be. Thank you. A neuropsych evaluation is sometimes a necessity, and when it's a necessity- Right it shouldn't be a luxury item. It shouldn't be unaffordable. Um, sometimes it's not a necessity, in which case don't do it. You know? Why, why spend all that money and all that time when you could just go to a psychiatrist and get an excellent and, and thorough evaluation for ADHD, right? Um- Okay. But, but let me just make it clear. This- Yeah there is a dearth of child psychiatrists. Most people are not seeing a psychiatrist nowadays. Yeah. Just saying. Right. Maybe where you are, but in general that's a problem. They're in general going to their pediatrician. I would say where I am, people are seeing psychiatrists, but they're not always high-quality psychiatrists. To see a really high-quality psychiatrist, you might have to. Maybe you're getting the, the, you're getting the appointments but they might be with, um, you know, with psychiatrists who are not doing as full of a job Right. Um, and it may not be necessary, right? I mean, a lot of pediatricians will say, "I'm really comfortable with ADHD," and they're really good at it. Mm-hmm. So I'm not saying p- pediatricians can't do it. Please do not have this be the takeaway from this talk, people listening- Okay that you can't go to your pediatrician, but just pay attention to the quality of the evaluation. You are your child's best advocate, right? Like anxiety should really be screened for, right? So can you speak to that? I would love you to speak to that. What would, when a parent's observing the pediatrician evaluating their child for ADHD, when do they know, "Okay, they did a good job," and when do they know no, this is not sufficient and I'm not, I'm not giving my kid medication based on just this"? So the pediatrician should do, of course, a medical review. You don't have to do a huge, um, a huge rule-out. You do not have to do testing for a million things at all. It is not the standard of care. It is a clinical diagnosis that you can make, and you can start a trial of medication. But my main concern is that we not miss really a few things: immaturity, like the young boy in the grade- Mm-hmm uh, anxiety, depression, sleep apnea, OCD. Like, a lot of emotional behavioral issues can present as ADHD if you don't look for it. Right. And so it's not terrible if your child gets an ADHD diagnosis and it's wrong. The medication goes in and out of the system. It's not terrible, but the parent is going to have to be paying attention to what's been looked at. You're not going to get a full psych eval from your pediatrician, and you're not going to get it from a lot of places where you're, I don't want to use the word psychiatrist, where they're doing ADHD evaluations. It, it, it tends to be basic. Okay. Well, so, uh, just a follow-up question for you. Um, would you, would you think that the pediatrician really has to, for example, give more than a screening questionnaire like the Vanderbilt or collect data from the teacher or from, from other settings other than the parents? Or you feel like- So you can never make a diagnosis of ADHD without a teacher Vanderbilt, a teacher input as well. Right. You're not allowed to. That's standard of care. It has to be that they're having deficits in, you know, attention- hyperactivity, impulsivity in at least two settings, school and home. Right. So there must be at least a parent and teacher Vanderbilt. Right. So if a chi- if a parent goes to a pediatrician or a neurologist and they give them the Vanderbilt and they s- which is a screening measure for ADHD, right? Mm-hmm. And it's, you know, whatever it is, 30 questions, 25 questions, and the parent fills it out, and then the teacher, the pediatrician says to them, "Does the teacher also report problems?" And the parent says, "Yes"- The teacher has to fill it out Okay, fine. That was my question to you. Thank you. Of course. So, so, okay, so, so this is for parents out there. If your pediatrician is not, or if your psychiatrist for that matter, isn't gathering data from more than one source, then you, you wanna advocate for that. You wanna say, "Hang on one second. Can we also collect... Can, can we... You know, could you give me some questionnaires to give the school, for example, so that we're really sure that this is what's presenting at school as well?" Right. I also believe that it's very important to screen for anxiety, and in the older kids- Mm-hmm particularly the teenagers, depression as well. Mm-hmm. Really, really important, because if the kid's not paying attention, you don't know what's going on inside their head unless you ask. Right. Right. And that- Right anxiety screen has to be from the child themselves if they're old enough, not just the parent. That's great. That's great. I love that. Yeah. That makes a lot of sense. Thanks. So that, that's really, really important. I think it's important to ask about sleep apnea symptoms, to look at their height and weight, you know, to do a full medical review, but not... One of my pet peeves as a pediatrician is that the kid will come to me saying, "The school thinks my kid has ADHD. They want you to rule it out." I'm like- Mm-hmm "It doesn't work like that." Or, "They want me to go to a neurologist to diagnose it." Like, I can diagnose it just like a neurologist can. You do not need an MRI or an EEG, unless there is the potential- Mm-hmm of seizures, which is only a minority of these kids. You should get a history to see- Mm-hmm, mm-hmm if they get staring spells, and then consider evaluation for that- Right and then a neurologist is appropriate. But not every kid needs a neurologic workup, and- Right they do not need to be ruled out by all these different specialties. I wanna make it clear that you should have a basic overview, but it doesn't have to be a deep dive to clear for the diagnosis of ADHD. And by the way, you can have ADHD and sleep apnea and a bunch of other things. Right. You know, ADHD phon- co- very commonly coexist with mood disorders, so it may not be either/or. Right. Right. And that's where that neuropsych piece may come in, when you start having a more complex kid. That's exactly right, yeah. I agree with that. So I think we covered a lot. We did. This was a fun conversation. There's a lot more that we could've covered, but this was a fun conversation. I know. And I think it's helpful. I, it really was, and I really wanna thank you because you provided the neuropsychologist piece, and I provided the pediatrician in the trenches piece. And together I really think- I love that we're helpful In the trenches, I love that. Yes. That was, that was, uh, that was, like, very grounding for me to hear like, okay, fine, now this is how it plays out in real life. That's a good- that's good to know and good to note. Thank you. Right. And again, hugs to all pediatricians. I, I know that you're doing so much for our kids with so little time. It's really hard. Again, for parents, do not try to fit this into your child's well visit. You know, make sure enough time is allocated for the visit to do this, and it may take multiple visits too, by the way. One of the things I have also is it's not one and done. Right. Just like- Right. You know, when you get these comprehensive evaluations by these professionals- Right developmental pediatricians, psychiatrists, that may not be accessible for money or just because of availability, and you're going to your pediatrician instead, accept, expect multiple visits. That's expectation management. Expect multiple visits, and they may be by telehealth because that may be the way it is. You know, it may be without your child, it may be without your child and with your child. It really should be done with enough time for them to go through all the pieces and come back with good information. That's a good takeaway. That's important. So I really wanna thank you for doing this with me. I really appreciate it. Pleasure. It's such a pleasure. I'm glad we finally managed to get it done. We did it. Thank you. Thank you for listening to Kids Matter. Raising Healthy, happy Children Takes a village, and I'm grateful you are part of ours. If today's conversation resonated with you, please share this episode with another parent, grandparent, teacher, or anyone who cares about kids. Together we can build a supportive community our children deserve. I'd love to hear from you. Share your thoughts, questions, or suggestions for future topics at Kids Matter podcast@gmail.com. With no explanation for your voice truly matters. Until next time, keep advocating for the children in your life because kids really do matter. They are our future. I'm Dr. Elisa Minkin and this has been Kids Matter. Please note that while I am a pediatrician, I am not your child's ped. This podcast is for informational purposes only and does not constitute medical. For any medical concerns or decisions. Reach out to your child's healthcare professional.