Once you have decided to take the initial step by scheduling an appointment for your child or teenager to be evaluated, we will email you our paperwork. This will save you valuable time during the initial visit.
We split our neuro-developmental new patient process into two separate office visits. The first visit will be the consultation and neurological examination. The second will be a visit to go over the findings of the examination with the parents. This two-visit process allows ample time for Dr. Childs to be as thorough as possible when analyzing your child's history, exam findings and lab results. Remember our process is very detailed because we are looking to find the specific underlying cause of your child's issue.
Here is exactly what will happen during each visit:
Visit 1:
Usually takes 60-90 minutes and includes the following:
Consultation:
We will sit down and discuss your child's case and review any prior testing to fully understand your child's issues. Some parents feel more comfortable when the consultation is done with the initial part being a time to talk with the parents while the child is not in the exam room. This allows the parents to freely discuss their concerns with Dr. Childs without worry of having their child listening. Usually the child can wait supervised in our reception area or play room. We then do a consultation with the child in the room to get to know them. After the consultation we will do a neurological examination which typically will include the following painless tests:
- Vitals
- Balance testing
- Working memory testing
- Eye movement and tracking
- Reflexes
- Muscle tone testing
- Sensory testing
- Coordination testing
- Gait analysis
- Posture testing
- Primitive/infantile reflex testing
- Gross and fine motor testing
- Core muscle strength testing
- Interactive metronome testing
- Advanced neurological testing if necessary (explained in detail below)
- If necessary, a preliminary bloodwork script will be given to be completed at a local center such as Quest or Lab Corp for another day prior to the report of findings
Visit 2:
Usually takes 30-45 minutes. After taking the time to review the history, exam findings and lab results Dr. Childs will sit down with both parents and discuss his findings, answer any questions you may have and then let you know if he has decided to acccept your child's case. Dr. Childs will discuss his recommendations for care and any necessary special lab tests beyond the preliminary bloodwork. On this visit all fees for continuing care and special lab testing will be discussed.
The advanced neurological testing procedures listed below allow us to pinpoint brain impairments that may be responsible for your child or teenager's neuro-developmental concern. Most children 6 years old and over have no problem having these computerized oculomotor tests performed. In fact most think the goggles are pretty neat. Some younger children or those with more advanced autism or sensory issues may not have these tests or others performed. In those cases we rely on the bedside neurologic examination testing.
Video Nystagmography VNG
VNG is a computerized system used in the assessment of the oculomotor system (nervous system control of eye movement) and the function of those areas of your brain controlling these movements.
The VNG test is comfortably performed in our office. We simply place special goggles with an infrared camera on your child or teenager's head to record and measure their eye movements in both light and dark conditions. Specific areas and pathways of your child's brain are activated during different types of eye movements. During the test, computer software is recording and graphing their precise eye movements as they follow a visual target with their eyes. By measuring their recorded eye movements and displaying them on the computer screen, we can see how they compare to normal measurements.
Specific areas and pathways of the brain are activated during different types of eye movements. During the test computer software is recording and graphing your precise eye movements as you follow the visual target with your eyes. By measuring your recorded eye movements and displaying them on the computer screen you can see your own eye movements and how they compare to normal measurements.
The following eye movements are measured by VNG:
- Gaze Stability: It is essential that the brain stabilizes the gaze of the eyes for proper focus and attention as well as motor coordination. One of the most common ocular motor deficiencies seen in neuro-developmental cases is poor gaze stability. This can be seen on the VNG tracing.
- Pursuits: Pursuits are slow and steady eye movements that allow you to track a moving object. Good, smooth pursuits are essential to everyday functions but are particularly important in the mechanics of reading. When a patient reads the line of words in a book they are using their pursuit mechanism. The smoothness of the pursuit mechanism is commonly altered in neuro-developmental disorders.
- Saccades: Saccades are fast eye movement used to shift a person's gaze from one object to another. Saccades are generated by the frontal lobes of the brain. The frontal lobes are important in executive functions such as attention. A child's saccades can be evaluated to determine their level of frontal lobe development and function. Saccades need to be fast and accurate. Saccades are also used in reading when a person shifts their line of site from one line they are reading to the next. If the saccades are not accurate this can affect a child's ability to read.
- Optokinetics (OPK): This is an essential eye movement that allows for visual function as the surrounding visual environment passes by. When these are dysfunctional it can indicate poor brain function. Rightward OPK is generated by the right brain and leftward OPK is generated by the left brain. The quality of the OPK response can help us determine what side of the brain is not functioning as well. This brain imbalance is seen in many neuro-developmental disorders
- Vestibular Ocular Reflex: When you child moves their head their eyes should move equally in the opposite direction if this reflex is functioning properly. This reflex is poorly developed in children with neuro-developmental disorders.
The VNG eye movement tracings provide invaluable neurologic information concerning specific areas of your child or teenager's brain. We are experts at analysing these specific eye movements and determining if they have been developed properly and are functioning properly. We correlate the VNG findings with our other testing and examination procedures to develop a specific therapeutic program for each individual child.
Saccadometry
We also measure your child's saccades using saccadometry. As described above saccades are quick movements of your eyes that allow you to voluntarily move your eyes quickly from one object to another or to react by moving your eyes to a suddenly appearing target reflexively. Saccades can also be measured using a device called a saccadometer. The saccadometer measures different aspects of the saccades than the VNG measures. The saccadometer is strapped around your child's head using an elastic headband. Within the unit, there is a laser that projects targets onto the wall that a patient will look at quickly or saccade to. The saccadometer will measure the eye movements at the same time.
Studies have shown saccadic testing to be a very accurate way to detect areas of improper brain development and function. This test cannot be altered voluntarily by the patient because you cannot consciously control the speed of your eye movement during each saccade; your eyes move as fast as they can. The purpose of your saccadic eye movement is to aim the part of your eye with the best vision (fovea) at the thing you want to see most, and then hold your eye there as you examine it.
Saccades are the only human physiological function that use every area of the brain. It is for this reason that we can evaluate a person's saccades to determine what areas of the brain are not functioning at par.
Some of the brain areas used in controlling saccades involves three main brain regions: the frontal eye fields, the parietal eye fields, and the supplementary eye fields; and several subcortical areas in the basal ganglia, thalamus and brainstem. These areas are commonly not developed as well as they should be in children with neurodevelopmental disorders.
Saccadometry very precisely measures these aspects of saccades:
- Latency: This is the reaction time taken for the saccade to fire or activate after a new stimulus or target is presented. A normal reaction time should be less than 200ms.
- Velocity: The speed of a saccade is highly related to health of areas in the brain stem commonly affected in neurological disorders.
Accuracy: The ability to make the eyes stop and land directly on the target they are saccading to or looking toward is essential to a person functioning in their environment accurately. If the saccade overshoots or undershoots the target it may indicate that the cerebellum or the area of the brain that makes the environmental grid may not be functioning so well.
The saccadometer computerized graph shows leftward saccades that are generated by the right brain hemisphere as red and the rightward saccades that are generated by the left brain as green. This can be very useful in determining what side of the brain is out of sync.
Interactive Metronome (IM) diagnostic testing
We use interactive metronome long and short form diagnostic testing to assess a child's focus, timing and ability to coordinate visual and auditory stimulation while doing a gross motor skill.
IM is an assessment and treatment tool used by therapists and other professionals who work with pediatric and adult patients with neurological conditions that affect cognitive and motor functioning. IM provides an objective method for measuring deficits and for tracking improvement.
IM is an evidence-based and engaging therapeutic modality that improves cognitive and motor skills. The design of the program ensures that patients recognize progress as it occurs, increasing their motivation toward therapy and their ultimate recovery.
IM is used to improve:
- Attention
- Coordination
- Language processing
- Reading and math fluency
- Control of impulsivity/aggression
