Developmental Neuropsychological Assessment
Fundamental Assumptions of Neuropsychological Assessment of Children
Clinical assessment in neuropsychology requires extracting diagnostic meaning from an individual’s history, observations of behavior, and performance on targeted tests with the goal of optimizing adaptive functioning.
In evaluating behavior the clinician must bring to bear knowledge of the neuroanatomic circuitry supporting behavior, strategies for elucidating relevant brain–behavior relationships, and understanding of environmental and cultural influences on the functioning of the individual child. The developmentally framed analysis of behavior entails an understanding of trajectories of behavioral change through childhood/adolescence and of the dynamic changes that occur in the neural circuitry that supports behavior.
At all points in development observed behavior is a function of the interaction of the brain with the environment—from fundamental genetic processes to the complex epigenetic interactions of personal experience and cultural variables that shape the neural circuitry and the individual. The neuropsychologist must analyze both neurological and psychological (behavioral) variables and must situate these within a wider social context, requiring sensitivity to issues of culture, language, and diversity.
Basic Assumptions of Developmental Analysis
Development implies a dynamic interaction between an organism and its environment. The principles at the core of a developmental neuropsychological (NP) analysis of behavior (p. 101) are those of the developmental sciences: structure, context, process, and experience. In the developing child the contribution of brain to observed behavior cannot be meaningfully assessed without reference to the child’s developmental course, maturational status, immediate environmental demands, and wider sociocultural context. Knowledge of normal development and its variation is a prerequisite for all developmental analysis.
A perturbation of the brain at any point in time is necessarily incorporated into the subsequent developmental course. Both neurological and behavioral development will proceed in a different fashion around the new brain organization.
A brain insult will have differential impact on behavioral outcome as a function of the developmental status of the disrupted brain system at the time of the insult.
The behaviors (symptoms) that prompt referral occur in the context of the expected competencies of the child at a given developmental stage. Thus, the same underlying neuropsychological problem will be manifest in different ways at different points in development. Over time, the intersection of brain difference and change means that the child is at risk for failure to acquire new skills at all developmental levels.
Indications for Neuropsychological Assessment
In contrast to adults, children with suspected neuropsychological problems undergo frequent psychological and/or educational testing. Overtesting thus becomes of serious concern. Clinicians should carefully review referral questions. In many instances NP consultation, rather than comprehensive NP assessment, is indicated. NP assessment should be considered under the following circumstances:
• Unexpected failure to meet environmental demands in academic or psychosocial contexts
• Lack of adequate explanation for presenting behavior, or insufficient information to guide intervention planning, subsequent to psychological, psychiatric, psychoeducational, or multidisciplinary assessment
• Change in behavior in the context of known/suspected neurological disorders, systemic disorders and/or treatment regimens with potential central nervous system impact, degenerative/metabolic/genetic disorders, and disorders associated with structural central nervous system abnormalities
• Need to clarify the relationship of behavioral change to specific medical/neurological/psychiatric diagnoses or to specific neural substrates
• Need for baseline profile and ongoing monitoring of neurobehavioral status to track recovery, effects of treatment, and/or the impact of developmental change on behavioral function
• Measurement of change in clinical research with neurological, psychiatric, and psychological populations
NP assessment provides important information to aid in the better understanding and management of behavioral consequences of childhood disorders (e.g., disruptions of executive capacities in spina bifida, prematurity, or attentional disorders; behavioral late effects in treated brain tumor and leukemias; the impact of seizure activity and/or medications in epilepsy) and of neuropsychological contributions to specific behavioral conditions (e.g., psychiatric disorders such as schizophrenia, obsessive-compulsive disorder, Tourette’s syndrome; language processing in reading disorders; the interplay of social and cognitive factors in outcomes of traumatic brain injury; deficits in processing socially relevant information).
NP services are typically provided in the form of the following:
(a) Comprehensive individual assessments (outpatient)
(b) Consultation—to educational, psychiatric, social work, medicine, and rehabilitation professionals—including review of records, analysis of behavioral data, application of neurologically relevant information to everyday settings (home, school), and assistance in diagnostic formulation and intervention strategies (p. 102)
(c) Inpatient assessment or consultation to localize function (seizures), monitor behavioral change in the intraoperative setting, and document behavioral functioning in patients with altered mental status
(d) Forensic evaluation to provide a comprehensive description of cognitive functioning and psychosocial adjustment to address future risks/needs or document damage in forensic situations.
Diagnosis in Neuropsychology
Diagnosis in neuropsychology is based on a formal assessment strategy that is ideally formulated as an experiment with an N of 1, theoretically driven, with hypotheses that are systematically tested and with a design and methodology that include appropriate controls for variability and bias. The expert clinician selects relevant evidence from a diverse knowledge base, entailing a multimethod approach to tap an appropriate range of behavioral domains. The strategy both addresses the referral questions and is framed within the biopsychosocial context of the child’s life. It incorporates adaptive competence, emotional well-being, and functional processing style, as well as cognitive and academic abilities. The strategy integrates the vertical dimension of development with the horizontal dimension of the child’s current neurobehavioral repertoire. Relevant diagnostic data are analyzed in the context of known neuroanatomic circuitry that underlies adaptive behavior and of the child’s unique sociocultural context. Brain–behavior relationships are derived from integration of data from a detailed history of the individual and his or her symptoms, closely observed/reported behavioral reactions/responses in ecologically valid settings, and structured behavioral observations and levels of performance on selected psychological tests.
The diagnostic formulation is the basis for referencing the child’s profile to categories of neurological, psychological, and/or educational disorders. These categories can be framed in terms of neuropsychological or neurodevelopmental variables, specific psychological (cognitive, perceptual, information processing, motivational) factors, primary academic deficits, and/or specific nosological schemes (e.g., DSM, ICD). The diagnostic formulation is the basis for determination of risk (prediction of future response to expectable challenges, both psychosocial and intellectual) and for the design and implementation of the comprehensive, individualized management strategy that addresses the pattern of risks faced by this child in this family with this history, this profile of skills, and these goals (both short and long term).
In NP assessment, behavioral domains are the units of analysis. These can be organized and labeled differently by clinicians with differing theoretical perspectives. What they have in common is that they are sufficiently wide-ranging to address both the behavioral repertoire of the individual being assessed and the referral question(s). Domains include the following:
• Regulatory and goal-directed executive capacities (arousal, attention, motivation, memory, learning, mood, affect, emotion, reasoning, planning, decision making, monitoring, initiating, sustaining, inhibiting, and shifting abilities)
• Skills and knowledge bases (sensory and perceptual processing in [primarily] visual and auditory modalities, motor capacities, communicative competence, social cognition, linguistic processing, speech functions, spatial cognition)
• Achievement (academic skills, adaptive functioning, social comportment, societal adjustment)
The neuropsychologist derives relevant data from personal interviews, the child’s history, observations of behavior, and psychological test performance. The history is typically obtained from interviews of the child, parent(s)/guardian(s), and relevant professionals; medical/educational records; and questionnaires/rating scales. The goal is to determine the child’s heritage (genetic, medical, socioeconomic, cultural, educational) derived from the family history and to assess the child’s ability (p. 103) to take advantage of this heritage (the child’s developmental, medical, psychological, and educational history). Systematic interviewing provides critical information about the social competencies of the child with peers and adults in different settings, as well as the attributions given by others as to the nature and source of the child’s presenting difficulties.
Observational data are derived from examination of the child’s appearance and behavior, questionnaire/interview information obtained from people familiar with the child in nonclinical contexts, direct observation of the child–parent interaction, analysis of the examiner–child dyad, and observation of the child’s behavior and problem-solving style under specific performance demands.
Tests provide psychometric data relating level of performance to that of same-age peers; behavioral data (behaviors elicited under different problem-solving demands, problem-solving strategies for reaching solutions); and task analysis data (complexity of task demands, allocation of resources, systemic relationships in task/situation). They tap specific aspects of behavioral function and are constructed according to sound psychometric principles, administered rigorously, and scored according to standard guidelines. Their normative data should be up to date, reliable, valid, and appropriate in terms of age and/or cultural or language group for the population under study. Population-based standardized psychological test instruments are an important component of a comprehensive NP assessment protocol. They comprise a measure of general mental/cognitive abilities, appropriate to the child’s age and general competency, that provides a context of general ability against which specific neuropsychologically relevant skills and weaknesses can be evaluated. Additional tests are selected to address other behavioral domains and provide more detailed analysis of specific psychological processes. These may have population-based or research-based norms. The latter typically have less extensive normative bases but can target specific skills more precisely.
Analysis of performance on psychological tests presents the clinician with a complex challenge. No test measures just one thing. All behavior, including test responses, is the result of a complex interaction of motivational/emotional, motor and sensory capacities, and perceptual, cognitive, and executive variables. Test performance varies in response to contextual factors, including the nature of the test setting, rapport with the clinician, age of the child, test format/materials, and test construction/scoring criteria. No test can be rendered so objective that the interaction between child and examiner is eliminated as an important source of diagnostic information. Test performance is also influenced by a child’s prior experience with test procedures and attitudes, and the cultural values ascribed to the testing activity and its purpose. It can be undermined by lack of effort/motivation, by emotional distress, and by physiological factors (lack of sleep, inadequate nutrition).
Communication of Findings
A clinical assessment is essentially worthless if the findings are not communicated effectively to the people responsible for the child’s care and development. The neuropsychologist communicates findings by means of an informing (or feedback) session and written report. These are both necessary and complementary. In the informing session the clinician’s responsibility is not only to communicate the clinical findings but also to explore and explain their meaning and relevance for the child’s ongoing adaptive functioning since intervention/treatment goals that lack meaning for patients/families are often not followed. The session also provides an opportunity for parents to discuss and reframe their understanding of the child with the goals of empowering them in their support of the child in the future. The report provides details of the assessment process, the meaning of behavioral observations, the scores derived from standardized measures, the diagnostic formulation, and the management plan and recommendations.
The goal of the informing session and the report is to educate the child, parents/guardians, and teachers/other professionals about (p. 104) the nature of children’s neurobehavioral development in general; to explain how brain– behavior relationships in children are examined in the evaluation; to normalize this child’s NP performance by situating it in the larger context of neurobehavioral development; to relate observed behaviors to the specific medical/neurological condition (where relevant); and to demonstrate the relationship of the diagnostic formulation to the management plan proposed. The written report summarizes relevant history, observations, and test findings organized so that the import of the findings is clear; integrates the findings into a clear diagnostic statement (not a list of performances on individual tests or of what the child can and cannot do); discusses the relationship of the diagnostic formulation to the child’s real-world adaptive functioning; addresses the referral question specifically; references the findings to the medical/neurological condition where relevant (noting specifically when data are, or are not, consistent with a known disorder and locus); identifies areas of concern (risks) based on or referenced to the diagnostic statement; and outlines the management plan and recommendations to maximize the child’s functioning in the real-world contexts of family, school, and society at large.
The Management Plan
A management plan has two important components: education and recommendations. The neuropsychologist educates the child, parents/guardians, and other involved professionals in several ways: describing/explaining neurobehavioral development in children; relating this child’s performance to that of other children (with and without a similar diagnosis); and providing detailed information about this child’s individual style, expectable risks (both short- and long-term), and educational and psychosocial/emotional needs. The clinician will also address issues of medical and psychological health, as well as development and achievement in academic/vocational and psychosocial spheres.
Recommendations respond to the specific risks that the child faces now and in the future; are tailored to different contexts as necessary; provide general guidelines for maximizing behavioral adjustment in both social and academic settings; foster specific cognitive, social, and academic skills; and address psychosocial development and emotional well-being. They include specific interventions involving accommodations, compensatory strategies, remedial instruction, rehabilitation programming, and/or assistive technologies, as well as referral for additional services/evaluation from medical, psychological, physical, and/or educational-vocational specialists as indicated.
Neuropsychological evaluation of the developing child will be increasingly informed by advances in understanding complex interactions among genetic risk factors, development, and medical conditions. Future research that compares developmental trajectories across conditions and evaluates the impact of neuropsychologically informed interventions will expand the evidence base for practice in this specialty.
References and Readings
Baron, I. S. (2003). Neuropsychological evaluation of the child. New York: Oxford University Press.Find this resource:
Bernstein, J. H. (2000). Developmental neuropsychological assessment. In K. O. Yeates, M. D. Ris, & H. G. Taylor (Eds.), Pediatric neuropsychology: Research, theory, and practice (pp. 401–422). New York: Guilford Press.Find this resource:
Donders, J., & Hunter, S. J. (Eds.). (2010). Principles and practice of lifespan developmental neuropsychology. Cambridge, England: Cambridge University Press.Find this resource:
Farmer, J. E., Kanne, S. M., Grissom, M., Kemp, S., Frank, R. G., Rosenthal, M., & Caplan, B. (2010). Pediatric neuropsychology in medical rehabilitation settings. In R. G. Frank, M. Rosenthal, & B. Caplan (Eds.), Handbook of rehabilitation psychology (2nd ed., pp. 315–328). Washington, DC: American Psychological Association.Find this resource:
Koziol, L. F., & Budding, D. E. (2009). Subcortical structures and cognition. Implications for neuropsychological assessment. New York: Springer. (p. 105) Find this resource:
Mash, E. J., & Hunsley, J. (2005). Evidence-based assessment of child and adolescent disorders. Journal of Clinical Child and Adolescent Psychology, 34(3), 362–379.Find this resource:
Morgan, J. E., & Ricker, J. H. (Eds.). (2008). Textbook of clinical neuropsychology. London: Taylor & Francis.Find this resource:
Stiles, J. (2008). The fundamentals of brain development. Integrating nature and nurture. Cambridge, MA: Harvard University Press.Find this resource:
Yeates, K. O., Ris, M. D., Taylor, H. G., & Pennington, B. F. (Eds.). (2010). Pediatric neuropsychology: Research, theory, and practice (2nd ed.). New York: Guilford Press.Find this resource: