PSYCHOLOGISTS'

DESK REFERENCE

AO Aaa |

TmHIirD EDITION

Editors
Gerald P. Koocher
John C. Norcross

Beverly A. Greene
- DEVELOPMENTAL
18 NEUROPSYCHOLOGICAL

ASSESSMENT

A
Jane Holmes Bernstein, Betsy Kammerer,
and Celiane Rey-Casserly

FUNDAMENTAL ASSUMPTIONS
OF NEUROPSYCHOLOGICAL
ASSESSMENT OF CHILDREN

Clinical assessment in neuropsychology

requires extracting diagnostic meaning from
an individual's history, observations of behav-
ior, 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 elu-
cidating 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/adoles-
cence 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 fundamen-
tal 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
18 o DEVELOPMENTAL NEUROPSYCHOLOGICAL ASSESSMENT 101

are those of the developmental sciences: struc-

ture, context, process, and experience. In the
developing child the contribution of brain
to observed behavior cannot be meaning-
fully 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 subse-
quent developmental course. Both neurologi-
cal 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 devel-
opmental stage. Thus, the same underlying
neuropsychological problem will be manifest
in different ways at different points in devel-
opment. 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 fre-
quent psychological and/or educational testing.
Overtesting thus becomes of serious concern,
Clinicians should carefully review referral
Juestions, 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 environmen-

tal demands in academic or psychosocial
contexts

* Lack of adequate explanation for present-

ing behavior, or insufficient information to
guide intervention planning, subsequent

to psychological, psychiatric, psychoeduca-

tional, 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 cen-
tral nervous system abnormalities
e 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 moni-
toring of neurobehavioral status to track
recovery, effects of treatment, and/or the
impact of developmental change on behav-
ioral function
+ Measurement of change in clinical research
with neurological, psychiatric, and psycho-
logical populations

NP assessment provides important infor-

mation to aid in the better understanding
and management of behavioral consequences
of childhood disorders (e.g., disruptions of
executive capacities in spina bifida, prematu-
rity, or attentional disorders; behavioral late
effects in treated brain tumor and leukemias;
the impact of seizure activity and/or medica-
tions in epilepsy) and of neuropsychological
contributions to specific behavioral conditions
(e.g., psychiatric disorders such as schizophre-
nia, obsessive-compulsive disorder, Tourette's
syndrome; language processing in reading
disorders; the interplay of social and cogni-
tive 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, psychiat-

ric, social work, medicine, and rehabilitation

professionals—including review of records,
analysis of behavioral data, application of neu-
rologically relevant information to everyday
settings (home, school), and assistance in diag-
nostic formulation and intervention strategies
102 PART 11 e PSYCHOLOGICAL TESTING

(c) Inpatient assessment or consultation to

localize function (seizures), monitor behav-
ioral change in the intraoperative setting,
and document behavioral functioning in
patients with altered mental status

(d) Forensic evaluation to provide a compre-

hensive description of cognitive function-
ing 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 knowl-
edge base, entailing a multimethod approach to
tap an appropriate range of behavioral domains.
The strategy both addresses the referral ques-
tions and is framed within the biopsychosocial
context of the child's life. It incorporates adap-
tive competence, emotional well-being, and
functional processing style, as well as cogni-
tive and academic abilities. The strategy inte-
grates 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 relation-
ships 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 obser-
vations 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 neurodevel-
opmental variables, specific psychological

(cognitive, perceptual, information processing,

motivational) factors, primary academic defi-
cits, 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 compre-
hensive, individualized management strategy
that addresses the pattern of risks faced by this
child in this family with this history, this pro-
file 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: dif-
fering 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;

e Regulatory and goal-directed executive

capacities (arousal, attention, motivation,
memory, learning, mood, affect, emotion,
reasoning, planning, decision making, moni-
toring, 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 cogni-
tion, linguistic processing, speech functions,
spatial cognition)
e 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 psy-
chological test performance. The history is
typically obtained from interviews of the child,
parent(s)/guardian(s), and relevant profession-
als; medical/educational records; and question-
naires/rating scales. The goal is to determine
the child's heritage (genetic, medical, socioeco-
nomic, cultural, educational) derived from the
family history and to assess the child's ability
18 e DEVELOPMENTAL NEUROPSYCHOLOGICAL ASSESSMENT 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 exami-

nation of the child's appearance and behavior,
questionnaire/interview information obtained
from people familiar with the child in non-
clinical contexts, direct observation of the
child-parent interaction, analysis of the exam-
iner-child dyad, and observation of the child's
behavior and problem-solving style under spe-
cific performance demands.

Tests provide psychometric data relat-

ing level of performance to that of same-age
peers; behavioral data (behaviors elicited
under different problem-solving demands,
problem-solving strategies for reaching solu-
tions); and task analysis data (complexity of
task demands, allocation of resources, systemic
relationships in task/situation). They tap spe-
cific aspects of behavioral function and are
constructed according to sound psychometric
principles, administered rigorously, and scored
according to standard guidelines. Their norma-
tive 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 psy-
chological 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 pro-
vides 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 analy-
sis of specific psychological processes. These
may have population-based or research-based
Rorms. The latter typically have less extensive
hormative bases but can target specific skills
More precisely.

Analysis of performance on psychologi-

Cal 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/emo-
tional, motor and sensory capacities, and per-
ceptual, 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/scor-
ing criteria. No test can be rendered so objec-
tive 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 cul-
tural 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, inad-
equate 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 com-
municates 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 adap-
tive functioning since intervention/treatment
goals that lack meaning for patients/families
are often not followed. The session also pro-
vides 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/guard-
ians, and teachers/other professionals about
104 PART 11 e PSYCHOLOGICAL TESTING

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 con-
text 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; ref-
erences the findings to the medical/neurologi-
cal 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 manage-
ment plan and recommendations to maximize
the child's functioning in the real-world con-
texts of family, school, and society at large.

THE MANAGEMENT PLAN

A management plan has two important com-

ponents: education and recommendations. The
neuropsychologist educates the child, parents/
guardians, and other involved professionals in
several ways: describing/explaining neurobe-
havioral development in children; relating this
child's performance to that of other children
(with and without a similar diagnosis); and pro-
viding 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 aca-
demic/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 aca-
demic settings; foster specific cognitive, social,
and academic skills; and address psychoso-
cial development and emotional well-being.
They include specific interventions involving
accommodations, compensatory strategies,
remedial instruction, rehabilitation program-
ming, and/or assistive technologies, as well
as referral for additional services/evalua-
tion from medical, psychological, physical,
and/or educational-vocational specialists as
indicated.

FUTURE DIRECTIONS

Neuropsychological evaluation of the developing

child will be increasingly informed by advances
in understanding complex interactions among
genetic risk factors, development, and medi-
cal 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, 1. S. (2003). Neuropsychological evaluation of

the child. New York: Oxford University Press.

Bernstein, J. H. (2000). Developmental neuropsy-

chological assessment. In K. O. Yeates, M. D.
Ris, £: H. G. Taylor (Eds.), Pediatric neurop-
sychology: Research, theory, and practice (pp.
401-422). New York: Guilford Press.

Donders, J., : Hunter, S. J. (Eds.). (2010). Principles

and practice of lifespan developmental neu-
ropsychology. Cambridge, England: Cambridge
University Press.

Farmer, J. E., Kanne, S. M., Grissom, M., Kemp, S.,

Frank, R.G., Rosenthal, M., 8: Caplan, B. (2010).
Pediatric neuropsychology in medical rehabili-
tation settings. In R. G. Frank, M. Rosenthal,
éz B. Caplan (Eds.), Handbook of rehabilitation
psychology (2nd ed., pp. 315-328). Washington,
DC: American Psychological Association.

Koziol, L. E, : Budding, D. E. (2009). Subcortical

structures and .cognition. Implications for
neuropsychological assessment. New York:
Springer.
19 e ASSESSMENT AND INTERVENTION FOR EXECUTIVE DYSFUNCTION 105

Mash, E. J., £: Hunsley, J. (2005). Evidence-based

assessment of child and adolescent disor-
ders. Journal of Clinical Child and Adolescent
Psychology, 34(3), 362-379.

Morgan, J. E., éz Ricker, J. H. (Eds.). (2008). Textbook

of clinical neuropsychology. London: Taylor 8:
Francis.

Stiles, J. (2008). The fundamentals of brain

development. Integrating nature and nur-
ture. Cambridge, MA: Harvard University
Press.

Yeates, K. O,, Ris, M. D., Taylor, H. G., éz Pennington,

B. E (Eds.). (2010). Pediatric neuropsychology:

Research, theory, and practice (2nd ed.). New

York: Guilford Press.

Related Topics

Chapter 8, “Interviewing Children's Caregivers”

Chapter 9, “Evaluating the Medical Components

of Childhood Developmental and Behavioral
Disorders”

Chapter 10, “Using the DSM-5 and ICD-11 in

Forensic and Clinical Applications with
Children Across Racial and Ethnic Lines”