Neuropsychological Assessment of Developmental and Learning Disorders 425
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Chapter 18. Neuropsychological Assessment of Developmental and Learning Disorders 425 18 Neuropsychological Assessment of Developmental and Learning Disorders Lois M. Black, Ph.D., and Gerry A. Stefanatos, D.Phil. INTRODUCTION In what follows, a summary description of what is involved in neuropsychological Neuropsychological assessment plays an evaluations of children with developmental important role in the diagnosis and treatment or learning disorders will be offered. The of children with developmental and learning chapter will review some basic issues in child disorders. A neuropsychological evaluation neuropsychological assessment, offer some can provide critical information regarding the guiding principles and procedures for the integrity of the central nervous system and assessment process, and give an overview of give a detailed picture of a child’s neurocog- a format for a comprehensive assessment. nitive functioningi across a wide range of To be noted is that the evaluation abilities. Notably, neuropsychological assess- approach to be sketched here is not a conven- ment can contribute to a functional develop- tional one: For one, as neuropsychological, it mental approach by elaborating upon a uses knowledge of brain-behavior relation- ships to orient its assessment and interpreta- child’s unique profile of strengths and weak- tion procedures. Moreover, it goes beyond a nesses and the particular component skills primary focus on standardized procedures, and processing deficiencies that may be con- structured tests, and quantitative levels of tributing to developmental, learning, and performance that may characterize more tra- social-emotional adaptation or difficulty. ditional psychometric approaches in psycho- Neuropsychological assessment can help dis- logical or educational testing. These may fall tinguish neurogenic (brain-based) from psy- short of capturing who the child with a devel- chogenic (psychological) conditions, sort out opmental or learning disorder may inherently how problems in one domain of functioning be because not exploratory nor flexible may impact on another, and guide education- enough, nor focused sufficiently on the al, remedial, and psychotherapeutic interven- dynamic process of how the child learns and tions. Neuropsychological assessment can the ways in which he can and cannot demon- also be used for monitoring progress or dete- strate what he knows. An evaluation must, rioration over time, and for refining our importantly, capture the impact that any understanding of the diversity and common- handicapping condition may have on the alities that may be inherent to a given devel- child’s ability to participate in the assessment opmental disorder across children. process, perform on any test, or function 426 ICDL Clinical Practice Guidelines adequately in life. For many children, espe- developmental neuropsychological assess- cially those with disorders in relating and ment currently in practice, for which there communicating, a more therapeutic, flexible, are a number of resources. (Baron, Fennell, & and clinically insightful approach must also Voeller, 1995; Bernstein & Waber, 1990, be adopted in order to woo the child into per- Fennell & Bauer, 1997; Fletcher & Taylor, forming in a way commensurate with what he 1984; Gaddes, 1985; Hynd & Obrzut, 1981; can do, or in order to find out what strategies Hynd & Willis, 1988; Obrzut & Hynd, 1991; will work to enhance functional developmen- Pennington, 1991; Reynolds & Fletcher- tal capacities, adaptation, and learning. In Janzen, 1997; Rourke, Bakker, Fisk, & addition, the approach outlined here is an Strang, 1983; Rourke, Fisk, & Strang, 1986; integrative one: It integrates neuropsycholog- Spreen, Risser, & Edgell, 1995; Stefanatos & ical assessment with clinical understanding Black, 1997; Teeter & Semrud-Clikeman, of the child’s inner world, as well as family 1997; Vanderploeg, 1994; Wilson, 1987, and school system issues, in order to provide 1992). Rather, it will briefly highlight some a more powerful diagnostic procedure that issues distinctive to child neuropsychology can also disclose the possible interweaving of and focus on an assessment approach that both psychological and neuropsychological emphasizes especially the importance of issues in the subjective experience and seeking out ways to capture a child’s inherent behavior of the child. abilities so as to best promote a child’s cogni- The aim of this chapter is to provide an tive and emotional development. overview of an approach to neuropsycholog- A summary of when, generally, to seek a ical evaluation that can serve as a guide to neuropsychological evaluation is contained assessing children with a wide range of in Chart 1. developmental and learning problems. Its focus is not limited to children with the more A NEUROPSYCHOLOGICAL severe disorders, such as autism or pervasive APPROACH TO EVALUATION: developmental disorders (PDD) (see, for ISSUES DISTINCTIVE TO example, Lord, 1997; Sparrow et al, 1997). DEVELOPMENTAL Yet, the principles to be reviewed here can be NEUROPSYCHOLOGY applied to assessment of children who show overt, severe difficulties as well as more hid- What is Neuropsychological den ones. For young children on the spectrum Assessment? of disorders in relating and communicating, these guidelines may be particularly relevant Neuropsychological assessment is dis- for those children who show characteristics tinguished from other forms of assessment (e.g., mild to moderate processing difficul- primarily by its attempt to understand a child’s ties, intermittent symbolic capacities) similar behavioral and psychological functioning in to a subgroup of children identified as mak- terms of brain-behavior relationships. In con- ing rapid progress over time and showing trast to psychological assessment of a child’s eventually more subtle problems (Type I intellectual and personality functioning, a neu- Disorder in relating and communicating, ropsychological evaluation bases its explo- Greenspan & Wieder, 1997, 1999). Neither is ration and interpretation of a broad range of this chapter meant to be a detailed treatment functions—spanning reasoning, attention, lan- of the various issues and approaches to guage, memory, visual, sensory-perceptual, Chapter 18. Neuropsychological Assessment of Developmental and Learning Disorders 427 Neuropsychological interpretation of a Chart 1. child’s functional difficulties rests on the inte- When to Seek a Neuropsychological gration of data obtained from performances Evaluation on formal and informal tests, clinical obser- • When it is unclear whether or to what vations, and history (including the child’s extent overt emotional, behavioral, or developmental, medical, educational, social, learning problems have a basis in CNS and cultural history), with what is known dysfunction. about the pathophysiology, brain basis, and • When greater specificity in a child’s neuropsychological profiles of different neu- unique profile of strengths and weak- rologically based developmental conditions. nesses is sought for therapeutic, edu- Although an understanding of brain cational, or remedial planning. development and brain-behavior relationships • When a baseline understanding of the may set it apart, many of its assessment prin- child’s functioning is needed to moni- ciples and procedures may, nevertheless, tor growth and progress or the effec- overlap with good psychological assessment tiveness of therapeutic interventions practice. Thus, the guidelines proposed here (e.g., biomedical, social, remedial). are considered applicable to good practice in • When there is a complicated condition psychological assessment more generally. that gives rise to differing opinions Neuropsychological assessment, as put forward and a clearer differential diagnosis is here, rests fundamentally on an hypothesis- sought. testing approach that incorporates principles • When a more active brain process or of dynamic learning into its core assessment neurological condition may be sus- procedures, understands the multifactorial pected and needs to be ruled out. nature of complex tests and behavior, and is inherently comprehensive and integrative in its approach to understanding the whole child motor, as well as affective and personality in the context of his environment. functioning—on a theory and model of the developing brain and on an understanding of Understanding Brain-Behavior brain-behavior relationships. A principle goal Relationships, Brain Maturation, of a neuropsychological evaluation is to deter- and Brain Plasticity mine the extent to which a child’s possible dif- ficulties in, for example, thinking, attending, Child neuropsychology has emerged as a talking, listening, remembering, learning, or distinct area within the field of clinical neu- even in emotional lability or behavioral dis- ropsychology largely as a consequence of the turbances, may form a pattern of impairment recognition that brain-behavior relationships related to central nervous system (CNS) dys- in children differ in many ways from those function. When coupled with clinical under- established in adults. The developmental con- standing of psychological dynamics in child text of child neuropsychology requires that and family, neuropsychological assessment attention be paid to normal brain maturation can also contribute to uncovering how neuro- and its correlation with the changing com- psychological dysfunction may become exac- plex processes that develop over childhood, erbated by or implicated