• Attention and processing speed – in other words the ability to orient to, recognize and sustain attention in auditory and visual modes as reflected in processing speed, accuracy, time on task, divided focus among tasks, mental manipulation and control, as well as resistance to both internal and external distraction.
  
• Motor Performance-the ability to perform both gross and fine motor tasks, the ability to perform purposeful motor tasks on each side of the body.
  
• Sensory Acuity-in short, the ability to detect basic visual, auditory, tactile, and olfactory sensations that are critical to processing information at higher levels.
  
• Working Memory – that is the ability to keep both auditory and visual information active so that it can be operated upon mentally.
  
• Processing – the capacity to encode new information, store it in a relational memory network, and retrieve it when needed in order to apply that information in new situations.
  
• Calculation – the ability o manipulate mathematical concepts and symptoms to perform operations.
  
• General Intelligence – which is basically as summary of multifaceted abilities that reflects one’s ability to comprehend, adapt to and interact with one’s environment in meaningful ways.
  
• Language – in terms of the ability to understand and express thoughts employing various symbols (words, gestures) both auditorily and in visual formats (writing and pictures).
  
• Visual spatial processing – as expressed in terms of the ability to process, interpret, organize and assign meaning to visual stimuli both receptively in terms of perception and expressively in terms of construction
  
• Problem Solving and Judgment – this involves assessment of advanced, higher-order information processing which relies upon the comprehension and application of rules and theories.
  
• Abstract Thinking – evaluation of the ability to use generalized information and apply it to novel situations through generalization and modification based upon new data and environmental demands
  
• Mood and Temperament – Here the evaluator assess self-regulation, cognitive processing style, personality traits, believes, mental organization,
  
• Executive Functions – the ability to achieve insight and self-awareness or metacognition is assessed in terms of the ability to approach problems flexibly, to reflect on information and actions, to connect cause and effect, to generate hypotheses, to evaluate, to activate and inhibit both thoughts and behavior and to make considered decisions through the utilizing judgment and feedback.

A complete neuropsychological assessment requires a complete assessment of the child and their functioning in the environment. Of necessity it must include developmental and adaptive information reported by parents, structured observations at home and in school, observation of the processes that children employ in problem solving, valid and reliable norm referenced standardized measures such as the Halstead-Reitan Neuropsychological Test Battery, Kaplan Baycrest Neurocognitive Assessment, the Luria-Nebraska Neuropsychological Battery or the Denman Neuropsychological Battery. Normally, an evaluator will begin with their standard battery which gives them a basis for comparing the student to all the other student’s they have evaluated on these same measures. Next, they will add other tests to further assess areas that appear to reflect dysfunction. This is to insure that the suspected deficit, is in fact, a true deficit and not just a function of testing error or the patient’s temporary mood, as well as to consider specific aspects of that domain in more detail. Below are a list of common individual tests that may be employed as part of neuropsychological battery to further investigate specific areas of concern.

Domain	Neuropsychological Test
Intellectual functioning	Wechsler Scales Wechsler Adult Intelligence Scale-Revised (WAIS-R) Wechsler Adult Intelligence Scale-III (WAIS-III) Wechsler Intelligence Scale for Children-IV (WISC-IV) Stanford-Binet Intelligence Scale-IV
Academic achievement	Wechsler Individual Achievement Test  (WIAT) Woodcock-Johnson Achievement Test Wide Range Achievement Test Wechsler Test of Adult Reading
Language processing	Boston Naming Test Multilingual Aphasia Examination Boston Diagnostic Aphasia Examination Token Test
Visuospatial processing	Rey-Osterrieth Complex Figure – Copy condition WAIS Block Design Subtest Judgment of Line Orientation Hooper Visual Organization Test
Attention/ concentration	Digit Span Forward and Reversed Trail Making Tests Cancellation Tasks (Letter and symbol) Paced Auditory Serial Addition Test (PASAT)
Verbal learning and memory	Wechsler Memory Scale (WMS) Logical Memory I and II - Contextualized prose) Verbal Paired-Associates WMS-III Verbal Memory Index Rey Auditory Verbal Learning Test - Rote list learning (unrelated words) California Verbal Learning Test - Rote list learning (related words) Verbal Selective Reminding Test - Selective reminding (unrelated words) Hopkins Verbal Learning Test Rivermead Behavioral Memory Test Verbal Word Fluency Tests
Visual learning and memory	Wechsler Memory Scale Visual Reproduction I and II WMS-III Visual Memory Index2 Rey-Osterrieth Complex Figure - Immediate and delayed recall Nonverbal Selective Reminding Test Continuous Recognition Memory Test Visuo-Motor Integration Test - Block design Ruff Figural Fluency Test Test of Memory and Learning (TOMAL)
Executive functions	Wisconsin Card Sorting Test                                                  Category Test Stroop Test Trail Making Test-B WAIS Subtests of Similarities and Block Design Porteus Maze test                                                                     Multiple Errands Test (MET) Tower of London
Speed of processing	Simple and Choice Reaction Time Symbol Digit Modalities Test - Written and oral Tactual Performance Test
Sensory-perceptual functions	Halstead-Reitan Neuropsychological Battery (HRNB) Tactual Performance Test and Sensory Perceptual Examination Luria Nebraska Neuropsychological Battery
Motor speed and strength	Index Finger Tapping Grooved Pegboard Task Hand Grip Strength                                                                          Thurstone Uni- and Bimanual Coordination Test
Motivation	Rey 15 Item Test Dot Counting Forced-Choice Symptom Validity Testing Validity Indicator Profile Word Memory Test Test of Malingering
Personality assessment	Minnesota Multiphasic Personality Inventory  (MMPI) Millon Clinical Multiaxial Inventory Beck Depression Inventory (BDI) Rorschach Test Thematic Apperception Test for Children or Adults Wonderlic Personnel Test SCL-90 Symptom Checklist 90 Shipley Institute of Living Scale

Sometimes, when the evaluator has the expertise, these assessments are correlated with either a Quantitative EEG or a functional MRI to more clearly associate the documented dysfunction with cerebral status. The Quantitative EEG which collects the typical 10-20 montage EEG data under eyes closed alert, eyes open and cognitive challenge conditions and compares the individuals brain wave patterns to a normative database of same age and same sexed individuals with normal cerebral functioning can be particularly helpful in guiding medication decision and in customizing EEG neurofeedback protocols for remediation of certain neuropsychological problems such as attention deficits.

The key aspect of neuropsychological assessment however, is not just the administration of objective psychological tests and related procedures which have been proven sensitive to the effect is of brain injury, but, the selection of examination procedures that are specific for measuring functional changes due to impairment of specific cognitive domains such as attention, short-term memory, social cues recognition, and so forth. Also crucial is the integration of the statistical and observation findings with the history to reveal a logically consistent pattern commonly seen with specific brain disorders and weaving this together with the medical history and mechanism of brain injury or disease to make sense of the present mental functioning and develop a program of rehabilitation and an Individualized Educational Plan based on the measured strengths and weaknesses in functional domains and the lifestyle of the individual. In other words, the final report should empower those who interact with the child to help the child maximize their strengths, rehabilitate cerebral dysfunction if possible, and compensate for weaknesses that will not respond to remediation.

So how do I know if my child needs a neuropsychological evaluation?

Because neuropsychological evaluations are performed by highly trained and experienced psychologists, and as they require an extensive amount of time they are also very costly. For this reason, parents don’t want to pursue this type of evaluation needlessly. Therefore, it is the early phases of diagnostic exploration and the presence of brain injury or disease is not yet compelling, but, there is just a suspicion, one might want to consider a neuropsychological screening rather than a full neuropsychological assessment. This abbreviated version will do a cursory assessment of only key areas of functioning. A neuropsychological screening will rely upon observation of behaviors, subjective complaints, and history to a good extent. It is indicated when a medical injury or condition is suspected to have affected brain health (such as carbon monoxide poisoning, a mild head injury, poor nutrition) or there is a sudden, unexpected and unaccounted for change in cognition or mental performance. It may also be appropriate if there is a gradual onset of unusual sensory, motor or physical changes, or when an individual who is receiving special education or therapies designed to address specific problems is not progressing or is regressing.

For screening the following measures may be employed: Cognistat (The Neurobehavioral Cognitive Status Examination), or Kaufman Short Neuropsychological Assessment

If the screening is positive for the likelihood of a brain disorder, then you want to proceed to a full neuropsychological evaluation. Alternatively, if a brain disease or injury has already been diagnoses (such as Autism) and you want to obtain a comprehensive understanding of its functional impact, it is time for a full neuropsychological evaluation. Likewise, when there is significant reason to suspect a brain disease or injury and a comprehensive profile of neurofunctional characteristics is need to complement the neurological examination and to further diagnostic comprehension, a full neuropsychological evaluation should be pursued. Educationally, a neuropsychological evaluation is important when one wants a comprehensive diagnostic and functional assessment of brain injury or disease for planning a program of rehabilitation, an individualized educational plan or a transition plan. Finally, a full neuropsychological assessment is required to provide careful, objective, serial measurement of neurofunctional performance across cognitive domains in order to monitor progress with the Individualized Educational Plan.

In general those who should be referred for neuropsychological assessment include: those who suffered from a mild head injury, those who failed to achieve developmental milestones at expected times or who regressed, those with learning or attention deficits, those who have been exposure prenatally to alcohol, drugs or tobacco, those who have been exposed either pre or post natally to toxic, chemical or heavy metals, those who have experienced strokes, evidenced signs of dementia, used illegal substances or who are suffering from psychiatric disorders that are having a negative impact on daily functioning.

For students on medication for impulsive control, anger management or attentional problems, neuropsychological evaluation is an important component in monitoring the effects of pharmacologic interventions upon the nervous system and upon behavior.

For students approaching the age of majority, neuropsychological evaluation is important to provide data to guide decisions about the student’s condition regarding competency to manage legal and financial affairs, capacity to participate in medical, educational and legal decision making, the ability to live independently or with supervision, and the ability to work.

Why is Neuropsychological Assessment Important for Educators?

Recent laws for the handicapped encourage it

Educators have turned to neuropsychological assessment in an effort to comply with IDEA and NCLB. require schools to search for and serve all handicapped children who are three years old and older. The act and its amendments require educators to screen, assess, and identify children with learning disabilities early on so that these children can receive an education that is best-suited to their needs. Neuropsychological screenings and assessments can be powerful tools in implementing Child Find and IDEA when appropriately administered, interpreted and utilized.

Schools are required to offer a wide range of programs

Programs in most schools address a wide range of functioning levels from the severely developmentally disabled to the gifted or talented. For these programs to work effectively, the school psychologist must identify the learning strengths and weaknesses of each child so that the children will be placed in the least restrictive educational environment that will permit them to close the gap between themselves and their nondisabled peers without impeding the ability of classmates to progress. The more extensive the neuropsychologist’s repertoire of insightful tools, the more complete the evaluation and the more appropriate the child's placement.

Learning disabilities are difficult to identify

Identifying learning disabled students is a challenging task because you need to make certain that the deficits evidenced are not a function of English as a second language, lack of appropriate learning experiences prior to school entry, inadequate instruction or erratic school attendance. In other words, the neuropsychologist has the responsibility not only of documenting that Joey can’t read but also whether this is because he is absent a great deal, he is emotionally disturbed, he doesn’t attend to instruction, he has an auditory processing deficit, or has other brain dysfunction that prevents the acquisition of learning material through traditional methods. In order to separate the many overlapping factors and provide the most accurate diagnosis possible, the neuropsychologist must use the best diagnostic instruments available.

What do Parents and Educators need to know about Test Selection?

Tests employed for neurological assessment need to be both reliable and valid. Parents need to understand these concepts so they can insure that school evaluators employ measures that meet these criteria. When we speak of reliability we refer to the consistency with which the same information is obtained by the assessment tool. Basically, barring confounding variable such as illness, injury or new learning) scores should remain stable even when administered by different examiners (interrater reliability), administered repeatedly by the same examiner (intrarater reliability) and administered to the same person on different occasions (test-retest reliability).

When we refer to validity we are talking about how well the test measures what it claims to measure. If the test measures what it purports to measure it is said to have construct validity. If the tests correlate highly with existing tests or independent measures of the construct it is considered to have concurrent validity (i.e. a measure of expressive language dysfunction correlates with an MRI showing damage in Broca’s area). If the tests appear to measure what it is suppose to measure we call that face validity. If he can accurately localize the area of focal lesions in the brain, we refer to localization validity, and if predicts real-life ability the test has ecologic validity. In particular performance on tests of motor functioning, speed of cognitive processing, cognitive flexibility, complex attention and memory are positive related to real world success. The amount of variance attributable to cognitive factors alone is relative small, however, therefore situational assessment is a critical adjunct to the actual administration of tests in the clinical situation. Because most neuropsychological tests were not developed with the goal of ecologic validity, but were validated against neurosurgical, neurologic and neuroadialogic data, they still have been shown to be good predictors of future behavior and to have demonstrated ecologic validity. Its validity is improved when a qualitative process approach to the administration and interpretation of the testing is employed, and this requires a neuropsychologist with specific training in this process approach.

The tests selected also need to have both sensitivity and specificity. By sensitivity we mean the test’s ability to detect the slightest abnormalities in central nervous system function. It also needs to be a reflection of the test’s true positive rate; in other words, its ability to identify people with a given disorder. By sensitivity we mean the tests ability to differentiate patients with a certain abnormality from those with other abnormalities or no abnormalities at all, as indicated by its true negative rate.

• By true positive we mean that a measure has a high sensitivity to dysfunction and therefore allows dysfunctions to be correctly detected.
  
• By true false positive we mean that a measure is sensitive to dysfunction, but lacks specificity to any particular dysfunction.
  
• Be true negative we mean that the test has a high specificity that allows those without disorders to be distinguished accurately from those with disorders.
  
• By false negative, we refer to a lack of sensitivity that result in individuals with disorders not being recognized as having a disorder.

What Are Some Limitations of Neuropsychological Assessment?

A significant advantage of neurological assessment is that it can accurately detect neurological damage or dysfunction without the need for obtrusive medical tests. Moreover, it provides a clear objective profile to serve as the basis for the development of an Individualized Educational Plan and for serial reassessment to monitor progress. There are, however, some limitations that need to be considered.

To perform neuropsychological assessments well, the evaluator must be thoroughly trained. This means they need to have a Ph.D. in psychology with additional training in neuroanatomy and brain behavior relationships; as well as considerable supervised practice in the administration and interpretation of these batteries with patients suffering from neurological injuries or diseases.

The results of a neuropsychological assessment are only as valuable as the sources of information accessed. If the patient lies or the school provides misinformation, this may negatively affect the interpretation of the actual test data.

Neurospychological assessment of young children remains a challenge and requires that the evaluator have significant knowledge of both normal child development and deviations from that normal development because the numbers of children in the normative databases for many neurological disorders is not as large as one may wish since it is difficult to get large numbers of children with the same neurological disorders together in the same place for normative testing purposes.

One limitation of neuropsychological testing has been the fact that student’s perform better in the quiet one on one testing situation than they do in real life situations. This is why home and classroom observations are such a critical part of the evaluation. It is also why we are seeing the development of tests such as the Multiple Errands Test (MET) that takes place in a shopping mall and requires the subject to conduct three tasks simultaneously (buying an item, meeting at a certain location at a certain time, acquiring information such as the foreign currency exchange rate) This test evaluations the student’s abilities in planning, task initiation, and task switching and requires the student to interact with other individuals in an effective manner. It has evidenced both sensitivity and specificity with the neurologically impaired performing considerable worst than the nondisabled.

As previously mentioned neuropsychological assessment batteries are long and time consuming, and therefore expensive. Still, they provide a wealth of objective information for development of IEP’s not available from typical psychoeducational assessments. Moreover, when compared to other diagnostic devices they are actually cost effective.

Neuropsychological testing is viewed by insurance companies and HMO's as medical diagnostics, not as a mental health issue. Thus, when you have a letter of medical necessity from your child’s pediatrician, they generally reimburse at the same rate as other medical specialties. Using neuropsychological tests early in the diagnostic decision tree can save money by avoiding unnecessary diagnostic imaging.

Compare:

• Standard Neuropsychological Battery $ 900 - 2,000
  
• MRI $ 6,000 - 12,000
  
• PET Scan $ 3,000

Neurological-imaging provides information on structural and physiological aspects of brain injury while neuropsychological testing provides the most accurate picture of patient's cognitive functioning.

Wouldn't I be better off taking my child to a neurologist rather than a neuropsychologist?

The function of a neurologist is significantly different from that of neuropsychologists. The neurologist's expertise lies in diagnosing and treating the structural and physiological consequences of brain injuries and neurological illnesses (such as identifying a seizure focus and performing surgery or prescribing medication). In contrast, neuropsychologists assess the effects of brain injuries and illnesses on cognition and behavior;. Neuropsychologists are experts in assessing functional deficits and how to address these in the home and school environments . Many patients need both neurological and neuro-psychological work-ups.

Why not just accept the school district’s psychoeducational evaluation?

Overall, a neuropsychological assessment is broader in scope and provides significantly more information for the development of IEP’s, for monitoring progress over time and for tracking the effects of pharmacologic intervention than psychoeducational evaluations which basically provide only level of performance information and no understanding of brain-behavior relationships. Basically there are five major reasons why a through neuropsychological evaluation performed by a pediatric neuropsychology is superior to a psych educational evaluation:

1. The inadequate range of a psycho educational evaluation,
   
2. The training of the personnel performing psycho educational evaluations,
   
3. The narrow focus of psycho educational evaluations,
   
4. The level of performance model employed in psycho educational evaluations, and
   
5. The failure of psycho educational evaluations to assess brain behavior relationships.

What should I tell my child to prepare him/her for a neuropsychological evaluation?

You need to assure your child that visits to the pediatric neuropsychologist will not involve shots or painful procedures or medications. You can tell your child that it will be more like a visit to a new school, and that the pediatric neuropsychologist will even come to your child’s school and home to visit them there a few times. Explain to your child that they will be doing many different activities, games and tests that involve looking and listening, building and drawing.

Reassure your child that while you will not be in the room, you will be waiting in the next room. Let them know that the evaluator is a person you have confidence in and that they may trust them. To help prepare your child for the appointments make certain they get a good night sleep prior to each appointment, that if they have a special toy that helps them feel secure they bring it with them, that they have a non-sugary nutritious breakfast, and that they bring a few snacks.

How do you participate in the neuropsychological evaluation of your child?

First, you will select the evaluator. This involves interview them to make certain they have sufficient training and experience evaluating children your child’s age with the suspected disorders that your child presents with. It also means that you will evaluate several of their previous evaluations with confidential information removed so you can ascertain the depth of their evaluations, the clarity of their reports and the specificity of their educational recommendations. You will also need to inquire as to their forensic training and experience as an expert witness in court settings.

Next you will need to provide copies of any previous psychological or neuropsychological or educational assessments your child has had. You will be asked to complete a number of parent report questionnaires and to ask the teachers to complete equivalent versions for some of them. Naturally, you will need to sign a release for the neuropsychologist to obtain you child’s medical and educational records, and will share with them any journals you maintain in the home and community. Finally, you will need to provide the neuropsychologist with specific examples of behaviors your child evidences that are of concern as well as information regarding the frequency of occurrence and under what circumstances. This is where your journal will prove very helpful. You will also need to share work samples that have come home from school as well as specific information regarding the type and amount of help your child requires with homework assignments and routine tasks at home.

One Final Word

Because of the length of time involved in a neuropsychological assessment, it is often advisable to begin this assessment process a two or three weeks before the first week of school. That way, the evaluator can review all your child’s records, complete their interview with you and other family members, the home observation, and the basic core battery all before school begins. Then, once school resumes, they can conduct the classroom observations and interview teachers and related service providers, and do any follow up testing on one or two occasions after school before the volume of academic work and homework is in full swing. This way, the neuropsychological report should be completed in time for the first progress report; at which time you will be ready to request an IEP team meeting to have your neuropsychologist come and explain both their results and their recommendations to the remainder of the IEP team; along with suggestions regarding particular methodologies, frequencies and intensities that will necessary for your child to make meaningful progress in school, at home and in the community. This is a crucial aspect of the report, so be certain to make certain that your neuropsychologist is willing to do this when you initially interview them as a potential evaluator. Prior to this, however, the evaluator should have meet with you, your spouse and your special needs coach or advocate to share the results, answer questions and discuss recommendations for both school and home. This way, you will be better prepared for the IEP meeting as you will have time to obtain copies of relevant research articles for any methodologies recommended by the neuropsychologist so you can share these with the IEP team.

Additional Reading you may wish to consider

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