1. Introduction to Child Clinical Neuropsychology

The manner in which disturbances are approached has been revolutionized by neuroscience and medical technologies, such that any serious study of developmental problems must consider neuropsychological theories, methodologies, and empirical findings if the science of childhood and adolescent disorders is to be advanced. For this reason, information has been provided in subsequent chapters about these new technologies. Although a relatively young science, child clinical neuropsychology has been significantly advanced by the use of medical technologies including magnetic resonance imaging (MRI), positron emission tomography (PET), computerized tomography scans (CT), and regional cerebral blood flow (rCBF) (Semrud-Clikeman, 2001). The potential for employing functional magnetic resonance imaging techniques (fMRI) for investigating brain activity by monitoring regional changes in blood flow in children with neurodevelopmental disorders shows promise. New technology called Diffusion Tensor Imaging (DTI) allows us to view the white matter tracts of the brain (the tracts that carry neuronal impulses throughout the brain) and provides an opportunity to evaluate how efficiently the messages are able to travel.

The study of the brain-behavior relationship has been revolutionized by these medical technologies. Many psychiatric disorders of childhood once thought to be mental or functional in nature, and behavioral disorders presumed to be related to noncontingent reinforcement systems and other environmental factors have been found to have a neurodevelopmental or neurochemical basis (Pliszka et al. 2006; Semrud-Clikeman, 2007). For example, children and adolescents with attention-deficit hyperactivity disorders (ADHD) may have dysfunction in alternate cortical pathways depending on the primary behavioral manifestations of the disorder, such as over-arousal, uninhibited, or cognitive deficits (Filipek et al., 1997; Semrud-Clikeman et al., 2006). Further, the presumed central nervous system dysfunction attributed to reading disabilities in some children has been traced to specific cortical regions in the left hemisphere that mediate phonemic awareness and linguistic-semantic processing (Gabrieli, 2003; Shaywitz et al., 2004).

The International Neuropsychological Society (INS), Division 40 (Clinical Neuropsychology) of the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN) are major professional organizations comprised of researchers and clinicians in neuropsychology and child neuropsychology. Professional training standards have been of particular interest to these organizations in an effort to assure the expertise of those individuals practicing clinical child neuropsychology. Table 1.1 summarizes guidelines established and endorsed by INS. Clinicians interested in becoming experts in child neuropsychology should consider the recommended curricula and internship standards. INS recommends Ph.D. training, with core coursework in general psychology, general clinical psychology, basic neurosciences, and clinical neuropsychology. Internship guidelines specify 1,800 hours, with 50 percent of that time devoted to clinical neuropsychology, including specialization in neuropsychological assessment and intervention techniques, and clinical neurology and neuropathology.

Many of the measures utilized for testing in neuropsychological practice have not been standardized on ethnicities beyond middle-class Caucasians. This problem has been present and is currently being studied as to what differences, if any, may exist. One aspect (culture) has only been studied recently in neuropsychology. Previously neuropsychologists have suggested that the study of the brain is nonculturally bound (Wong, Strickland, Fletcher-Janzen, Ardila, & Reynolds, 2000) However, more current studies have suggested that handedness, specialization of the cerebral hemispheres for tasks, and self-reports of behavioral functioning may be related to cultural issues as well as brain development (Best & Avery, 1999; Carlson, Uppal, & Prosser, 2000; DuPaul et al., 2001; Mandal, Ida, Harizuka, & Upadhaya, 1999).

Some have studied the effect of immigration to America and the reasons for such immigration (Llorente, Ponton, Taussig, & Satz, 1999; Llorente, Taussig, Satz, & Perez, 2000). Economic and political factors were found to affect the patterns of immigration to various geographical regions of the United States. These factors were also suggested by the authors to affect normative samples for tests that are commonly used in neuropsychological and psychological practice. One study by Rey, Feldman, Rivas-Vasquez, Levin and Benton (1999) in Florida compared neuropsychological results in three Hispanic groups: Cuban, Mexican and Puerto Rican. Findings indicated differences on neuropsychological test performance that were later related to level of educational attainment. In this study the Cuban population had a higher educational attainment than the other two Hispanic groups. Thus, demographic samples that would include more Cubans than other types of Hispanic groups may bias the results and thus lead to an inappropriate interpretation of the findings. Similar issues have been demonstrated with African-American samples where educational level appeared to be the strongest variable associated with poor neuropsychological performance rather than ethnicity (Peters, Fox, Weber, & Llorente, 2005; Vincent, 1991).

Another aspect that needs to be addressed when considering multicultural issues is differences in language. With the major increase in Spanish-speaking immigrants, neuropsychological testing of these children is affected by language differences. Many neuropsychological (and psychological tests for that matter) are not normed on large Spanish-speaking populations. Most neuropsychologists are not bilingual. One common practice is to translate an English test into Spanish. However, since the norms are unlikely to be appropriate, this can be problematic. There is no easy solution to this problem since test development is expensive and unlikely to be accomplished in the near future. These concerns are present for Asian children as well as Native-American children.

A study by Keith and Fine (2005) focused on possible ethnic differences in learning. Quality and quantity of instruction, previous achievement, and motivation were statistically evaluated across Anglo-American, African-American, Hispanic, Native-American, and Asian-American groups. Higher quality of instruction was found to lead to better achievement across the groups. Quality of instruction appeared to be less important for Native-American groups than quantity of instruction. Quantity of instruction was also found to be important for the Asian-American population. For the Anglo students academic motivation and prior achievement were the best predictors for learning. For African-American and Hispanic students motivation, previous achievement and coursework were strong influences on their resultant learning. For those of Native-American descent academic coursework and motivation were the strongest influences. Thus, these findings indicate that children of different ethnicities may benefit from differing strategies. It is also possible that the patterns of neuropsychological test performance may also differ. This area requires further study to tease apart these issues and determine what influence, if any, cultural differences may play in task performance.

This problem will probably not be resolved quickly. It is important that practitioners become familiar with these issues and that test administration and interpretation be carefully utilized. Sensitivity to multicultural issues is very important and difficulty is likely present when practitioners are not fully in touch with these possible differences. Books that provide additional information about cultural differences that are important include Frisby and Reynolds’ (2005) Comprehensive Handbook of Multicultural School Psychology and Ethnicity and Family Therapy by McGoldrick, Giordano, and Garcia-Preto (2005). The interested reader is referred to these texts for further information.

The guidelines described here are provided for clinicians who may function as child clinical neuropsychologists. Other professionals working with children and adolescents should consider different levels of training. Psychologists in private practice or in schools as well as educational professionals, including diagnosticians and regular, exceptional, and remedial education teachers, may provide some services to assist in the diagnosis and treatment of children. However, these services are not considered practicing neuropsychology. There are ethical issues of providing services without the proper training. At this time most states do not have a specific license for neuropsychology and the practice of providing neuropsychological services is often left up to the discretion of the provider. At the very least to provide neuropsychological services the provider needs to comply with the above guidelines as well as complete an internship and a post-doctoral fellowship that has at least 50 percent of study devoted to neuropsychological training.

Ethical guidelines for the American Psychological Association and the National Association of School Psychologists specify that services should be provided within the competence of the clinician (American Psychological Association, 2002; National Association of School Psychologists, 1997). For school psychologists the NASP ethics specify that the individual has a responsibility to determine his/her competencies to administer tests and to interpret these tests. Without the requisite training in neuropsychology, the use of neuropsychological procedures, measures, and interpretation should not be conducted. At the very least the school psychologist needs to have doctoral training in neuropsychology, an internship and post-doctoral experience with supervision from a trained neuropsychologist.

For a clinical psychologist, the APA guidelines also state that the practitioner works within his/her competency. With the guidelines from INS, NAN, and Division 40 of the APA as well as the guidelines set by practitioners (Johnstone, Frank, Belar, & Berk, 1995), clinical psychologists must also abide by these training requirements. If a clinical psychologist has completed his/her internship and is currently licensed and now wishes to provide neuropsychological services, the guidelines indicate that the prerequisite coursework and another internship must be completed to deliver these specialized services. While the state licensing boards do not necessarily monitor such changes in practice, nor do most provide a separate license for neuropsychology, ethically practitioners need to monitor themselves and provide only those services for which they have been fully trained.

For clinical and school psychologists who have not received specific and intensive training in neuropsychology but, who work with children with neurological, medical, and/or learning difficulties, basic neurology and neuroanatomy training is important. With children now surviving severe traumatic brain injury as well as cancer and other disorders, it is important to have some basic knowledge of the brain in order to understand when and whether to refer a child for an outside neuropsychological evaluation. Practitioners who have not had the recommended training for neuropsychological practice should not “diagnose” brain difficulties, but should be familiar enough with brain anomalies to know when to refer.

Working in teams with medical professionals, education and clinical professionals can be helpful in designing educational interventions and psychosocial conditions that improve the probability of successful integration of children with severe brain injury, trauma, or disease (e.g., leukemia or brain tumors). Without adequate knowledge, serious problems can arise when the child returns to school after brain surgery or trauma. This concern is illustrated in the story of a child who underwent surgery to remove a large portion of the left hemisphere and received intracranial irradiation as part of his medical treatment for a brain tumor. When the child returned to school after his surgery, the educational staff was unaware of his subsequent neurological status. They were unsure of how his neurological status was related to his present level of academic and intellectual performance, and they did not know what to expect regarding the course of recovery of function for skills that were impaired. Further, the school staff had little confidence in their ability to design effective educational experiences for the child and had little information about what to expect from him in terms of psychosocial functioning.

By working with the child neurologist, the neuropsychologist, and the clinical psychologist, the school staff was able to develop reasonable expectations and to provide a more appropriate education for this child. When the tumor reappeared and later proved fatal, school professionals, again in conjunction with the medical team, were better able to provide the needed psychological support to the child and his family. School staff were also able to help peers and other school personnel deal with the untimely loss of a classmate. By working together as part of a collaborative team, education professionals knowledgeable about brain action and recovery can work effectively to promote the adjustment of children following treatment for brain tumors and other diseases or injuries affecting the CNS.

In another case, school staff were not prepared to integrate a child back into the school system following severe brain injury. Medical records indicated that the child had suffered severe language and memory losses following a prolonged (one week) coma. When the child returned to school, he was immediately referred for a multidisciplinary evaluation. When the school psychologist observed the child, his language processes were significantly better than described in the medical records, although he was struggling with his academic work. Further, in discussions with the mother it became apparent that the family was dealing with a great deal of stress because the child's injury was sustained during a beating from the mother's boyfriend. At the time, the mother was cooperating in a police investigation of the incident and was unable to participate fully in the school's attempt to evaluate her child. In this instance the school staff were unsure about how to proceed in this complex case and needed help in determining the best course of action for designing an educational intervention plan for the child.

Educational and clinical professionals are often the individuals who first observe behavioral, psychological, and cognitive problems exhibited by children with brain-related disorders. In this position, knowledge about when to refer for further neuropsychological, neurodiagnostic, or medical evaluations is crucial for the proper diagnosis and treatment of some disorders (e.g., seizures, brain tumors, or neurodegenerative diseases). Psychologists who work with very young children often play a pivotal role in identifying subtle neurodevelopmental disorders that respond positively to early intervention or in providing educational interventions for previously diagnosed children. A better understanding of various neurodevelopmental anomalies, normal and abnormal brain development, and effective treatments will no doubt aid in rigorous early and effective intervention programs. Early interventions are particularly important for the optimal development of some children, particularly low birth weight babies, infants with intrauterine exposure to prenatal drugs and alcohol, infants with congenital acquired immune deficiency syndrome (AIDS) infection, and toddlers and preschool children with significant cognitive, speech1 language, and/or motor delays.

Finally, a number of children and adolescents receive medication for various disorders (e.g., Tourette syndrome, seizures, ADHD, depression, and schizophrenia). School and clinical psychologists are in a unique position to provide detailed, systematic feedback to physicians and parents concerning the side effects and efficacy of such medications. Knowledge of common medications and their impact on cognitive, social, and behavioral functioning will greatly facilitate this process. A knowledgeable professional is better informed about the benefits and risks of psychopharmacotherapy and understands the need for combined psychosocial and behavioral treatments for medicated children. Thus, by understanding the neuropsychological basis of other childhood disorders, educational professionals can help design and implement effective interventions. The task of understanding the multiple factors affecting the cognitive, academic, psychosocial, and behavioral development of children is challenging. Increased knowledge will require an expanded curriculum and will no doubt be difficult to manage in rigorous graduate programs in clinical branches of psychology that are already packed with numerous course, practica, and internship requirements. At the very least, all psychologists should be required to take a course in the biological basis of behavior, a requirement that APA enforces for all professional psychology training programs. The potential benefits for children who come in contact with educational professionals who are knowledgeable about neuropsychology, neurodevelopment, and effective interventions for brain-related disorders can hardly be ignored or underestimated.

While ethical guidelines guide the practice of psychology in any arena, it is also important to understand appropriate laws that govern placement in special education programs as well as in practice. These laws include the Individuals with Disabilities Education Act (IDEA), Section 504 of the Americans with Disabilities Act as well as the HIPAA guidelines. The Americans with Disabilities Act of 1990 (ADA) and Section 504 of the Rehabilitation Act of 1973 require that reasonable accommodations be made for individuals at all levels of school and in the workforce. While these laws also apply to the K-12 school environment, they are often overshadowed by the Individuals with Disabilities Education Act (IDEA), which ties federal funding to schools to the mandate that children with disabilities receive a free and appropriate education in the least restrictive environment (Magden & Semrud-Clikeman, 2007). IDEA was reauthorized in 2004 (P.L. 108–446).

Child clinical neuropsychology has emerged as an important theoretical, empirical, and methodological perspective for understanding and treating develop-mental, psychiatric, psychosocial, and learning disorders in children and adolescents. Child clinical neuropsychology can be formulated and articulated within an integrative perspective for the study and treatment of child and adolescent disorders. By addressing brain functions and the environmental influences inherent in complex human behaviors, such as thinking, feeling, reasoning, planning, and executive functioning, clinicians can provide much needed service to children with severe learning, psychiatric, developmental, and acquired disorders.

A neurodevelopmental perspective is helpful in understanding childhood disorders for several reasons. First, the influence of developing brain structures on mental development is sequential and predictable. As study of the developing brain has been made possible by new technologies, we are better able to understand how the brain changes with development, what structures vary depending on age, gender, and experience, and what interventions may alter brain activity. Secondly, the effects of brain injury in children have been documented by numerous studies. Children with traumatic brain injury have been more closely studied in the past decade and our understanding of recovery, appropriate interventions, and therapeutic assessment have helped in providing assistance to the child, the school, and medical personnel. Moreover, attention to the scope and sequence of development of cortical structures and related behaviors that emerge during childhood is important to assess the impact of the environment (i.e., enrichment, instructional opportunities, and intervention strategies) on this process.

Thirdly, studies have begun to demonstrate that the nature and persistence of learning problems is dependent on an interaction between dysfunctional and intact neurological systems. Some children respond to one intervention while others profit from another type of strategy. Until recently the ability to evaluate brain activity changes following interventions has not been present. With the advent of such technology, it is now possible to study these changes. Finally, the developing brain is highly vulnerable to numerous genetic and/or environmental conditions that can result in severe childhood disorders (Klein-Tasman, Phillips, & Kelderman, 2007).

Due to the complexity of the brain, particularly the developing brain, a transactional approach to the study and treatment of childhood and adolescent disorders is most appropriate. For this reason theories and research findings from diverse fields, including the neurosciences, neurobiology, behavioral neuropsychology, clinical neuropsychology, cognitive and developmental psychology, social and family systems psychology, and behavioral psychology have been incorporated into this book. A transactional perspective is advanced to illustrate the following: (1) how abnormalities or complications in brain development interact with environmental factors in various childhood disorders; (2) how disorders develop over time depending on the nature and severity of neuropsychological impairment, and (3) how neurodevelopmental, neuropsychiatric, and acquired disorders (i.e., traumatic injury) need to be assessed and treated within an integrated clinical protocol addressing neuropsychological, cognitive, psychosocial, and environmental factors. We propose that all assessment, correctly completed, is therapeutic. In this view the child’s performance on appropriate measures, as well as the feedback to the parent and school, provide a basis to assist these involved people in understanding the child’s strengths and weaknesses, and to participate in developing appropriate interventions. A transactional approach stresses consultation and collaboration with the caregivers of the child as well as assisting the child in adjusting to his/her areas of challenge. In summary, this book presents child clinical neuropsychology within an integrated framework, incorporating behavioral, psychosocial, cognitive, and environmental factors into a comprehensive model for the assessment and treatment of brain-related disorders in children and adolescents.

Theoretical orientations have often been pitted against one another: “medical” versus “behavioral,” “within-child” versus “environmental,” and “neuropsychological” versus “psychoeducational.” Further, some have adopted one approach over others in an attempt to describe and treat childhood disorders. Various theoretical orientations in clinical child psychology will be discussed briefly and will be integrated throughout the text whenever possible. An integrated paradigm serves as the foundation of our conceptualization of clinical child neuropsychology. Teeter and Semrud-Clikeman (2007) assert that diverse perspectives should be integrated for a comprehensive approach to neurodevelopmental disorders and for the advancement of the science of childhood psychopathology. To conduct a comprehensive child study, clinicians need to incorporate various paradigms. Child clinical neuropsychology is then viewed as one essential feature to consider when assessing and treating childhood and adolescent disorders. Differential diagnosis, developmental course, and intervention efficacy should be explored utilizing psychosocial, cognitive, behavioral, and neuropsychological paradigms.

Neuropsychology is the study of brain-behavior relationships and assumes a causal relationship between the two variables (Lezak et al., 2004). Neuropsychology offers several advantages for child study. It provides a means for studying the long-term sequelae of head injury in children, to support children who are undergoing treatment for cancer and brain tumors, to assist parents and school professionals in understanding the developmental course of learning, social, and behavioral difficulties in children, and to provide assistance in treating various psychiatric disorders. Despite the advent of new methods for studying brain functioning and development, the exact nature of brain functioning and behavior is complex, and our knowledge is incomplete, particularly con- cerning the developing brain.

Although behavioral psychologists argue that neuropsychology diverts attention from behavioral techniques with documented treatment validity, clinical child neuropsychologists utilize techniques that consider the interaction of psychosocial, environmental, neurocognitive, biogenetic, and neurochemical aspects of behaviors in an effort to more fully understand the relationship between physiological and psychological systems, and frequently incorporate these same behavioral techniques. While neuropsychological approaches provide useful information for understanding and treating childhood disorders, they need to be included with various complementary methods of assessment. Behavioral, psychosocial, and cognitive variables also should be addressed in a comprehensive child clinical study. Critical aspects of each of these paradigms will be reviewed briefly in the following sections.

Behavioral approaches have long been recognized for their utility in assessing and treating childhood and adolescent disorders (Kratochwill & Shernoff, 2003) Analysis of the antecedents and consequences of behaviors is an essential feature of behavioral approaches with attention to the impact of the environment on the understanding and remediation of learning and behavioral difficulties in children (Shapiro & Cole, 1999) Assessment and intervention techniques in a behavioral paradigm are closely related and often occur simultaneously. For example, a functional analysis of behavior is an ongoing assessment of the efficacy of a treatment plan (Kratochwill & Shernoff, 2003). Within this perspective, behaviors are targeted for analysis, and subsequent treatment plans are developed to address areas of concern. A functional analysis of behavior is now a required piece of an evaluation for determining appropriateness of a special education placement for behavioral difficulties.

Although some might suggest that behavioral and neuropsychological approaches are mutually exclusive, important information may be lost about a child when these two approaches are not integrated (Teeter & Semrud-Clikeman, 2007). The integration of behavioral assessment and intervention into a clinical neuropsychological paradigm is an important aspect for developing ecologically valid treatment programs of children and adolescents with brain-related disorders. There are several behavioral factors that can interact with neuropsychological functioning. Our understanding of the effects of malnutrition on the developing brain as well as exposure to lead and various environmental toxins has increased in recent years and been found to affect the child’s behavior and learning. For example, exposure to lead has been found to decrease attention, increase distractibility and disinhibition (Freeman, 2007). It has also been found to decrease learning abilities and academic performance. At times the effects can be subtle while at other times they are more dramatic. Combining neuropsychological as well as behavioral evaluations assists in developing the most appropriate interventions.

Another example where behavioral and neuropsychological evaluations can equally inform one another is to evaluate the impact of environmental demands on the child (e.g., school, home, and peer-family interactions) when making predictions about recovery from brain impairment (Semrud-Clikeman, 2004). Children who are at high risk for traumatic brain injury are often those children who come from chaotic homes, have a previous diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD), and who are poorly supervised (Semrud-Clikeman, 2004). These children often show poorer recovery even with mild head injuries than children who come from more intact families (Wade, Carey, & Wolfe, 2006) Thus, working with these families who are at highest risk requires skilled behavioral techniques as well as a strong understanding of the effects of the injury on brain systems. Some studies have found improvement with appropriate behavioral support particularly when a comprehensive evaluation has provided a background for the child’s difficulties (Sohlberg & Mateer, 2001). Further, behavioral interventions are frequently incorporated in treatment programs for children with disorders known to have a central nervous system basis, including learning disabilities (Berninger, Abbott, Abbott, Graham & Richards, 2002), attention-deficit hyperactivity disorders (Pelham et al., 2005; Teeter, 1998), and traumatic brain injury (Donders, 2007). Psychosocial and cognitive factors are also considered in an integrated clinical neuropsychological model for studying and treating childhood disorders. The importance of these non-neurologic factors will be discussed briefly in the following section.

The fact that various neurodevelopmental, psychiatric, and behavioral disorders have associated psychosocial and cognitive deficits increases the importance of investigating these features in child clinical neuropsychological assessment and of addressing these deficits in treatment programs. The relationship among cognitive functioning, psychosocial characteristics, and neuropsychological deficits for various childhood disorders is multidirectional or transactional in nature. In some instances neuropsychological functioning may help to explain many of the behavioral, cognitive, and psychosocial deficits found in childhood disorders such as ADHD and dyslexia (Semrud-Clikeman, 2007; P.A. Teeter & Semrud-Clikeman, 1997). In other instances cognitive and/or psychosocial features, such as premorbid intelligence, language and reasoning abilities, and/or social-emotional adjustment, have an impact on function recovery following traumatic brain injury in children and adolescents (Butler, 2007).

The relationship between brain morphology and activity on cognitive and psychosocial functioning has been investigated in children with neuropsychiatric disorders, including ADHD. Brain-related ADHD symptoms (inattention, overactivity, poor impulse control, and behavioral disinhibition) often result in significant social and peer difficulties (Semrud-Clikeman, 2007; Teeter, 1998). Moreover, children with ADHD frequently experience learning disabilities (Martinez & Semrud-Clikeman, 2004), depression (Ostrander & Herman, 2006), and anxiety (Power, Werba, Watkins, Angelucci, & Eiraldi, 2006).

Stimulants are the most frequent intervention for children with ADHD (Wilens, 2004) These medications are known to modify the neurochemical activity of the brain and appear to have a positive impact on cognitive and social functioning in the majority of children with ADHD. Deficits in regulation, planning, and organization skills have been found to have a negative impact on the social and emotional adjustment of children and adolescents with ADHD. For example, children with ADHD are characterized as non-compliant and rebellious and are often described as rigid, domineering, irritating, and annoying in social situations (Barkley, 2003; Nigg et al., 2002) Peer rejection is also common among children with ADHD (Semrud-Clikeman, 2007), particularly when aggression is present (Waschbusch, 2002)

The extent to which these social outcomes are related to impulsivity, distractibility, and disinhibition, which have been found to have a neurobiological basis, needs to be explored within an integrated paradigm. What appears evident is that ADHD can produce persistent social isolation and that it has been found in adults after major symptoms of hyperactivity are no longer present (Wilens, Faraone, & Biederman, 2004) Reports of depression (75%), juvenile delinquency (23–45%), and alcoholism (27%) in older ADHD individuals further suggest the limiting influences of this biogenetic disorder on psychosocial adjustment even into adolescence and adulthood (Barkley, 2003).

Children and adolescents with ADHD also have associated cognitive disturbances that are severe and chronic in nature. For example, school failure, academic underachievement, and learning disabilities are frequently reported in children and adolescents with ADHD; and few adolescents with ADHD complete college (Martinez & Semrud-Clikeman, 2004). Difficulties in self-regulation and response inhibition may result in academic decline, de- creases in verbal intelligence, and related psychosocial problems. Thus, basic neurochemical and neuropsychological abnormalities interact with social, psychological, and behavioral factors to create significant adjustment problems for children with ADHD.

There are several distinct neurophysiological and neuroanatomical findings that may be related to the associated psychosocial and cognitive problems found in children and adolescents with ADHD, including the following: (1) underactivation or hypoarousal of the reticular activating system (RAS), a subcortical region that activates the cortex (Klove, 1989); (2) subtle anatomical differences in the right caudate nucleus (near the lateral ventricles) (Filipek et al., 1997), and the frontal lobes (Semrud-Clikeman et al., 2000); or (3) smaller genu and/or splenium in the corpus callosum (Castellanos et al., 1996; Giedd et al., 1994; Semrud-Clikeman et al., 1994).

Frontal lobe arousal apparently occurs when methylphenidate is administered. Once activated, the frontal lobes exert a regulatory influence over sub-cortical and cortical regions of the brain that ultimately monitors motor activity and distractibility. Further, the frontal lobes have been found to be underactivated in parents with ADHD who also have ADHD children (Zametkin et al., 1990). Functional studies have found differences in children with ADHD with a history of medication compared to those children with ADHD without such a history (Pliszka et al., 2006). These findings suggest that changes in brain activity can be traced to medication status and may assist in understanding how these brain changes affect behavior.

Barkley (1994) has argued that ADHD is not an attentional disorder, but rather a disorder of dysregulation. Thus, specific symptoms of ADHD (i.e., response disinhibition and poor self-regulation), are likely a result of impairment in executive functions mediated by the frontal cortex (Barkley, 1994). This theory is supported by structural imaging studies that have found changes in the anterior cingulate (a structure in the frontal lobes believed important for directing of attention and error checking) when a medication history is present (Semrud-Clikeman et al., 2006). Such findings suggest that treatment can alter brain structure and also assist in modifying behavior or at least providing an opportunity for the child to “learn” a different method for solving problems.

While various neuropsychological functional systems are involved, children with learning disabilities (LD) also exhibit psychosocial and cognitive deficits that may be related to underlying neural mechanisms. Children with LD who also possess low verbal skills and intact visual-spatial abilities appear to have higher rates of depression than those with average verbal abilities (Palacios & Semrud-Clikeman, 2005). In addition, children with LD who have more social difficulties have also been found to be at higher risk for mood disorders (Martinez & Semrud-Clikeman, 2004). Another example of learning problems affecting poor social adjustment has been found in studies of children with nonverbal learning disabilities (NLD) (Semrud-Clikeman & Hynd, 1990).

Investigating data across divergent paradigms makes it possible to build an integrated model for understanding, assessing, and treating children and adolescents with various disorders. Child clinical neuropsychology can serve as a vehicle for an inte-grated assessment to determine the nature of disturbances and to develop treatment programs for childhood disorders such as ADHD, dyslexia, and other learning disabilities. Psychiatric disorders such as anxiety and depression may also need to be investigated from a neuropsychological perspective. Once neuropsychological status is assessed, the interaction of environmental-behavioral, psychosocial, and cognitive factors can be explored more fully.

To date, a transactional neuropsychological paradigm has not been studied systematically across different types of childhood psychopathology. Emerging literature suggests that this is a promising endeavor for studying learning disabilities, ADHD, traumatic head injury, and other neurodevelopmental disorders. This text discusses the neuropsychological correlates of psychiatric, neurodevelopmental, and acquired (e.g., traumatic brain injury) disorders of childhood; the neurodevelopmental course of these disorders, and the impact of moderator variables such as cognitive, social, and behavioral aspects on the overall adjustment of children and adolescents with various disorders. The extent to which neuropsychological weaknesses limit cognitive and psychosocial adjustment or change across different age ranges will be explored within a transactional model. In isolation, neuropsychological approaches have limitations in terms of definitive answers about the relationship between brain dysfunction and the cognitive, psychosocial, and behavioral characteristics of childhood disorders because this is a relatively young science. Within a transactional model, however, it is possible to investigate how intact versus impaired functional neuropsychological systems interact with and limit cognitive-intellectual and psychosocial adjustment in children and adolescents. This text presents a transactional model of child clinical neuropsychology. In a transactional model, basic biogenetic and environmental factors, including prenatal and postnatal toxins or insults, influence the development and maturation of the central nervous system. This relationship is depicted in Fig. 1.1.

The transactional neuropsychological model for understanding childhood and adolescent disorders suggests that regions have a bidirectional influence on various neural functional systems affecting the intellectual and perceptual capacity of the child. These functional systems ultimately interact with and influence the expression of various behavioral, psychological, and cognitive manifestations of childhood disorders. Social, family, and school environments also interact in mutually influential ways to exacerbate childhood disorders or to facilitate compensatory or coping skills in the individual child. Sameroff (1975) and Sameroff & Emde (1988, 1989, 1998) have hypothesized that behavioral and biological functioning need to be incorporated into a model for developmental regulation. In other words, biological vulnerabilities influence and are influenced by coping skills and stresses experienced in the child's life. Sameroff and Emde (1989) further state that psychopathology should be understood not only in terms of the child's ability to cope or not cope with situations, but also in relation to the “continuity of ordered or disordered experience across time interacting with an individual's unique biobehavioral characteristics” (pp. 20–21). Sameroff's developmental approach attempts to identify the variables that impact the child's organization of his or her experience into a method of adaptation. Such adaptation may or may not be efficient or “healthy,” but can be viewed as the child's attempt to achieve self-stabilization (Sameroff & Emde, 1989). In such a paradigm, the individual reacts to both internal and external environments as he or she attempts to make his or her way in the world.

In our transactional model, Sameroff's theory of a biobehavioral interaction plays a major role. The transactional model presented in this text assumes a dynamic interaction among the biogenetic, neuropsychological, environmental, cognitive, and psychosocial systems. Further, biogenetic forces shape the child's experiences and are most predominant during embryogenesis and early infancy (Sameroff & Emde, 1989). As the child becomes more independent, he or she begins to experience influences from the social as well as the cultural environment. In turn, the child's basic temperament also interacts with the social environment and causes changes in that environment. For example, an infant or toddler who is “easy” to manage will fare reasonably well with a caregiver (parent) regardless of the parent's temperamental characteristics (i.e., calm or disruptive). In contrast, a more “difficult,” fussy, demanding infant or toddler will not mesh well with a caregiver who is also fussy and demanding (Rothbart & Sheese, 2007). This same “difficult” infant would be more likely to prosper under the care of a parent with an even temperament. The “difficult”/“difficult” dyad will interact in mutually unsatisfactory ways. This parent-child interaction may be characterized as distant and non-reinforcing, which is more likely to result in attachment or bonding problems. Thus, the child's constitutional temperament forms a template on which psychopathology can develop or is forestalled. In contrast, a “difficult” child/“easy” parent match may be advantageous in that the parent can help reduce the adverse affects of the child's inborn biological tendencies. So, although parental caretaking may not change the biological tendencies of the child, it may buffer biological vulnerabilities (Rothbart & Sheese, 2007).

While our transactional model acknowledges the role of the developing nervous system, it also recognizes that severe childhood disturbances are not necessarily inevitable. Appropriate psychosocial, cognitive, and/or educational interventions, in conjunction with changes in the ecological systems of the child (i.e., home, school, and social environment), can reduce the negative effects of many neuropsychological or biogenetically based disorders. For some childhood disorders, psychopharmacological therapy can also be beneficial. The important point to emphasize is that brain-behavior relationships are dynamic and fluid, and this dynamic transaction should be investigated in the clinical assessment and treatment of childhood disorders. Thus, an integrated model will be used throughout this book as a method to inform neuropsychological assessment and intervention.

Child clinical neuropsychological assessment originally focused on identifying the presence or absence of brain damage in individuals, comparing cognitive differences among children and adults following injury, and determining the specific type and nature of cognitive deficits associated with brain damage (Semrud-Clikeman, 2004). Historically, the search for a single item or test to localize and lateralize brain damage was of primary importance (Lezak, 2004). A functional organizational approach to child clinical neuropsychology was subsequently recommended by others, with the emphasis placed on assessment of the sequence and rate of skill development and on the measurement of how disabilities interfere with and disrupt normal development (Fletcher & Taylor, 1984).

Currently the emphasis is not on determining where damage is given the use of direct measures of brain function, such as MRI and CT scans, in cases involving traumatic brain injury or tumor processes. In contrast to the previous emphasis on localization of brain damage, the focus in neuropsychological assessment with children and adolescents revolves around the following tenets.

Therefore, this book advances the perspective that clinical neuropsychological assessment should be comprehensive enough to answer referral questions while integrating the behavioral, cognitive-intellectual, psychosocial, and environmental variables within a developmental framework. In a multidisciplinary setting these areas are frequently evaluated by various professionals. In other settings, the child clinical neuropsychologist is responsible for evaluating all of these variables. In both cases, a comprehensive evaluation addresses the main referral question while also screening for additional explanations for the child's areas of concern. Regardless of who actually conducts the evaluation of psychosocial, educational, and family systems problems, the child clinical neuropsychologist will consider these results when formulating diagnostic and intervention plans.

There are several misconceptions that are present in the field when comparing adult and child neuropsychology. Adult neuropsychology has a longer history than child neuropsychology. The neuropsychological instruments that have been utilized in the past to evaluate children were often adapted from those used for adults. For this reason there continues to be some confusion over what is child neuropsychology. Some fallacies that have been described in the literature include assuming that children are just “small” adults and that childhood disorders are similar to adult disorders (Fletcher & Taylor, 1984). In addition, tests that are used for both adults and children have been assumed by some to measure the same skills in both populations. This misconceptualization can lead to misinterpretation of test data and to inappropriate interventions. For example, children’s motor skills develop over time. One measure that is frequently utilized requires the child/adult to connect numbers, and then numbers and letters, in alternating order as quickly as possible. A child with weak fine motor skills will likely score poorly on this test, not due to problems with working memory, but due to motor difficulty. A neuropsychologist not trained in child development, but who is working with children, may misinterpret these findings.

Similarly, children’s development can be very uneven. Some skills may develop at different ages in different children. Development problems with visual-spatial, visual-perceptual, and visual-motor skills appear to be more prominent in younger children with learning problems. Older children are more likely to have difficulty with reasoning and complex language skills. Thus, lags in motor and visual processing abilities in younger children may be developmentally overcome while deficits in skills that require more complex processing will not become obvious until later ages. Children with reading problems have been found to show delays in motor development that improve with time, but who continue to have problems with phonemic processing. Those with autistic spectrum disorders may show excellent abilities to read single words, but experience significant problems with reading comprehension at older ages. For these children early reading may considered a strength which by fourth grade becomes a weakness. Such difference in skills and types of tasks for different ages needs to be carefully evaluated and a background in these areas is needed for an accurate neuropsychological assessment. Again, a neuropsychologist trained in child development will understand the influence of development on performance and not interpret poor performance inaccurate to brain impairment of deviancy.

In an effort to avoid these fallacies, Fletcher and Taylor (1984) describe a procedure for conceptualizing developmental neuropsychology. The basic postulates of this model (the functional organization approach) emphasize the significance of dividing the behavioral characteristics of developmental disorders into those that form the basis of the disability, and identifying those deficits that are correlated with the disability. One should also consider how moderator variables, including environmental and social factors, influence the basic competencies and disabilities of the child where the central nervous system is viewed as one of several influences. Questions in child clinical neuropsychology begin to focus on the sequence in which skills are developed, the rate at which skills are developed, and the ways these skills change at each developmental stage. Further, there is an emphasis on how disabilities interfere with or disrupt normal develop-ment, rather than on identifying which brain areas are deficient.

An integrated neuropsychological paradigm is recommended for making accurate clinical diagnoses, for determining the course and prognosis, and for designing treatment interventions for childhood and adolescent disorders. Adherence to a single theoretical perspective or the adoption of one paradigm to the exclusion of others leads to missed opportunities for more fully understanding the nature of complex human behaviors in children (Teeter & Semrud-Clikeman, 1997). Comprehensive clinical practice, accurate diagnosis, and effective intervention rely on an integrated perspective. Further, educational programming, psychosocial interventions, and psychopharmacological regimes must be multifaceted to be most effective for many childhood disorders. There are several reasons for an integrated approach in assessing and treating child and adolescent disorders. First, research demonstrates that neurodevelopmental deficits identified in young children are associated with later learning disabilities and adjustment problems (Berninger & Hooper, 2006). In some cases a fairly predictable course of development can be anticipated when specific neurocognitive deficits are present, including nonverbal learning disorders (Forrest, 2007), verbal language-related reading disabilities (Berninger et al., 2002), phonemic awareness deficits (Shaywitz, Mody, & Shaywitz, 2006), and impaired temporal processing deficits of auditory information (Tallal, 2003).

Neuropsychological and neurocognitive assessment procedures have been used to identify children with early learning problems. Recent evidence suggests that remediation can be successful for reading-disabled children with phonemic awareness deficits (Gabrieli, 2003). Tallal (2003) also reports that children with linguistic or cognitive impairments show remarkable progress in language comprehension when the rate of acoustic stimuli is modified using computer programs. Understanding the nature of the neuropsychological features underlying specific childhood disorders allows the developmental course of the disorder to be described and treatment planning to be enhanced. Emerging literature suggests that, for some learning disorders, the adverse affects of neurodevelopmental abnormalities can be altered with effective and highly specific early intervention.

Many children with traumatic brain injury and cancer are now surviving their difficulties through improved medical care. The nature and severity of traumatic brain injury is related to cognitive, psychosocial, and adjustment problems in children (Semrud-Clikeman, 2001). Approximately 1 million children each year sustain brain injuries, with about 20 percent requiring hospitalization (Donders, 2007). Careful evaluation and monitoring of these children is imperative, and federal legislation recognizes traumatic brain injury as a special education need. Nearly 50 percent of children with severe brain injury have been found to develop some psychiatric disturbances post-injury, and related behavioral problems persist long after cognitive deficits improve (Semrud-Clikeman, 2004). Further, social disinhibition is frequently observed in children with closed head injuries. Even mild head injuries can result in various cognitive difficulties, including grade retention, underachievement and, in some cases, increased need for special education or resource support (Semrud-Clikeman, 2007). Knowing the neuropsychological systems involved, the level and degree of injury, the pervasive nature of the injury, and the developmental course of the injury is imperative to successful rehabilitation and reintegration into the school, social, and familial milieu for the child or adolescent with head injuries.

Finally, converging data suggest that many psychiatric disorders have a biochemical basis, and some require psychopharmacological therapy in conjunction with more traditional behavioral and psychosocial interventions. Many childhood disorders are chronic in nature and severely limit the long-term adjustment of children. There is a growing need to utilize an integrated model so that presenting problems and the core features of disorders can be understood in relation to biological indices (Ewing-Cobbs, Prasad, Landry, Kramer, & DeLeon, 2004). Further, the extent to which non-neurological and environmental moderator variables influence this interaction is also of interest. In this manner, behavior, biology, and environment interact with resulting cognitive, social, and emotional functioning.

Since the purpose of this book is to provide practical guidance to beginning child clinical neuropsychologists, the remainder of the text addresses practical issues related to the assessment, diagnosis, and treatment of childhood and adolescent disorders. The book is divided into four sections:

Chapter 1 provides an overview of definitions of neuropsychological practice, appropriate laws that are involved, and training and ethical issues. Chapter 2 presents an overview of the functional neuroanatomy of neurons, subcortical regions, and cortical structures and discusses the functions of these various structures. Chapter 3 describes the stages of brain development and discusses factors affecting this process. Chapter 4 provides an overview of neuroradiological techniques as well as clinical issues and procedures.

In the second section clinical issues and procedures are emphasized. Chapter 5 presents guidelines for making referrals for neurological and neuropsychological examinations and for integrating these results with psychological assessments. Chapter 6 reviews the various neuropsychological domains and measures. Chapter 7 discusses the procedures used in a neuropsychological examination with examples of parent and child feedback as well as a neuropsychological report. Chapter 8 reviews available procedures for neuropsychological assessment, including the Halstead Reitan batteries, the Luria-Nebraska battery, the Boston Hypothesis approach, and other related techniques. A framework for investigating neuropsychological functioning within an integrated assessment paradigm, incorporating measures of psychological, behavioral, and cognitive-intellectual functioning is also presented.

In the third section frequently encountered disorders are discussed from a neuropsychological point of view. Each chapter features a case study of a child to illustrate the issues that may arise. Chapter 9 reviews behavioral disorders of childhood, including Tourette syndrome, ADHD, conduct disorder, and low-incidence disorders. Case studies are provided at the end of the chapter. Chapter 10 presents the neuropsychological correlates of various mood disorders of childhood, and adolescents are presented within an integrated neuropsychological perspective. Chapter 11 provides information about pervasive developmental disorders and Asperger syndrome. Chapter 12 presents a discussion of neurodevelopmental disorders, including language and articulation impairments, reading disabilities resulting from phonological core deficits, written language disorders, and nonverbal reading disabilities. Select metabolic, biogenetic, seizure, and neuromotor disorders are presented in Chapter 13. Acquired neurological disorders including traumatic brain injury, exposure to teratogenic agents (e.g., alcohol and cocaine), and infectious diseases including meningitis and encephalitis are discussed in Chapter 14. Chapter 15 presents information about childhood cancer including leukemia and brain tumors.

The final section provides information about interventions that include cognitive, behavioral, and pharmacological methods. Chapter 16 presents interventions and treatment approaches for various childhood and adolescent disorders within an integrated neurodevelopmental paradigm. Metacognitive, academic, behavioral, psycho-social, and classroom management techniques will be integrated for a comprehensive, multidimensional intervention plan to address neuropsychologically based disorders. Finally in Chapter 17 pharmacological interventions are provided.