5. Integrating Neurological, Neuroradiological, and Psychological Examinations in Neuropsychological Assessment

Neurological examinations are conducted by neurologists generally specializing in childhood and adolescent neurology. Because it is sometimes difficult to differentiate normal developmental variations from abnormal neurodevelopment in the first few years of life, it is important to access child neurologists when there is a question about chronic and serious neurodevelopmental delays. The neurologist will identify disease, injury, developmental, or genetic processes that interfere with CNS functioning. The neurological examination usually consists of the following: (1) an in-depth review of medical and developmental history; (2) an assessment of mental status; (3) an assessment of the functional capacity of the CNS, including the cranial nerves; (4) an evaluation of motor systems; (5) an assessment of sensory functions, and (6) an assessment of autonomic functions (Swaiman, Ashwal, & Ferriero, 2006). Each area is systematically evaluated through a series of activities designed to measure muscle tone, cranial nerves, and primitive and autonomic reflexes. Interpreting information from the neurological examination is complicated by the child’s age and intellectual and functional capacity. A look inside the examination room with a neurologist and patient would show the physician initially conducting an in-depth developmental interview. Since the child is present during this procedure and the physician notes the child’s participation, attention, and language. Moreover, the child’s facial movements are noted with attention to head nodding, eye blinking, staring, tics, and movement disorders. In addition, the physician observes the child’s behavior with regard to his or her impulsivity, dependence on the parent, and activity level. Additional observations of parent-child interaction are obtained. Swaiman et al. (2006) suggests that the physician consider the following questions: “Does the child respond positively to the parent’s interaction? Does the child attempt to manipulate the parent? Is the response transient or persistent? Is the parent’s attitude one of caring or hostility?'

After age four, a motor screening examination is conducted. The neurologist has the child stand in front of him or her and demonstrate the required motor acts. The child is asked to hop on one foot and then the other, to walk forward and backward, to walk on tiptoes, and to walk on heels with toes pointed up. Additionally, the child is asked to rise from a squatting position, and to stand with feet together, eyes closed and arms and hands outstretched from the body and parallel with the floor. These maneuvers are designed to check for balance, extraneous unnecessary movement, and the Romberg sign. The Romberg sign is indicative by the child’s inability to stand still when his or her eyes are closed (Swaiman et al., 2006). The child then is asked to touch his or her nose with the finger, both with eyes closed and with eyes open. Based on this initial screening, the neurologist will follow up on any abnormalities in motor coordination. The next portion of the examination involves testing reflexes. Both deep tendon reflexes (also known as muscle stretch reflexes) and reflexes appropriate at various ages are assessed. For the deep tendon reflexes, the neurologist elicits the reflex with a rubber reflex hammer while the child is seated quietly. Hyper reflexes (contraction of muscles that generally are not involved in the reflex) are a sign of corticospinal dysfunction. Hypo reflexes are most often associated with motor unit abnormalities of the spinal cord (Swaiman, 1994) or of the cerebellum. Cerebellar functions are assessed by asking the child to first touch his or her nose and then the examiner’s finger at various positions. The child is also asked to run his or her heel down the shin of the opposite leg. Inability to complete these tasks smoothly may indicate cerebellum dysfunction.

Cranial nerves are evaluated next. Congenital anomalies as well as traumatic injury can produce observable neurological signs. See Table 5.1 for a review of some common anomalies that might be identified when conducting an examination of the cranial nerves.

The sensory system is assessed next. The ability to sense vibrations, position of limb, and joint sense is evaluated. To evaluate the child’s ability to localize tactile information, the neurologist touches various places both unilaterally and bilaterally with the child’s eyes closed. The inability to localize touch is associated with parietal lobe dysfunction (Swaiman et al., 2006). The child is also asked to recognize various objects which are placed in his or her hand (stereognosis) with eyes closed. Although these tasks are believed to provide information as to the integrity of the parietal lobes, attention to task can interfere with performance.

Muscle strength is also assessed. The child is asked to push against the examiner’s hand with his or her hand or foot as hard as possible. He or she may also be requested to push his/her head against the neurologist’s hand as hard as possible, or walk on his or her hands while the examiner holds the child’s feet. Once the child’s feet are placed on the floor, the child is asked to stand up. Inability to stand without aid is another measure of muscle strength. To evaluate gait, the child is asked to walk back and forth and to run. Running exacerbates problems with gait and can show additional signs of spasticity or jerking movements (Swaiman, 1994). This section was a brief overview of a typical neurological examination. The interested student may wish to observe a neurological examination in order to obtain a first-hand experience. You may wish to ask a parent if you can accompany him or her to such an examination.

Despite their research potential, CT scans and MRI procedures are not necessarily part of the typical diagnostic process for identifying developmental disorders unless there are other accompanying neurologic signs (e.g., seizures, dysphasia). CT and MRI techniques are relatively expensive and for the most part are reserved for diagnosing and treating medical or neurological conditions affecting the CNS.

Neuropsychological assessment procedures are described in detail in Chapter 6. Neuropsychological tests are generally administered to investigate the brain-behavior relationship in children and adolescents and to determine whether cognitive, academic, and psychiatric disorders are related to abnormal brain function.

Medical and university labs and clinics are exploring integrated research protocols including neuroradiological and neuropsychological data in an effort to more fully understand the nature of childhood disorders. Clinicians and researchers that are prominent in this effort include Castellanos et al. (2002), Giedd et al. (2004), Papanicolaou (2003), Gabrieli (2003), Semrud-Clikeman et al. (2006), and Shaywitz et al. (2004), to name a few. In these efforts, researchers are revealing evidence linking neurocognitive and neuropsychological deficits to functional brain regions or systems. In essence, these investigators are providing information to establish the bidirectional nature of the neuroanatomical/morphological neuropsychological-functional link. (This relationship is depicted in Fig. 1.1). While the link between anatomy and function has generally been downward, these efforts start at the functional and neuropsychological level and build upward, establishing a function-to-structure linkage that may lead to a better understanding of childhood disorders.

Researchers postulate neurobiological models of childhood disorders, such as dyslexia, and, in an effort to test these models empirically, information from divergent sources is analyzed. Typically theories about how the brain functions are tested by administering neuropsychological tests to carefully defined groups of children (e.g., dyslexic children with language-related deficiencies), and then by studying morphological variations in brain structures using neuroimaging techniques and, more recently, fMRI procedures. The degree to which specific neurolinguistic deficiencies are related to morphological abnormalities or functional differences in brain activation can thus be investigated. In doing so, researchers are beginning to answer questions such as these: Do children with language-related reading disorders have structures that are similar to those typically found in children in regions presumably mediating language processes? And, are the measured linguistic difficulties a function of these unique patterns of brain asymmetry? Shaywitz, Shaywitz, Pugh, Fulbright, and Skudlarski (2002) have discussed these morphological-functional relations for children with dyslexia in detail. The reader is also referred to Pliszka et al. (2006) for a better understanding of these brain/behavior interactions in children with ADHD.

The next logical and critical step in developing a neurobiological model of childhood disorders is to investigate the extent to which children with cognitive-processing and/or linguistic deficits respond to differential intervention programs. Efforts to identify cognitive correlates of reading deficits have been reviewed by Eden and Moats (2002). A meta-analysis of phonologically based approaches to remediation found that stressing phonological processing skills for poor readers improves reading performance (National Reading Panel, 2000). These interventions will be explored in more detail in Chapter 10.

In summary, efforts linking neuroradiological and neuropsychological findings are underway establishing the bidirectional nature of the relationship between brain structure and brain function. Integrated research paradigms are important in this effort, and will advance our basic understanding of childhood disorders. In the clinical setting, children referred for neuropsychological evaluation do not necessarily receive neurological or neuroradiological testing unless there is accompanying brain damage or suspected CNS disease. Cognitive, academic, behavioral and psychosocial functioning are also of interest to the neuropsychologist because these factors may affect test performance on neuropsychological measures. Thus it is important to explore alternative hypotheses (e.g., attentional deficits, motivational variations, depression, anxiety, and/or oppositional defiance) before making inferences about brain pathology on the basis of neuropsychological test results. Tests of psychological functioning that are commonly incorporated into neuropsychological evaluations are reviewed next. Psychological factors that have a negative impact on the neuropsychological evaluation are also explored.

Achenbach (1990, 2005) suggests that at least six microparadigms be incorporated in the study of childhood disorders: biomedical, behavioral, psychodynamic, sociological, family systems, and cognitive. By drawing from each of these diverse approaches, questions about childhood disorders can be framed into an integrated “macroparadigm.” Achenbach describes a model of multiaxial assessment with specific suggestions for measuring child behavior:

Neuropsychological evaluations could be appropriately incorporated into Axis IV of this model. Various components and techniques recommended for use in a comprehensive psychological evaluation are discussed briefly. Information gathered from this evaluation informs the neuropsychologist and others about the child’s overall cognitive-intellectual, psychosocial, and academic functioning. This information is helpful in describing the extent to which brain-related dysfunction affects these important functional areas of the child.

A number of psychological conditions or factors can have an impact on neuropsychological evaluations that should be considered when evaluating children and adolescents. These factors may interact differentially depending on whether the child’s condition is a result of acquired anomalies (e.g., traumatic brain injury) or developmental anomalies (e.g., learning or neuropsychiatric disorders). First, children sustaining traumatic brain injury may display symptoms of “psychic edema” that interfere with performance on neuropsychological tests. Inattention, distractibility, and motivational problems may be present soon after injury. Although these features frequently subside within weeks of injury, once the child has stabilized, initial or baseline neuropsychological evaluation may be contaminated by these short-term problems (Semrud-Clikeman, 2004). Furthermore, these psychological aspects may mask other deficits that could ultimately be long-lasting (e.g., impaired reasoning and planning). For example, tests of executive functioning (e.g., Wisconsin Card Sort or Category Test) may be sensitive to these psychological problems.

If a child is inattentive and distractible, then careful and thoughtful analysis is lacking. Impulsive responses may be inaccurate. Some children with TBI do continue to display ADD-like symptoms long after recovery, but the clinician is advised to consider the initial impact on test results if inattention and distractibility are observed, particularly when the child’s history does not suggest that the problems were present preinjury. Second, language and/or reading delays may make some neuropsychological items difficult. If a child does not understand the verbal directions of a test and responds inaccurately, this may indicate a language comprehension problem rather than a deficit in the underlying neuropsychological function of interest. For example, instructions on some psychological and neuropsychological measures tests (i.e., Trails B from the Halstead Reitan) may prove too complicated for a child with a receptive language delay. In this instance, it is imperative to determine whether low scores result from true reasoning or planning deficits, or from problems in comprehension. Testing the limits or simplifying instructions may be helpful in this determination. Further, cognitive delays also may produce poor performance on measures of global (e.g., reasoning, abstract formation, memory) versus specific brain functioning (e.g., motor speed).

Third, children with conduct-related or oppositional defiant disorders may show signs of passive aggressiveness and poor motivation. Refusal or poor effort should not be confused with neuropsychological deficits. It is also not uncommon for children with these psychiatric problems to have poor frustration tolerance. They may give up quickly and become easily frustrated when they begin to struggle on items that are difficult (e.g., reasoning tasks). Efforts to improve frustration tolerance may include using reinforcers (e.g., a soda, a candy bar) or shorter testing intervals. Fourth, children with ADHD also may make careless, impulsive errors. Testing on and off medication often gives the clinician a better picture of the child’s underlying neuropsychological problems beyond the impulsivity and distractibility that may be paramount in ADHD. Breaking testing periods into shorter periods may also improve performance.

Finally, depression and/or anxiety may interfere with a child’s ability to put forth sustained effort. Children may appear apathetic, withdrawn, or overly nervous. It is important to build rapport with the child and to create a supportive, reinforcing testing climate. Again, testing the child both on and off medication may be indicated, especially for children who take antidepressants. The neuropsychological report should reflect any special testing administration changes or modifications, and should describe the conditions under which the behaviors were elicited. It may be helpful to conduct a follow-up evaluation (three to six months later) if the clinician believes that psychological factors have rendered the interpretation of neuropsychological findings suspect or contaminated. An important part of the neuropsychological evaluation process is a comprehensive presentation of the information gathered on the child’s behavior and method of interacting with the examiner.

Patient Name:  Sam

Date of Evaluation:  8/5, 8/12, 8/26/

Chronological Age:  13–10

Teaching Behaviors which are helpful:

Focus on the following:

Physical Arrangement of Room

Lesson Presentation

Worksheets and Tests

Behavior

Thank you for the opportunity to work with this young man and his family. If you have any questions about this report, please do not hesitate to contact me at the XXX-XXXX.

Dr. X. Ph.D.

Licensed Psychologist

cc: Dr. K

   Dr. R