7. The Neuropsychological Assessment Process

It is helpful to assist the parent in preparing the child for the assessment. Many times children assume they will “fail” the assessment, or believe the outcome of the assessment will determine if they “pass” their current grade. It is far better for the parent to discuss the upcoming visit the night before the appointment to give the child an opportunity to ask questions as well as to adjust to the idea. It is not a good idea to label the tasks that are going to be done during the testing as “games.” In this case, the child believes he/she will be coming to have fun and be very disappointed as most of the tasks are not games, but are work. I generally recommend that the parent describe the various tasks that will be done with the child and provide specific examples like building with blocks, looking at pictures, drawing, and answering questions.

For children with high anxiety, autistic spectrum disorders, or any disorder that requires additional transition time, it is helpful to prepare the child in sufficient time prior to the meeting. For some children that are particularly emotionally fragile or brittle, it is a good idea to have the child visit the office so that he/she can become more comfortable with the surroundings. It is not a good idea for these children to attempt to do the testing all in one day—rather it is better to parcel the testing into smaller amounts. The better the child is prepared for the evaluation, the easier the testing will be and the more applicable the results will be to estimate the child’s current level of functioning.

For the most part, a neuropsychological evaluation is similar to a psychological evaluation. It is the examiner’s job to provide a comfortable and safe environment for the evaluation whether the examiner is the neuropsychologist or a technician. It is very helpful to give the child time to become acclimated to the room. Furniture should be the appropriate size and be comfortable. Setting the rules for the room often is very appropriate particularly for children that have behavioral difficulties or those who are anxious. The basic rules often regard not hitting, leaving the room, talking quietly, and not breaking materials. It is often very helpful to have tangible rewards particularly for children that may be recalcitrant or resistant to the testing.

It is not generally recommended to have the parent present in the evaluation room unless the child is unable to separate after a try or if the child is very young and requires the parent’s presence. Often a parent will believe that she/he needs to be present, but if the examiner is firm and appears confident the child will often not require such presence. For more difficult cases it is possible for the parent to initially be present (with the caution to not answer for the child) and then leave after the child is comfortable. Many children can manage this type of separation, particularly if they know that the parent is in the waiting room.

If the examiner has decided to utilize a non-battery approach, then the appropriate tests should be readily available. For beginning practitioners it may be helpful to have a list ready, while for more advanced examiners may not need a list. If the testing is to be done by a technician, then it is important to prepare the technician for the tests that may be needed and to be available if testing results require flexibility. As will be discussed in Chapter 8, neuropsychological testing from a hypothesis testing approach provides flexibility to determine what measures may be utilized to best answer the question.

The initial portion of the evaluation can be simply talking with the child and getting to know him/her. It is very appropriate to talk to them about their likes and dislikes as well as querying why they believe they have come to see you. Depending on the developmental age of the child, I find it helpful to begin with tasks and then gradually talk about feelings and issues as the child becomes more comfortable with me. For other children who need to talk about why they are present, a discussion of why the testing is occurring and how the child feels about it is appropriate. Interviewing is an art and relies on the examiner being adept at sensing and interpreting the child’s mood and affect, and adjusting the questioning appropriately (Semrud-Clikeman, 1995). Some children really need to talk about their concerns immediately while others need time to get comfortable with the examiner.

Testing should begin with measures that are relatively easy and fun so the child can ease into the situation. As the child’s comfort increases, it is possible to bring out some of the more challenging measures. It is also strongly suggested that the tests be alternated so that the challenging measures are not all grouped together, but instead interspersed with measures that may be easier. It is also important to end the session with a task for which the child feels success. In this manner the child is more likely to leave with a good feeling about how she/he has performed and happy about returning for another visit. For children who are anxious or rigid, it is often helpful to tell how many tests will be used for that period of time and to cross out the tests as they are completed. This strategy offers a feeling of completion and lets the child see there is an end to what is being asked of him/her. Moreover, as appropriate, the examiner can let the child choose which test is used. For example, we have often said, “Today we have to do a mathematics test and drawing test—which test would you like to do first?” In this manner the child has some control over the situation and feels a part of the decision.

At the end of the session, it is appropriate to tell the child that he/she has worked well and that there were a lot of things that he/she could do well—listing the tasks that he/she felt most comfortable with is helpful. If there is another appointment, it is very appropriate to state, “I will see you again in five days” or a specific date for older children. If the testing is completed, it is very appropriate to tell the child/adolescent that the testing is done and that you will meet with him/her in the near future to discuss the results.

It is important to be cognizant of the parent’s level of anxiety as they approach the feedback session. For many parents there are great fears that the neuropsychologist will actually find something seriously wrong with their child or that it is their fault. The feedback session can be very therapeutic if managed in a careful way. Work to keep jargon out of the feedback and, for beginning neuropsychologists, it may be difficult to realize what jargon is for the lay person. For example, one student began a feedback with a parent in this way:

Thank you for coming today. Joey completed the WISC III, the WIAT II, and the Rey-Osterreith in our first session. We found that he had difficulties with working memory, processing speed, phonological coding and visual-spatial integration. These problems are consistent with LD as well as possibly sensory-integration difficulty.

Keep in mind the main goal for the feedback is not just to provide scores and information to the parent (Handler, 2007), but to provide a forum to discuss possible interventions and remediation of difficulties. For example, it is a good idea to begin the feedback by summarizing the main reason the parent has sought the evaluation. This can be done simply, for example:

I want to thank you for coming today to discuss the results of Cindy’s testing. As we talked in our first meeting, I understand you are concerned about Cindy’s difficulty with completing her work and following directions. You were concerned whether Cindy has any attentional problems or whether the work is too hard for. Cindy and I completed many tests to look at these issues and I’d like to talk to you about the results at this time. Please do not hesitate to stop me and ask a question if what I am saying is not clear.

In beginning the feedback it is advantageous to provide examples of how the child related to the examiner as well as the behaviors that were noted. For example if the child had difficulty remaining seated or paying attention it is appropriate to remark on these behaviors and then ask if the parent sees this type of behavior at home or in school. As one begins the feedback try to remember that the parent is going to be very anxious, wondering what the bottom line (diagnosis) is. It is important to convey to the parent that you really know their child and that you care. Relating an anecdote of how the child worked on a task is one way to convey your knowledge of the child. If the clinic or hospital in which you work uses technicians for the testing, it is important that you met and interacted with the child. This helps you build a rapport with the parent and lends credibility to the later recommendations.

It can be very helpful to provide concrete examples of areas of strength and/or weakness. If the child has difficulty with Block Design on the WISC IV then phrasing this problem as, “Cindy had difficulty using blocks to copy a model in a short period of time. When I gave her extra time to do this task, she was able to copy the model. It appears that the difficulty in her skills is not that she cannot interpret what she sees, but that it takes her longer.” The neuropsychologist can also discuss tasks where the child succeeded. “Cindy is very good at explaining what words mean. She approaches many tasks by using her excellent verbal skills to solve the problem.”

As the feedback continues, check with the parent to determine if the neuropsychologist’s observations are consistent with what is happening at home. Anticipating questions and prompting parents to give examples of what you have seen are very helpful in engaging the parent in the process, and to ensure that the information may be more readily used when the parent communicates with the school or interested parties (Baron, 2004). Generally, relating the findings should not focus on the scores but rather on the broad picture. Stating something like:

“Cindy shows good overall ability with her scores in the high average range for her age. She shows particular strengths in her verbal ability to answer questions, define words, and recall facts. She has more difficulty when she is asked to solve a problem in her head (like 2 × 12) quickly or copy a block design quickly. Cindy has difficulty on tasks that require her to complete them quickly and which are monotonous. Her attention on these tasks started out well but then as the boring task continued she began to fidget and have difficulty staying with me. She would return to the task when I asked her to, but then would again need to be drawn back to the task at hand—are these behaviors you see at home?

In this manner the parent is drawn into the feedback and begins to relate the findings to the real world. Of course if they ask for the numbers you need to provide them. I often will utilize a normal curve and then mark the areas of strength in one color and the areas that are problematic in another.

This graph can then be taken home to help the parent explain the results to the teacher. I use a similar one with the child during feedback, emphasizing the child’s strengths as well as areas that could be strengthened.

It is important to provide the diagnosis for the child, if there is one, and to discuss what the diagnosis means. During this discussion, explore how the parent understands the diagnosis and whether he/she agrees with it. At times there may be disagreement between the parents and the practitioner can assist with resolving some of these issues. One parent may be comfortable with the diagnosis while another may dispute the findings. It is important to stay calm and collected during these discussions and to not become combative or defensive. Helping the parent to think about what the disagreement is about, as well as trying to come to a resolution, is an important part of the feedback. Sometimes the disagreement is due to having fewer interactions with the child over the problems or not attending school meetings and thus being less informed. At other times, the disagreement may be due to the diagnosis hitting too close to home—in other words the parent has a similar problem and has not resolved the issue for him or herself.

If the child has a learning disability, it is important that you be very aware of the laws that are present in your state and nationally to obtain services (Magden & Semrud-Clikeman, 2007). It is disconcerting to the parent to be told a child qualifies for an educational service (such as a learning disability program) only to find out that the state law does not support such a conclusion. Thus, the practitioner needs to be cognizant of the rules and to write his/her report and conduct the feedback accordingly. It is imperative that the practitioner be aware whether the child is most appropriately referred for a special education evaluation or for a Section 504 evaluation (Magden & Semrud-Clikeman, 2007). It is also important for the practitioner to be able to discuss the difference and provide support in contacting appropriate school personnel.

Finally, and the most important part of the feedback, is discussing interventions. Provide concrete and direct suggestions to help the child in school and at home. The interventions also need to be realistic. At times the practitioner will use a “shot-gun” approach and recommend everything to be done at once. It is easy to lose sight of the fact that financial resources at home and school may be stretched and purchasing individual physical therapy in addition to school physical therapy may not be feasible. It is also important to realize that emotional resources may also be strained. Helping the parent to prioritize interventions can be very helpful and prevent burnout as the parent attempts to do everything at once. I find it helpful to say the first priority is … and then name it. If the child has a learning disability, then that is the first priority area to obtain services. If the child is ADHD, then determining whether a medication trial is appropriate should take precedence.

For a few patients it may take more than one session to fully manage the findings and secure appropriate interventions. For others, the feedback session may be followed up by a phone call to support the parent’s efforts. Providing the written report at the end of the feedback session is very appropriate and allows the parent to read and reflect upon it. I always offer that they can come back and talk more if needed. Finally ending the session with a short summary of what was discussed is very helpful so that everyone understands what was said.

This section should briefly describe the reasons the client is currently being referred for testing, indicate who referred the child and what the main question is. In addition, this section should briefly describe where the client is currently, what grade he/she is in, and if he/she is in any special programs.

A developmental and background history is important for a number of reasons. First, a developmental history can be important to identify risk factors during pregnancy and delivery that have been associated with neurodevelopmental disorders of childhood of a specific (e.g., learning disabilities) or global (e.g., cognitive disabilities) nature. Second, previous head trauma and/or other health factors (e.g., recurring ear infections, high fevers, or febrile seizures) can be uncovered in a review of developmental history. Third, a careful history is important to determine the presence of similar or related disorders in other family members or hereditary linkages that might be helpful to understand the etiology of a particular disorder. Fourth, a history of when the child attained motor and language milestones (walking, talking, etc.) is essential to determine the nature and extent of the developmental correlates of the child's problem. Fifth, background history is essential to determine the presence of coexisting disorders (e.g., conduct disorders, depression, anxiety) that affect long-term outcomes for children with various neurodevelopmental disorders. These conditions often must be addressed separately in treatment plans. It is important to include any pertinent medical and medication history. Finally, background information will shed light on the child's educational, psychosocial, and academic opportunities, which may assist in the proper diagnosis of a disorder (i.e., reading deficits). It is important to briefly discuss interventions that have been attempted and the success of these interventions in this section.

The extent to which environmental, genetic, and experiential factors affect the manner in which some CNS disorders progress or influence treatment approaches can be explored with a complete review of the child's history. This information is crucial for accurate differential diagnoses, particularly when the clinician is trying to determine whether the problem is neurodevelopmental in nature or the result of a lack of opportunity to learn, or the absence of appropriate modeling, stimulation, or reinforcement.

There are several methods for obtaining reliable background information, including the structured parent and child interviews from the Child Behavior Checklist (Achenbach, 1991) and the Behavior Assessment for Children-2 (Reynolds & Kamphaus, 2004). Most neuropsychological clinics use semi-structured interviews [i.e., K-SADS; (Kaufman, Birmaher, Brent, Rao, & Ryan, 1997)] for gathering information, and many utilize questionnaires designed specifically to investigate a particular disorder, such as ADHD. Medical and school records also provide crucial information for identifying the child's biogenetic, health, and environmental history. A careful review of these materials often reveals risk factors and predisposing conditions that may interact with the child's specific problem, and this information may be useful in designing effective interventions.

Behavioral observations allow the person reading the report to truly understand what it was like to be in the room testing the client. At the very least the behavioral observations need to describe the client’s language abilities, attention to task, ability to manage frustration, and his/her mood and affect. This section should describe how the child/adolescent communicated—was it with full sentences or just one word responses? Was he/she distractible? If so, was the examiner able to bring the client back to the task at hand? Most reports also provide information about how the child reacted to encouragement and praise, and how the client responded to frustration. Was the child’s affect flat, animated, expansive, appropriate to the situation? How did the child approach certain tasks? Did she/he talk their way through the task? All of these behaviors can assist in understanding the findings. In this section, also, if changes needed to be made to standardized tests, then those changes need to be enumerated and qualified.

This section lists the tests that were administered. It then discusses the findings generally in the various neuropsychological domains (i.e., cognitive, academic, executive functioning, attention, memory, psychosocial). A good neuropsychological report provides not just the scores, but an interpretation that is understandable to the lay reader. Each domain should be presented clearly but concisely so that the findings are usable. We find it helpful to provide a short summary at the end of each domain that includes the strengths and weaknesses in that domain. This section provides the backbone of the report and the interpretation of what these findings mean.

In this section of the report it is often helpful to put the measures into a context with which the reader is familiar. For example, we generally state that standard scores are in the average range when they fall between 85 and 115, with similar statements made for scaled scores and for T scores. Many neuropsychologists prefer to have the body of the report to reflect the findings and attach a separate psychometric summary at the end of the report. See the attached report for a model.

This section is the most difficult to write and yet the most important section of the report. It ties together all of the issues involved and meshes the findings with the tests and recommendations. Some neuropsychologists will not include a diagnostic formulation here while others do. We suggest that when the diagnosis using DSM axis format is helpful, then it should be used and included.

The summary is also described as a case formulation. In this section the developmental history, medical history, school history, family history as well as the test results are integrated. In addition this section discusses findings that are unusual or difficult to understand and attempts to place them in a framework for the reader. Scores and statistics should not be present in this section. The summary is also the aspect of the report in which specialists (neurologist, psychiatrist, etc.) are generally most interested. Some practitioners now put this section at the beginning of the report.

The interventions need to be appropriate to the case at hand and reasonable. Many school professionals bristle at reports that tell them the child needs one-on-one intervention; a practice that is likely unfeasible. The interventions should also be tied to the diagnosis. For example, if ADHD is diagnosed there should be interventions that address problems with organization, attention, possible medical interventions, and impulse control problems. Likewise, if a learning disability is present it is helpful to explain what types of reading and/or mathematics assistance and methods are appropriate (Semrud-Clikeman, 2006).

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 Hospital.

Dr. X. Ph.D.

Licensed Psychologist