What’s Needed in a Thorough Neuropsychological Evaluation?

The importance of a comprehensive neuropsychological or psychoeducational assessment to prevent misattribution of diagnosis cannot be overstated. In Learning Disorders Across the Lifespan: A Mental Health Framework, edited by myself and Amy E. Margolis, Jack Davis and I discuses the critical role of a thorough evaluation for understanding and treating learning disorders.

Testing can help explain what may be getting in the way of academic success. A clear knowledge of neuropsychological strengths and weaknesses is needed for treatment planning purposes, to aid understanding of the student, and to provide specific, individualized recommendations for interventions. Additionally, these evaluations are needed to provide information for determining whether eligibility for an specific learning disability (SLD) under the Individuals with Disabilities Education Act (IDEA) Section 504 or ADA has been met. Once testing is completed, a comprehensive report should be generated from the evaluation that summarizes and explains all the data collected, relevant diagnoses, eligibility codes, and the resulting treatment recommendations.

What’s in a Report?

Report structures vary, but generally include the following:

• Developmental, medical, and educational history
• Behavioral observations during testing as well as elsewhere (classroom, playground)
• Testing data generally structured by cognitive area
• Diagnostic impressions that integrate behavior observations, interview data, and test results
• Specific referrals, recommendations, and a guide for developing a treatment plan
• Technical data presented either in an appendix or throughout the report.

Decisions then can be made regarding with whom to share the evaluation, so that the information can be best used. Parents can also schedule meetings with the school’s learning support personnel to review the evaluation findings and determine a plan for next steps. Learning Disorders Across the Lifespan: A Mental Health Framework offers a description of what a thorough evaluation battery should include. This is summarized below, but the reference should be consulted to understand them in detail (the terms in parenthesis are frequently used in a report).

Key Domains

The key 16 domains that should be addressed are the following:

1. Math: includes all areas of academic math, the ability to do math calculations quickly and accurately, solve arithmetic problems (math concepts, calculation, application, and fluency).
2. Written expression: the ability to write quickly and accurately using correct punctuation, organization, grammar, and spelling (handwriting fluency, spelling, compositional fluency, writing mechanics, and composition: both narrative and expository).
3. Reading: the ability to decode written material quickly and accurately with comprehension (reading comprehension: both literal and inferential, word identification [basic and pseudo] and fluency).
4. Intellectual abilities: thinking skills that are most associated with academic learning. (verbal or crystalized, fluid/pattern analysis, visuospatial, quantitative).
5. Receptive language: the ability to accurately perceive and understand spoken language (phonemic awareness, morphological, syntax, semantics, pragmatics, receptive vocabulary).
6. Expressive language: the ability to accurately speak and convey language (rapid naming, expressive vocabulary, pragmatics, word retrieval, and verbal fluency).
7. Visual memory: the ability to retain things you see and immediately remember, and then transfer into long-term memory (concrete vs. abstract, recognition vs. retrieval, sequential vs. nonsequential, and immediate vs. working vs. long term).
8. Verbal memory: the ability to retain spoken language and immediately remember and then transfer into long-term memory (contextual vs. de-contextual, recognition vs. retrieval, sequential vs. nonsequential, and immediate vs. working vs. long term).
9. Executive functions: the ability to make meaning, manage, and utilize all information (visual scanning, cognitive flexibility, initiation, working memory, planning/organizing, internalized, externalized, self-monitoring, task completion, sequencing, switching between sets of information, and attention).
10. Attention/focus: the ability to sustain attention (concentration, sustained attention, maintenance, direct optimal arousal, selection of information to attend to).
11. Sensory motor: the ability to perceive, organize, and remember the varieties of sensory input (bilateral, efficiency, simple vs. complex, timed vs. untimed, sequential vs. nonsequential, proprioceptive, and pencil grip).
12. Sensory processing sensitivities: how the environment impacts your sensory systems (light, heat, sound, touch, and taste). It is important to consider sensory issues in the diagnostic process.
13. Visual processing: the ability to follow visual material (tracking, sequential vs. nonsequential, timed vs. untimed) accurately and efficiently.
14. Orthographic processing: the ability to recognize spelling and written conventions accurately and efficiently (grapho–symbol, grapho–nonsymbol).
15. Graphomotor: pencil and paper skills (untimed: visual-motor integration, design, drawing, and handwriting).
16. Affect and behavior: how one deals with feelings and behaves around others (depression, anxiety, thought problems, social problems, attention problems, oppositional behaviors, conduct disorder, self-esteem).

Tests Used to Assess

Within each domain area, there are also multiple measures or options to assess a particular construct, with different measures available for different age groups. Selecting appropriate measures requires clinical judgment. Broitman, Davis, and Margolis (2020) offer a list of measures used in their typical/sample assessment that would include a combination of tests that would cover each of the required domains listed above through a norm-referenced process. Additionally, a family, developmental, medical, and social-cultural history is needed to complete the picture. Clinical observations from the sessions or at the school setting add important data. A complete intake form is included in their clinical guide to assessment and treatment (Broitman et al. 2020).

Use of Projective Tests

Projective testing, however, is not included in this battery, as children, adolescents, and/or adults with perceptual processing challenges are underrepresented in the standardization populations for projective tests. Perceptual processing challenges can produce responses on projective instruments that can sometimes be misconstrued as psychopathology. Hence, projective tests are not recommended when trying to evaluate and understand clients with learning disorders.

Summary

A comprehensive neuropsychological or psychoeducational assessment is an essential tool to allow clinicians a way to better understand interactions between learning disorders, their socio-emotional sequelae, and their psychology. This is a critical trifecta to consider when dealing with people with learning disorders.

Up next: Talking about the results of a neuropsychological evaluation can be a therapeutic event!