Why Neuropsychological Evaluations In Lieu of Psychoeducational Evaluations? Susan Crum-Norris, Ph.D. (Note: The following item is being used with permission and the views expressed herein are those of the author.)
There are five major reasons why a thorough neuropsychological evaluation performed by an pediatric neuropsychologist is superior to a psychoeducational evaluation. These are the inadequate range of a psychoeducational evaluation, The training of the personnel performing psychoeducational evaluations, the narrow focus of psychoeducational evaluations, the level of performance model employed in psychoeducational evaluations, and the failure of psychoeducational evaluations to assess brain behavior relationships.
In terms of inadequate range generally, psychoeducational test batteries do not thoroughly cover the range of abilities which need to be assessed if one is to obtain an accurate profile of the nature and degree of an individuals abilities and disabilities. Even when extensive batteries such as the Woodcock Johnson are employed, school personnel typically omit many of the subtests, or use one primary measure as their assessment tool without verifying performing through the administration of confirming measures.
The individuals administering tests within school districts vary significantly in the fields of their professional training and most importantly in their psychometric sophistication. For example, some schools have teachers, special education consultations, speech language teachers or school psychologists all of whom may administer psychological tests. A major limitation which results from this diversity of testers is a decreased reliability of the obtained results.
Psychoeducational assessments focus almost exclusively on the demands of the typical classroom situation, often paying little or no attention to the individual's ability to adapt to social relationships within the family, or with age peers, long-term learning and social developmental demands in the community, informal learning situations or employment settings. They neglect to address the fact that the ultimate purpose of education is to prepare young people to be functionally independent contributing members ofsociety not to prepare them for proficiency in conforming to highly structured situations with narrow demands. Thus, their focus is too narrow to be of true benefit.
Psychoeducational evaluations are normally interpreted primarily from a level-of-performance perspective in a theoretical manner with high emphasis on the face validity of the tests administered. But, there is absolutely no evidence to show that what a child can produce when assessed one on one inan distraction free environment without peer pressure is in any means a reflection of what that child's level of performance will be in real-life situations.
Finally, psychoeducational evaluations do not assess brain behavior relationships. It is important to include measures which evaluate the relationship between the brain's functioning and the observed deficits because they help us to identify which are likely to respond to remediation and which are more likely to benefit from mastery of compensatory techniques. Such evaluations include a neurological evaluation (as opposed to an examination by a general practitioner), an audiological evaluation (in addition to any evaluation done by a speech language pathologist, an evaluation by a physical therapist, an evaluation by an ophthalmologist, and a neuropsychological evaluation. It may also include an MRI or a EEG or Spect Scan.
The scope of a neuropsychological evaluation is significantly greater than that of a psychoeducational evaluation. It includes the level of performance evaluation where the individual's level of achievement is compared to age or grade peers, but, it moves beyond this level to include: a sign analysis, a profile analysis, a body side comparison and to look at adaptive functioning. In terms of sign analysis a good neuropsychological battery includes testing for signs (specific deficits) that are indicative of cerebral dysfunction. In other words, it looks to see whether the types of errors the individual makes are the types of errors which occur almost exclusively among brain-damaged subjects. This permits one to rule out issues such as inadequate instruction, lack of educational exposure or emotional factors. It also includes a profile analysis where the trained clinician is searching for patterns and relationships among test scores which localize the dysfunction in certain areas of the brain or which are symptomatic of certain types of disorders. In other words, does the subject show striking variability in socres on different test which fits a pattern that relates to the known functions of the anterior and posterior regions of the brain, the cerebral and subcortical regions of the brain, or of the two cerebral hemispheres, or areas within the cerebral hemispheres?
The body side comparisons included in a neuropsychological evaluation involve administration of tasks which evaluate the adequacy of motor and sensory-perceptual functions on the two sides of the body with identical tasks (adjusting for dominance) to determine if they reveal lateralized disparities that exceed expected limits for subjects with normal brain functions. This demonstrates whether the deficits imply dysfunction or damage in the cerebral hemisphere contralateral to the defective side of the body.
Finally, when looking at adaptive functioning, the neuropsychologist is working to determine how any cerebral dysfunctions impact upon the individual's day to day functioning in their routine environments. Differentiating deficits which are a psychological reaction to neurological problems and need to be treated with therapy and environmental modification form those which are a direct result of the neuropathology and need to be addressed through remediation (speech language therapy, occupational therapy, cognitive rehabilitation, physical therapy, neurofeedback) and compensatory mechanisms such as special educational instruction.
A neuropsychological evaluation can not only identify whether or not there is a learning disability or ADHD or another condition, but, it can o ften identify the subtype of learning disability - ie. Verbal linguistic learning disability or a nonverbal learning disability. It can identify whether a child has a dysphonetic or dyseidetic form of dyslexia, a mix dyslexia, a restricted receptive dyslexia, a dyseidetic or visual perceptual dyslexia, a phonetic dyslexia or a normal diagnostic profile with a child performing below level because of social, motivational and educational factors as opposed to neurobehavioral deficits. A good neuropsychological evaluation can identify whether there are problems not only with attentional functions, but, whether these problems involve orienting responses, selective attention, single focus attention, sustained attention or vigilance, divided attention, hemi-attention or sustained concentration. It can tell you whether perceptual motor problems involve motor impersistence, simple, complex or disjunctive psychomotor speed. It can identify agnosia, form blindness, defective visual analysis, impaired facial recognition, and can differentiate between achromotopsia and impaired color naming. It can investigate problems with spatial localization, visual neglect, ideational apraxia and constructive apraxia. It can identify whether there is aphasic agraphia or apraxia agraphia. It can reveal auditory agnosia, word deafness, problems with figure ground discrimination, problems with prosody.
In the area of memory it can hone in on problems with sensory registration, echoic or iconic storage, active or working memory and long term or remote memory. It terms of cognition a thorough neuropsychological evaluation can identify whether a child can discriminate stimulus characteristics, has mastered concrete concepts, defined concepts, rules or higher order rules.
A neuropsychological evaluation can tell you about how a person approaches problem solving, information gathering, what their retrieval strategies are, their openness to insight and flexibility, how well they can brainstorm, how well they can identify patterns or sequences, how well they can analyze a situation and restate the problem in a format that will permit them to scan effectively for clues so that they can estimate, predict, project, examine their assumptions, elaborate upon information and evidence fluency, flexibility or originality when interacting with their environment.
Now I know that not every neuropsychologist does the kind of in-depth thorough neuropsychological evaluations I am talking about. But, if you are going to get an evaluation, ask the individual to see five or six of their former evaluations with identifying information removed. Make certain it includes all of the above and that they give specific recommendations for both remediation and compensation both in school and at home. And, for the skeptics among you, I am not plugging my field or my practice. I am retired, but I know how many children I was able to help because a thorough evaluation finally identified the issues and mapped out a plan of intervention.
To give just a few examples, I had one patient referred to me for Depression who, indeed had all the signs of depression, but, no family history and no disturbing life circumstances that could explain the findings. I did a neuropsychological evaluation with a EEG which were both contraindicative of depression, but, pointed to a viral infection. Further blood work revealed a long-term undiagnosed case of Lyme disease, which remediated completely with appropriate medical intervention. In another case, I had a number of children from the same school district evidencing signs of ADHD and being treated unsuccessfully for this condition with medication. I became suspicious when I realized none of the children had shown signs of ADHD prior to entering school. A neuropsychological evaluation with EEG confirmed my suspicious that something more than ADHD was involved, and blood tests combined with dental measures of lead in teeth revealed the children were suffering from lead poisoning. Which happened to come from old pipes in the school district having been soldered with lead. Not all neuropsychological evaluations are the same and not every neuropsychologist would have correctly identified these problems, but, I can guarantee you that a psychoeducational evaluation would never have caught such problems, and consequently, the appropriate interventions could not have been pursued.
Reprinted with permission from Susan Crum-Norris, Ph.D.