What is a Neuropsychological Evaluation?
A neuropsychological evaluation is a very thorough assessment of a brain’s strengths and weaknesses. The goal is to capture what the brain can and cannot do, in order to best treat and provide recommendations for the patient and their family. The recommendations are used to maintain strengths and improve weaknesses.
It is necessary to look at many factors in order to conceptualize a person’s strengths and weaknesses and determine whether any diagnostic criteria is met. Pediatric neuropsychologists analyze information gained during the hour-long clinical intake with caregivers (and the patient themselves, depending on their age), test results, behavioral observations, and responses on self, parent, and teacher questionnaires. These “puzzle pieces” are put together to create a comprehensive picture of what the patient is experiencing.
Neuropsychological testing lasts anywhere from 4-8 hours and can be conducted across several days of testing depending on scheduling conflicts, presenting concerns, and age. Testing data includes intelligence/cognitive skills, academic achievement, language, memory, attention and executive functioning (i.e., simple attention, sustained attention, inhibition, cognitive flexibility and problem solving, planning and organization, multitasking, etc.), and personality or behavioral, social, and emotional functioning. Referrals vary, but can include anxiety, depression, anger or other behavior concerns, ADHD, learning disorders, and traumatic brain injuries.
Neuropsychological evaluations can be helpful to tease apart what is the origin of a patient’s presenting concerns as many diagnoses present similarly, but treatment recommendations are vastly different. Understanding the cause behind a child’s difficulties and developing appropriate treatment recommendations helps to provide the support and space a patient and their family requires to gain a better and deeper understanding of the child and their needs. Lastly, testing will help guide patients and their family in navigating what services (i.e., academic accommodations, psychotherapy, occupational therapy, etc.) are needed to help the patient become their best, most successful self.
The ideal candidate for neuropsychological testing is a child who is at least 6 years old or in at least 1st grade where they are comfortable working for 2-3 hours at a time with 5-minute breaks. There are exceptions to this. If you think your child may be an exception, please call the front office to discuss, but this is when neuropsychological evaluations may be the most helpful. Testing is a financial investment for caregivers, and a significant time and energy commitment for a child to make. Marvelous Minds understands this. We hope this information can help determine when neuropsychological testing is warranted and should be included as part of a treatment plan. Our goal is to help you make an informed decision while doing what is best for your child and family.
When a child is at least 6 years old or at least in 1st grade, there are more tests the neuropsychologist can do to diagnostically rule disorder(s) in or out with greater confidence. Children at this age usually have adjusted to completing work to the best of their abilities, whether they have an interest or not in the task, through school. Scores can be interpreted best when the child puts forth their best effort. It is part of the neuropsychologist’s job to be their patient’s “personal cheerleader” and encourage their best work, but if children are not ready for testing, it can hinder the accuracy of the data gathered. If the data gathered is not the best representation of the child’s performance, neuropsychologists must interpret data with caution, which leads to more unspecified or provisional diagnoses. This happens when data appears to meet diagnostic criteria, but it is not certain, or some criteria is met, but not all criteria is met for a more specific diagnosis. Although this can still happen with valid testing, there is a greater chance of it happening when children are not ready for the evaluation or resistant to it.
A way to help improve validity is through the recording of behavioral observations during neuropsychological evaluations, which are always taken into account to best interpret the scores. For example, two children can earn the same test score, but if one is giving low effort, being defiant, etc., their scores would likely have a completely different interpretation than one who is trying their hardest. Even though behavior can impact testing validity given the variable nature of children, there is an increased chance of invalid results when working with children who are not ready for testing. This leads to difficulty discerning a pattern of strengths and weaknesses, which then leads to difficulty diagnosing with confidence. Moreover, if we attempt testing and there is a high level of uncertainty when interpreting the scores, children cannot be tested again for another year at the earliest given testing protocols. Marvelous Minds wants you to “get the best bang for your buck,” which may mean delaying testing.
Furthermore, the timing of early development varies in children and, as such, their skillsets do not develop at the same time/rate. With younger children, it can be harder to discern if the conceptualization is a result of a true clinical disorder (e.g., anxiety, ADHD), a result of being disinterested in testing, a result of lack of sleep, a result of transitions or major changes in the home, or a combination of all the above or another factor not listed. A child’s profile also may be age-appropriate or “within broad normal limits.” Though there may still be personal weaknesses, such abilities may need slightly more time to develop. Also, keep in mind the impact COVID-19 and remote learning has had on your child’s executive functioning skills, emotional and behavioral management, and academic abilities. If a child appears to be behind in these areas, it could be due to lack of support, though it also could be due to a lack of opportunity/exposure to situations to strengthen these abilities. School-age children entering for the first time or back into in-person learning and managing academic as well as social responsibilities may just need more time and opportunities to develop their skills independently before bringing them in for an evaluation. Sometimes weaker (i.e., not impaired) skillsets do not need to be over-pathologized in children.
Additionally, most children younger than 6 years old coming in for an evaluation are usually children with behavioral and/or emotional concerns. These concerns may warrant clinical support and services, but that does not always mean testing. Caregivers should consider having their child participate in therapy for 6-12 months before coming in for an evaluation. Therapy would help the child learn and practice coping skills and explore other successful interventions that help with regulation. Therapy may be the first step needed to help children manage their symptoms well enough to participate in testing. Regardless of if you pursue testing or not, this will likely be one of the neuropsychologist’s first recommendations. There are also situations where, after several months of therapy, the presenting problem(s) resolve without testing.
In addition to younger children, older children and teenagers may benefit from therapy before testing depending on their presenting concerns. Marvelous Minds provides individual therapy for more one-on-one care with a qualified and skilled therapist. This can be done by itself or also in conjunction with group therapy. For example, we offer an excellent executive functioning (EF) skills group for middle school and high school students, as well as a PEERS group for teenagers who feel like there is a social uneasiness. The latter is a group for caregivers and teenagers to discuss this concern and provides a safe place to practice prosocial skills (i.e., initiating conversations, responding/recognizing rejection, and maintaining relationships that do progress). Marvelous Minds also provides a parenting education program (PEP) to help caregivers have an outlet for stress and space to gain parenting support and strategies. There are many different therapeutic paths that can be the right next step for you.
Neuropsychological testing is a valuable tool that can be helpful for initial conceptualization, diagnostic clarity, and treatment planning, including providing academic accommodations. However, all cases are different and, as such, consideration should be given to the most appropriate first steps. We want to help devote resources, time, and effort into what is going to best help your child. Marvelous Minds is in the business of providing quality service to you, your family, and our community, and that includes helping you make an informed decision to best support your child’s needs.
DR. JENALYN VANSUMEREN