Neuropsychological Evaluations: What are they? What are they not? Myths, Misunderstandings and Common Fears
By: Jane Paley, PsyD
Looking at a childhood photo or video, startling juxtapositions often appear. Some aspects of one’s child (or oneself) seem completely transformed by time (“I was so tiny!” “His voice was so high!” “She was such a firecracker back then - we never thought she would calm down!”). Others remain constant over years, within a lifespan, even across generations (‘that face is unchanged!” “She has the exact same laugh as she did when she was little!” “That gesture right there - the spitting image of grandma!”) How such transformations take place in the midst of constancy, how some aspects persist despite continuous, kaleidoscopic change, is one of the few seemingly universal miracles of human development and is unique to each individual.
The neuropsychological evaluation (also called “comprehensive neuropsychological evaluation” “neuropsychological testing” or “neuropsychological assessment”) can be likened to a snapshot; a living portrait of a child* at one moment in time. The evaluation process involves the mobilization of collective attention on a child. The portrait is created from multiple observations and pieces of data, gathered and synthesized. The child and parents/guardians are participant-observers in a process that allows the image or profile to emerge and come into sharper focus, so that the child can truly be seen.
NEUROPSYCHOLOGICAL EVALUATIONS: WHAT ARE THEY?
Neuropsychological evaluations are short-term clinical interventions. Usually, a referral is made when a child is struggling with one or more aspects of learning or school functioning, social or emotional development, communication or behavior. Often, the problem/s are partially, though not fully understood. They emerge or “announce themselves” at different points in development: for one person, this may be in kindergarten, for another, at age 40. At whatever age or stage, a person coming in for an evaluation presents a question to be answered; a puzzle or a mystery to be solved.
To solve it, that is to say, to understand it more fully, requires a collaborative investigation. In this process, psychologists ideally, are working as co-detectives with a child, seeking to uncover mysteries or the questions about their own learning, brains and experiences, and filling in the blanks of the puzzle they present. The investigation involves taking time to notice, observe, and explore, with the help of parents, teachers and other important adults in the child’s life, what is happening in the child’s experience of learning and growing.
Some feel that the word “functional” should precede the terms “neuropsychological evaluation.” This is because this process looks to describe the interaction of brains and environments: how children apply their abilities and skills to the tasks and demands of their lives, how they learn to do so, what is working well, and what is not.
Comprehensive neuropsychological evaluations are not therapy, but they are often therapeutic. They are not medical tests, neither lab nor brain scans, yet they look at brain and body processes, such as memory and attention. They are neither wholly quantitative, nor qualitative, but a synthesis of both. They assess strengths and weaknesses and help to identify how these strengths can be applied in the service of further growth. They are an assessment of a child’s functioning in the real world.
The clinical team serves as the instrument, or camera, shining light on, perceiving, gathering and integrating the data. The data include: direct observations of the child in the office, in the classroom, and at home, and gathered in conversations with the child, parents and teachers. The child’s own observations, behavior, questions, perceptions and insights are critical pieces of data. Additionally included are child’s scores on a wide variety of normed measures or tests administered in the office, and rating scales or survey questionnaires completed by parents/guardians, teachers or other adults who know the child well. The hows of the scores achieved are as important as the whats: in other words, the way in which a child got to a particular score on a given day is as, if not more meaningful than the actual number itself.
The settings in which a child lives (the family, home, school, neighborhood) and the qualities of these environments (the light, temperature, sounds; the emotional tenor, the expectations and demands) are important to round out and interpret this picture, as is the child’s background, life history and family history.
The results, both qualitative and quantitative, are described and integrated in a written report. A dynamic portrait of the child in context illuminates not only their processing, abilities, skills and social emotional functioning, but the interplay of all these dimensions in the child’s world and life. In what ways are motivation, mood and attention intertwined? How does executive functioning affect reading comprehension? How do learning and social relationships interact in the classroom? In the playground? Within the context of a structured, perhaps rigid classroom (or job setting for an adult), or a flexible but less predictable teacher (or boss)?
Diagnoses or useful behavioral, developmental and learning patterns are clarified. The findings and the report are shared with parents in a thorough conversation that optimally allows time for questioning and revisiting. They can also be shared in a developmentally and individually appropriate way with the child in a separate conversation. The discussion about labels or diagnoses, what they really mean, and how they can most effectively be used, is an essential part of the feedback and can take place with parents/guardians, and potentially, with an adolescent, if developmentally appropriate for the person at that moment in time.
A set of recommendations, formulated by the clinical team, based on understandings or hypotheses gleaned in the evaluation is also included in the report. The document, shared with parents or guardians, is intended to serve as a road map, a rough guide, to which to refer over time. The report can be used in schools to help children and families obtain support and accommodations, and to communicate to the adults providing this support the specific ways in which it should be provided for an individual child. It is the primary tool used in school systems to access supports and services under the federal entitlement FAPE, a child’s right to a free and appropriate public education guaranteed by the Rehabilitation Act (1973) and the Individuals with Disabilities Act of 1972 (IDEA).
As with any clinical intervention, the clinicians and the interactions with the child and testing participants, not the tests, are the real instruments. The child being evaluated, at whatever age, is a key player, as co-detective, in the experience. The adults who know the child best: parents, guardians, teachers, tutors, therapists, are important participants because they offer differing perspectives and experiences of the child across settings.
NEUROPSYCHOLOGICAL EVALUATIONS: WHAT ARE THEY NOT?
Misunderstandings and false assumptions about development and children abound. Often, they are at play in how children are seen, approached and interacted with. Conversations with children and adults in the assessment process often uncover the ways in which they may be at work, underlying or guiding the narrative in a particular family, classroom or setting, or within a child’s own self-concept or experience.
COMMON FALSE ASSUMPTIONS
Children hit milestones, learn and grow at the same rate.
Development is linear and takes the same trajectory for everyone.
Personality, and “intelligence” are monolithic, static and unchanging.
People don’t remember or retain much (if anything!) about their early lives, especially infancy, toddlerhood or early childhood. What happens in the early stages is relatively insignificant; the early grades don’t matter as much as the later ones.
Neurobiological ways of being wired, learning variations or disabilities will be “outgrown.”
These misunderstandings, while having been soundly and frequently debunked and corrected by psychologists, neurobiologists, mental health counselors and therapists, developmental pediatricians, nurses, educators and parents themselves, unfortunately, persist in our a hypercompetitive culture, and tend to amplify anxieties that parents and guardians often have about the evaluation process. They interact with fears that, within a highly pressured context, fuel other longstanding, and unhelpful myths about many of the children who come in for neuropsychological evaluations. These include: the myth of “not living up to potential, ” the myth of “laziness and not trying,” the myth of “just not motivated” and the myth of “does not really care enough to want to do well.”
COMMON FEARS
It is not at all unusual or surprising that the testing process sparks a host of anxieties and fears, particularly among parents and guardians. Some of the most common ones are below:
The neuropsychological evaluation will predict the future and reveal how my child will do in school and/ in life.
My child will be labeled and stigmatized. These labels/ diagnoses will follow my child for the rest of their lives, preventing access and opportunities, making them feel lesser than their peers, and leading to low self-esteem and underestimation or exclusion.
I will be criticized as a parent (by myself and others) for failing to see this coming, or taking better action to prevent my child (or myself) from experiencing these struggles or difficulties.
My own “shortcomings” (learning vulnerabilities, attention/organizational problems, trauma) will be exposed.
My child will be subjected to an exhausting battery of clinical tests that will be painful, impersonal and frightening, and will feel as if something is wrong with them, or that they are “abnormal” or “defective” in some way.
My child will use their diagnoses/labels as a crutch or excuse, rather than work hard and live up to their potential.
My child will never find their path. Their vulnerabilities will keep them from achieving success (i.e., getting into college, getting a good job, finding a partner, etc).
What I have found in over two decades of testing is that most parents and individuals are neither shocked nor surprised by the findings of a neuropsychological evaluation. Parents and guardians, more often than not, are experts in their child, keen observers who can readily describe their child's learning, preferences, emotions, relationships and skills in great detail. Children themselves are often the keenest observers of all. Usually, the assessment process fills in the blanks, providing numbers and other data to support an overall profile, giving a sense of proportion, and perspective. Surprises frequently pop up. These often come in the form of untapped strengths or areas of growth, like unnoticed elements of a snapshot that are perceived when the time is taken to look longer and more carefully. Because our educational system and society tend to emphasize and reward an extremely narrow band of skills and abilities, and to use limited (and limiting) measures to assess learning and development, a resulting emphasis on so-called weaknesses or “failures'' tends to eclipse strengths, and the many forms of intelligence, creativity, adaptability and skill that children possess.
THE BEST OUTCOMES OF NEUROPSYCHOLOGICAL EVALUATIONS
The mobilizing of attention on a child helps adults to see the child in a fuller, more empathic, and often, more realistic way. Understanding what lies beneath any behavior, and sharpening awareness of a child’s strengths,struggles,and patterns is a rich and often rewarding process. A good comprehensive neuropsychological evaluation shines light on what a child can do and on how, where and under what conditions they flourish. It can clarify potential pathways and options for support, helping parents and children to free themselves from repetitive cycles of trying the same ineffective things over and over, or rigid frameworks that reinforce feelings of frustration, failure or shame. A good evaluation encourages curiosity, questioning and flexible thinking, and often poses the question, “why not”? Adopting this stance and embarking on the process of asking questions takes courage on the part of parents, guardians and children, who often feel great pressure to try to force their children or themselves to learn and perform in particular ways.
Understanding what underlies a child’s struggles can also offer relief from the tendency toward selfblame that is rampant in segments of U.S. parenting culture. Parents and guardians who find that, to their surprise, they recognize in their children many of their own overlooked, undiagnosed learning, emotional or processing struggles often discover new-found empathy for their children (and themselves), and can move past the “blockage” previously created by fear to mobilize, devise or enlist creative support. Children often experience a sense of relief when, at last, their struggles are seen and understood for what they are, rather than misinterpreted (misunderstood?) as signs of laziness, inferiority or lack of motivation or drive. And most of all, when their strengths are recognized.
THE GOOD NEWS/BIG PICTURE
Current research in neurodiversity and learning styles, neuroplasticity, trauma and the Inclusion and Disability Rights movements have all led to increased awareness and a greater societal ability to encompass broader and more nuanced ways of being neurobiologically wired. Our deepened understandings of gender, learning, attention, personality and development have sparked new, evolving conversations about what “ability” and “giftedness” really mean, what strengths and skills are needed to live in our current time, and the necessity of biodiversity, cultural diversity, learning diversity and neurodiversity.
Teens and young adults, more than ever before, are more likely to see themselves, rather than as “defective” or “weird,” as wired in a particular way, to recognize the advantages and disadvantages they face within their current culture or subcultures, to advocate for themselves, and to connect and bond with fellow like-wired peers. They are more likely to experience themselves in a more truly holistic way, rather than jump to a self-deprecating or pathologizing framework. In short, they are in the best position to help capture, behold and interpret the snapshot that is the neuropsychological evaluation, to be co-detectives investigating their own learning and growth, and to appreciate the nuances that are contained and dynamically at play, at any given moment in time, within and beyond the frame.
* “child” will be used throughout this article but can also refer to adolescents and adults
