Testing; A way of Looking
By Jane Paley, PsyD
So anyway, I told him I was in a band
He said, ‘Oh yeah…What’s your music like?’
I said, ‘It’s um…um…well it’s kinda like, you know, it’s got a bit of, um…you know…
Joe Strummer and the Mescaleros
When people ask, “What is neuropsychological testing?” I am often stumped as to how to answer. There is no quick way to sum it up - to capture the process: its nuances, limitations, or possible benefits.
I tend to hit upon a few bedrock phrases: “A collaborative process of observation.” “A short term clinical intervention.” “A living snapshot of a person at one moment in time.”
Why “testing” is a misnomer
What if a child in school knew that Friday’s test would result neither in a grade, nor the possibility of failure? Instead, it would mean being a co-detective on an investigation into their own learning and brain, searching for clues to help understand their challenges, and uncovering evidence of their strengths? What if an adult knew that next week’s performance review would yield, instead of a critique, deepened self-understanding, a greater capacity for empathy and a more solid appreciation of their unique profile?
“I think ‘testing’ harkens back to the type of classroom tests or standardized (e.g. S.A.T.) tests that everyone did during their school years. This process really is…a multifaceted approach [toward] a more holistic understanding of a person,” says Dr. Laura Hackimer, a psychologist on the Interactive Discovery testing team. “You have to take all of these distinct pieces and interweave them with the experience of sitting with this person, the conversations we have with their family and the other professionals they know to make a full, meaningful tapestry of who this person is.”
Why scores matter - and don’t
In the context of neuropsychological testing, a single numerical score tells so little so as to be essentially meaningless. It may reveal how, at one moment on one particular day, a person scored on a task in comparison to peers in the norming sample population. It may even reflect the person’s capacity to tackle this type of task - for example, to solve a visual puzzle or remember a story after a delay. What that number does not reveal, however, is how and why a person achieved that score. Two people may arrive at the 50th percentile, but get there in totally different ways.
A raft of questions arises: How did this person approach the task? What were their errors and why did they make them? Is there a pattern that can be gleaned? What parts of the task came most easily? What elements of the external environment (e.g., the temperature, background noise) may have affected their performance? Which aspects of the internal environment were at play (e.g., mood, hunger, fatigue)? What took place before the testing session and what is coming next? What was happening in the context of the person’s life (e.g. family, neighborhood, school, culture) at the moment the testing took place?
To be understood, scores must be interpreted vertically - within the context of a person’s overall profile, and in light of their developmental history. They must also be viewed horizontally- in relation to attempts at similar tasks across settings. An example is a student who scores in the 90th percentile on a writing task during the testing while scoring consistently in the 70th percentile on writing assignments at school. Many possible variables underlie this discrepancy, ranging from difficulty with an ability or skill (e.g., language processing, graphomotor control) to the emotional impact of the task or environment (e.g., anxiety, sensory overload). In determining the hows of a given score, it is always necessary to look below the surface – and usually, to look again.
Testing findings, whether quantitative (e.g. a score on a math task) or interpretive (e.g. the way a person draws a tree) are opaque, not transparent. Tests may serve as partial windows into someone’s thinking, perception, learning, and emotional life; at the same time, they are never free of their inherent limitations, and should never be viewed as evidence of a singular truth. If approached realistically, tests may serve as signposts pointing to larger regions for exploration - pieces of data to be incorporated into a larger, multifaceted process of reflection and integration.
Why diagnoses matter - and don’t
Diagnoses, like tests themselves, are essentially invented constructs. Diagnostic categories are collectively agreed upon clusters of observations that gain momentum over time, ascertained and reinforced by the dominant cultural group, and that like many self-reinforcing notions, accrue a status of “fact” (Fleck, 1937; Kendi, 2023, p. 57).“Intelligence” testing’s dubious beginning and grotesque history of racism, segregation and exclusion have been extensively documented (Gould, Kauffman, Russell). The tests themselves, mass produced by profit-driven corporations are subject to continual revisions that purport to make them more culturally sensitive, inclusive or “evidence-based.” And while some revisions may partially achieve these goals, it would be inaccurate to declare the testing tools totally free of bias, or truly able to measure the shaky constructs we call “abilities” or “intelligence.”
Diagnoses are like ready-made templates, used to match, describe and partly explain patterns. While delinations are artificial, and they almost always overlap, there is utility in discerning clusters of behavior and patterns to help “make order out of chaos” (Russell, p. 7). In looking at the underlying roots of behavior - to the degree that we can - and exploring ways to ameliorate problems they create or tap their offerings, we find ways to reorganize ways of being in the world, revise our narratives, and arrive at greater understanding and acceptance. As a society, sizable shifts in how we think about human neurobiology and development have occurred over the past half century. Formative writers and thinkers, including Stephen Jay Gould and Howard Gardiner, took the unitary theory of intelligence to task. The disability, gender diversity and neurodiversity rights movements have helped us see the limitations of our assessment tools and categorizing lenses. As diagnoses run up against a broadening understanding of neurodiversity, they gradually begin to lose their rigidity. Led by younger generations, we have been learning to make room for a multiplicity of identities that include ways of being wired - our differing “operating systems'' (Silberman p. 471).
We continue to rely on diagnoses to determine eligibility for services and support through state and federal laws. In facilitating essential services for students, granting access to curriculum through IDEA (Individual with Disabilities Education Act) or working toward more equal opportunities through the ADA (Americans with Disabilities Act), we are compelled to engage with and recognize diagnoses. However, we have the obligation to employ them, and the tests we use to substantiate them, in a manner that if incapable of transcending their inherent biases, keeps their limitations front and center in our thinking. An investigative, collaborative testing process that incorporates multiple viewpoints, multiple tests, and multifaceted ways of interpreting them has the best chance of offsetting, at least to a degree, the limitations of our testing tools and diagnostic criteria.
Integration: the key
Another key offsetter is the intrinsic understanding that the clinical team serves as the primary instrument - not the tests themselves. The primary function of the clinical team is integration. An Integrative stance entails taking neurodiversity as a starting point, identifying and challenging the assumptions embedded in our tools and our thinking, while maintaining enough structure for the process to work in the service of understanding.
Integration also requires:
Avoiding the interpretation of a single score or measure in isolation - giving equal value to qualitative data gathered in the process.
Working collaboratively with the person who has come for the assessment, while embracing their role as participant-observer, and expert in their own experience.
Including multiple observations from the important people in the person’s life, thus allowing for differing perspectives and interpretations.
Considering results or findings in light of a person’s overall development, while keeping sight of the possibilities for growth and change.
Maintaining a strengths-based perspective with the knowledge that strengths are not secondary concerns or afterthoughts, but rather serve as critical components of growth (Kauffman, 2015).
A primary goal of testing is the relief and liberation that can come with the ability to see ourselves and our children with more clarity and empathy. Testing can provide validation to counter the myths of laziness, lack of motivation or oppositionalism (to name a few common “mis-explanations”) to be able to look beneath behavior for understanding and see it as part of a multifaceted profile. As Dr. Alexa Algios, a psychologist on the Interactive Discovery testing team put it, “We are gathering information from different sources with different perspectives and putting all of that together into a cohesive story. I think about it as a puzzle - the data are the individual pieces and we are trying to figure out how they all fit together within the context of a person’s everyday experiences. Having this cohesive story can be extremely valuable not only for the individual receiving the evaluation, but for the people in their lives (parents, caregivers, teachers, therapists).”
Diagnoses offer the chance to know that we are not alone - that as different as we may seem to one another from our limited perspective on the ground, we are remarkably homogeneous as a species (Gould, P. 322). The testing process allows us to derive information and insight that can allow us to more fully resonate and connect with others who share aspects of our experience.
A way of looking
The neuropsychological testing process involves a paradox: on the one hand gathering that which is already known and observed about a person, while at the same time, looking afresh, as if for the very first time. In this sense, testing is as much as anything, a way of looking. An integrative neuropsychological testing resides at the intersection of certainty and possibility.
References:
Fleck, L. (1935). Genesis and Development of a Scientific Fact. Chicago: University of Chicago Press.
Gardiner, H. (1983). Frames of Mind: The Theory of Multiple Intelligences. New York: Basic Books.
Gould, S.J. (1981). The Mismeasure of Man. New York: WW Norton & Company.
Kaufman, S.B. (2013). Ungifted: Intelligence Refined. New York: Basic Books.
Kendi, I.X. (2023). How to be an AntiRacist. New York: Random House.
Lyford, C. (2023, September/October). The Future of Diagnosis: Traveling beyond the limits of the DSM. Psychotherapy Networker.
Paris, J. (2015). The Intelligent Clinician’s Guide to the DSM-5 (Second Ed.). Oxford: Oxford University Press.
Rosales, J., & Walker, T. (2021, March 20). The Racist Beginnings of Standardized Testing. NEA Today.
Russell, M. (2021). Systemic Racism and Educational Measurement: Confronting Injustice in Testing, Assessment and Beyond. New York: Routledge.
Silberman, S. (2015). Neurotribes. New York: Penguin, Random House.
