Psychological tests were developed as a means to measure individual differences. Although diverse with regard to content, such measures shared a common use, which was to categorize and classify individuals based on observations of their behavior under uniform conditions (1). At the outset such measures were applied toward educational, personnel, and military classification. Differential diagnosis was also identified as a concern in the context of changes taking place in the nineteenth century in institutional care, and as test development was intended to aid in the educational placement of children, specifically in the study and instruction of children with mental retardation. Experimental psychology was concerned with universal descriptions of human behavior, in the physiology of sensory responses at this time; however, the general emphasis on the need for controlled conditions when making observations has remained at the heart of the standardization of procedures (uniform conditions) in psychological testing (1).

Early interest in educational testing led to the development of more sophisticated principles and measurement techniques that are now used to assess a wide variety of domains of functioning, including social, emotional, neuropsychological, and adaptive behavior. However, it is intellectual assessment that holds a place of notoriety in the history of psychology. Two of the more fundamental issues that have beset intelligence testing are the definition of intelligence, and the use and interpretation of measures of intelligence. As illustrated in Table 4.2.4.1, theories of intelligence abound. More than this, each theorist posits multiple components or abilities as part of his account of intelligence. As such, it is worth keeping in mind that intelligence is a construct that is neither unitary nor fixed. Additionally, there is a distinction to be made between theories of intelligence and psychometric intelligence. Whereas the former provides conceptualizations of the nature of intelligence, the latter represents the measurement of general mental ability using standardized tests. The global scores yielded from these measures are usually stable and have general predictive value for educational, social, and job outcome. The instruments are limited to what they are measuring and their interpretation is contingent on valid use, and are of course subject to misuse.

The use and interpretation of IQ scores is an important matter and a lengthy subject. In brief, from a psychometric perspective, early approaches to psychometric intelligence focused on quantifying a general level of intelligence as represented by a single number (the IQ score) and assignment to a descriptive classification (e.g., “dull” or “very bright”). Subsequent methods have involved profile analysis or a consideration of individual areas of strength and weakness. This approach may be most powerful when integrated with theories of cognitive abilities (13). Indeed, the cross battery assessment approach (14) that has emerged of late in the arena of psychological assessment emphasizes the usefulness of identifying
cognitive processes versus, for example, reporting cognitive functioning in the context of a single IQ number. This represents a shift in thinking of cognitive activity in terms of a single function— intelligence— to a multifaceted entity.

A fundamental first step toward treatment planning is gaining a full understanding of the individual child. As noted, the psychological/neuropsychological examination is considered to be an integral part of this process. The psychologist/neuropsychologist is also in a unique position to consider the influence of the child’s cognitive functioning on academic and social emotional functioning. One purpose for seeking an assessment is that of diagnosis and/or differential diagnosis. The referral question may focus on a diagnostic ambiguity or the question may be one of level of functioning or development of a specific skill. A second major purpose for an evaluation is to gain information about a child’s cognitive and academic profile and/or an augmented understanding of his/her behavioral and emotional functioning. Diagnosis is often emphasized, but what may be needed to design educational as well as treatment objectives is a more detailed assessment of the child’s strengths and weaknesses in several areas. For example, language deficits may interfere with the child’s ability to form a personal narrative; memory deficits may account for challenges in learning or treatment gains; a child’s learning strengths/difficulties may inform the best modality for presenting information. Third, clinically and in research, assessment measures may be used for pre- and post-comparisons (in the case of brain trauma, in the evaluation of medication or a treatment program). Measurement through well constructed tests further serves an important function in research toward the identification of environmental and biological factors associated with behavioral differences (e.g., gene–brain–behavior relationships).

The traditional neuropsychological assessment is distinguished by its emphasis on producing a description and understanding of the relationship between brain and behavior. A fundamental approach to neuropsychological assessment is measurement of multiple ability domains sufficient to i) represent the principal areas of functioning thought to be mediated by the brain and ii) gather the information needed to address the clinical problems presented by the child (15). The assessment is typically quite comprehensive, as it is designed to sample a broad range of skills and abilities in the child. Given the emphasis on brain and behavior, it has been the longstanding practice of neuropsychologists to consider cognitive functioning as multidimensional. In describing the
brain–behavior relationship, there is the implicit recognition that cognition as an operation of the brain is complex and any inferences that are made about behavior conceptualized in terms of cognition should reflect this complexity (16).

The basic neuropsychological framework for understanding dimensions of behavior reflects the functional systems of the brain. These divisions may be represented broadly as cognitive, emotional, and control processes, and as connected systems in the brain they can be thought to have reciprocal influence. The domains for assessment include: i) alertness/arousal; ii) sensory perception; iii) attention; iv) memory or the encoding, storage, and retrieval of information; v) information processing, such as analysis and synthesis of information, problem solving, concept formation, etc.; vi) motor activity; and vii) intentional or goal-directed activity, i.e., the organizational programs of behavior, sometimes referred to as executive functions. Alterations in motivation and emotional capacity are also evidenced in brain injury or disease and should be considered for their impact on these other systems.

A neuropsychological assessment specifically may be sought to: i) ascertain the likelihood that the child’s problems in adaptation are the result of compromised brain functioning (versus, for example, the result of a psychiatric disturbance); ii) enhance understanding of the child’s psychosocial behavior by examining cognitive and control processes, such as how information is received, processed, and expressed by the child; and ultimately iii) identify the pattern or constellation of neuropsychological assets and deficits displayed by the child toward developing strategies for behavioral or educational intervention.

The referral question(s) are initially identified by the parents and/or referring professional involved in the child’s care. They are further refined by obtaining information from multiple sources, including interviews with key people in the child’s life (parents, teachers, and other professionals), a review of past records (school reports, previous testing, and medical information), thorough history-taking, and talking with the child.

The types of assessment methods used and the breadth of the battery formed are key to test selection. Typically, a comprehensive evaluation will make use of a variety of assessment methods and assess a range of domains of functioning. One reason for sampling a range of functions lies in the fact that most psychological measures are not “pure”— that is, they do not assess one ability domain alone. It is important to discern whether, for example, on a timed task in which the child is asked to copy figures, poor performance is related to a motor, visual perceptual, attentional, and/or speed of processing issue. Difficulty on a measure of math skills may reflect limits in understanding numerical concepts, remembering math facts, understanding the language of mathematics (symbol use), knowing which operations to apply when sequencing (e.g., performing the correct steps in the correct order), copying errors, and/or attending to meaningful visual details (operational sign, place, columns of numbers). Test selection is guided by evaluation of the test itself and related constructs such as norm groups, reliability, and validity (see Table 4.2.4.2 and discussion below).

Test administration variables include the environmental setting (e.g., quiet, well lit room, free of interruptions), establishing rapport with the child, and engaging the child in a manner so as to obtain the best possible performance. The rationale for creating optimal performance conditions is related to the purpose of the evaluation; that is, to determine if the child has the component cognitive skills or abilities necessary to function adequately (or more than adequately) at home, at school, or with others. Standardization, which refers to the uniformity of procedure in administering and scoring a test, is also a key concept in test administration. The examiner must know and adhere to the test procedures, including presentation of directions, use of materials, response to queries, etc. In all, the assessment must be conducted effectively to obtain information regarding the level of performance that the child is capable of but also in a standardized manner to ensure comparability of the scores obtained.

In addition to obtaining test data, the examiner makes qualitative observations of the child’s presentation and performance during the test sessions. Clinical observation is an essential aspect of test interpretation. Test scores represent how a child performs on a particular test at a particular time. Qualitative observations must be integrated with the quantitative information or test scores to provide a more complete understanding of the results and conditions under which they were obtained. This includes variables such as attention, motivation, persistence, fatigue, illness, and rapport, as well as observations regarding how the child approached the tasks (e.g. use of verbal mediation, trial and error, slow but accurate style).

Test interpretation typically involves an analysis of levels and patterns of test performance. The clinician engages in a dynamic process of hypothesis testing and information gathering, reasoning deductively and inductively from the data collected. Interpretation of test results also requires taking into consideration the behavior observed during testing and other relevant behavioral data (e.g., suspicions of a primary visual or hearing impairment) and case history information (cultural, economic, family variables).

Assessment conclusions and recommendations should be based on all sources of information. The comprehensive assessment is designed to identify the child’s assets and deficits in a variety of domains of functioning. This approach promotes an understanding of the challenges the child faces and why, but also the strengths he/she possesses and how these can be used to help remediate areas of weakness. Inferences are made from these data to determine the services and strategies that will facilitate the child’s social, emotional, and academic functioning.

The raw scores obtained from tests are for practical purposes meaningless without a basis of comparison. As such, the data obtained from psychological tests are interpreted with reference to a norm group. This aspect of test development and use is fundamental as it permits that evaluation of a child’s behavior need not rely on subjective interpretation alone. Rather, such norm-referenced tests offer: 1) quantification of the child’s level of performance with reference to his/her peer group 2) an ipsative (“of the self”) comparison or analysis of the child’s performance across different measures to determine areas of personal asset and deficit, and 3) longitudinal comparison or assessment of gains/loss over time.

Norms are developed empirically on the basis of the performance of the normative sample, also sometimes referred to as the standardization sample. Standardization sampling represents the procedure used; the normative data are obtained under standard conditions with regard to consistency of item content, administration procedures, and scoring criteria. The norm group should be evaluated for representativeness, size, and relevance (17

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