How else can neuropsychological testing be useful for my child?

The Role of Attention and Executive Functioning in Academic Performance

Many children who struggle academically perform fine on tests of intelligence and academic
skills, but exhibit problems related to attention and/or executive functioning. The ability to focus
and sustain attention on tasks is critical for effectively learning and retaining new information.
Even when memory functioning is strong, lapses in attention during class results in incomplete
knowledge of what has been heard. Deficits in auditory attention span (how much information can
be held in mind at once) can result in difficulties immediately remembering new information, as
well as distractibility.

Executive functioning refers to higher-level cognitive processes that are critical for achieving
goal-directed behavior. Examples of executive functions include the initiation of activities; the
ability to flexibly shift between different activities without becoming stuck; working memory (i.
e., the ability to hold multiple pieces of information in mind at once, which is critical for
performing multi-step tasks or when sequencing skills are needed), self-monitoring of behavior
(e.g., the ability to critically evaluate one's performance and self-correct as needed), planning
abilities (e.g., preparing for complex projects), organizational skills (e.g., organizing academic
material or the home environment); and inhibition (e.g., the ability to hold back behavior and
regulate one's responding to avoid impulsivity and poor decision-making). Abstract reasoning
abilities and general judgment/insight are also important in the process of problem-solving.
Executive functions are not assessed within psychological and psychoeducational evaluations.
Therefore, a child receiving a psychoeducational evaluation may not show signs of a learning
disability, yet with neuropsychological testing may be found to have significant deficits in
attention and executive functioning, which in turn are impacting performance.  

Children with deficits in attention and/or executive functioning may achieve well on standardized
tests, yet struggle on classroom tasks. For instance, a child may have strong math abilities, yet
performs poorly on math assignments because of impulsive/careless responding without double-
checking of work. These children may have difficulty following through with longer sequences
(which involves both planning and working memory), resulting in errors on mult-step math
problems. These children may also have difficulty initiating (getting started) math assignments
because of deficits in initiation and/or organizational skills. Aside from executive functions,
some children have difficulty lining up columns in written math because of visual-spatial deficits.
Although various areas of the brain have roles in attention and executive functioning, the frontal
lobes of the brain are particularly implicated in problems within these domains. This helps explain
why individuals with ADHD, autism-spectrum disorders, and other psychiatric disorders with
frontal lobe dysfunction often demonstrate deficits in these and similar domains.

For children with complex or inconsistent academic difficulties, a neuropsychological evaluation
is much more effective than a psychoeducational evaluation in exploring the reasons behind the
academic problems. When problems with attention/concentration and/or executive functioning
are found on testing, there are numerous interventions and accommodations available to improve
the child’s functioning.

The Role of Learning/Memory and Phonological Awareness in Academic Performance

Neuropsychological evaluations also provide information about other domains that may be
impaired that are not typically assessed within psychoeducational evaluations, including deficits
in learning/memory and phonological awareness. For instance, a child with normal intelligence
and academic abilities could have problems memorizing science facts because of problems
encoding and/or recalling/retrieving the information later. Children with reading problems may
show deficits in phonological processing (e.g., phonological awareness or rapid naming), and
discovering these deficits can result in tailoring specific interventions to improve these abilities.

The Role of Cognitive Impulsivity in Predicting Behavioral Impulsivity

Children are often referred for testing by their parents because of concerns about problems
regulating emotions. In such cases, cognitive testing often demonstrates evidence of deficits in
cognitive inhibitory processes, which means from a cognitive standpoint the child has difficulties
regulating their reactions, and this dysregulation also shows up in behavior. The additional
information about the neuropsychological aspects of this ability helps to determine the
underlying reasons for these problems, which informs the appropriate treatment recommendation.

The Role of Social Perception in Predicting Social/Interpersonal Functioning

There are other developments within the field of neuropsychology that are exciting. For instance,
new tests of social perception have been developed to assess the strengths and weaknesses for
individuals who seem to have problems understanding or picking up on social cues. This includes
tests of facial affect naming (e.g., naming emotions being depicted within faces in pictures), as
well as being able to pick up on emotion within tones of voice being played on a CD.
Furthermore, memory for faces, as well as assessment of one’s ability to understand another
person’s perspective ("Theory of Mind” task), can greatly assist in understanding important social
consequences of a persons cognitive deficits. There are many groups who show deficits in social
perception, including individuals with autism-spectrum disorders, ADHD, psychotic disorders,
and neurological disorders (e.g., traumatic brain injury or stroke). The assessment of these
abilities can lead to the development of interventions to improve social perceptual skills, which in
turn should result in a significant improvement in quality of life and relationships.

Neuropsychological Assessment for Monitoring Treatment Effectiveness and Developmental

One very strong benefit of neuropsychological testing is the ability to track progress over time
for a child or adolescent with cognitive, academic, and/or emotional/behavioral problems. For
instance, if a child shows deficits in learning/memory, understanding of emotions in faces, and
inhibition of behavior, she/he could receive treatment to work on these areas. After 1-2 years, the
child could undergo a brief re-evaluation of these domains to help determine treatment
effectiveness. Neuropsychological testing can help determine if there has been a larger gain than
what would be expected by the passage of time alone. Unfortunately, sometimes (particularly
without intervention) there is a plateau in improvement in which the child fails to make age-
appropriate gains, resulting in later being even more impaired relative to the age group despite
making small improvements over time. For instance, if a child shows mild deficits in abstract
reasoning at 6 years old but has only slight improvement in these abilities over the next 3 years,
these abilities could fall to the severely impaired range compared to similar-aged peers. After a
neuropsychological baseline evaluation, children can have neuropsychological testing done at any
point in the future to monitor progress. This information is very helpful for revising the original
recommendations and exploring alternative strategies for improving abilities if the original
interventions were not effective enough.

One pattern we have observed in quite a few children pertains to worsening of higher-level reading
(relative to peers) over time. Although the child may demonstrate improvements in phonological
awareness and word reading over time, reading comprehension seems to decline as the material
becomes more complex. Although this is sometimes due in part to deficits in rapid naming and
reading fluency, some children with deficits in abstract reasoning struggle to understand higher-
level reading material, which can be due to problems making inferences about material that is
more ambiguous.

Aside from exploring the development of cognitive and academic skills over time,
neuropsychological retesting is very useful for tracking emotional and behavioral functioning.
Parents and teachers complete a wide variety of behavioral rating forms that offer comparisons to
children in the child’s age group. With intervention, the child may later show a dramatic
improvement in certain abilities, suggesting documentable and quantitative changes for the better.
On the other hand, sometimes during the baseline evaluation a child might be found to have mild
problems related to anxiety, depression, and/or social skills. If academic performance is poorer
upon retesting, it could be due to a lack of development in cognitive or academic skills. On the
other hand, it is also possible the child has shown adequate or strong improvement in cognitive
and academic skills, but has developed worsening of anxiety, depression, and/or social skills.
Therefore, the monitoring of specific progress over time can be very useful in revising treatment
interventions and other recommendations.