By: Stephanie Monaghan-Blout, Psy.D.
Pediatric Neuropsychologist
When a family books an intake for neuropsychological evaluation, they are typically asked to complete a few pieces of paperwork and to bring previous testing and other educational documents such as an Individualized Education Program (IEP) for their intake appointment. Despite this request, many parents will come to the intake session with empty hands. Understanding that parents have an enormous number of tasks on their plate, one could expect that paperwork was left at home due to timing or organization difficulties. However, when I ask parents about the missing paperwork decision, the reasons for leaving it behind generally fall into two groups: (1) lack of knowledge about the purpose of testing; and (2) concerns about creating some form of bias in the examiner’s mind. Some parents don’t share prior testing with me because they don’t have a clear idea of what the testing is and how it is going to be used for my evaluation. This is very common with families who are new to the special education or mental health process. Some parents are reluctant to share past testing because they want a “fresh view” and are concerned that looking at someone else’s work may create a bias. This often comes up when there is disagreement between parents and their school or past provider as to the nature of the child’s difficulties. Sometimes the parents and child have had a bad previous experience with testing and/or with the examiner, and they do not feel that the test results accurately (or at least empathetically) describe their child. In any of these situations, I find that parents feel more comfortable if they know more about how the tests we use are developed and why we find it helpful to view previous testing.
Purpose of Testing: The purpose of neuropsychological testing is to find out if a child 
(or adolescent or adult) is developing skills at a rate and capacity commensurate with their age and ability level. In order to do this in an efficient, equitable, and consistent manner, test developers identify skills they think are important in learning, devise a task that appears to quantifiably measure that skill, give that task to children in different age groups and then transform the raw scores attained by the children into a common scale. This allows them to compare different children within an age group, and this also allows them to compare the same child at different ages. Some common measurement scales are standard scores, scaled scores, Z scores, T-scores and percentiles. All of these formats are based on a normal distribution (remember the bell curve?) in which the majority of scores fall within a certain area with increasingly fewer scores falling at either end. The “bump” where most scores fall is described as average (between 25th and 75th%ile) with the tails receiving an above or below average description. While these descriptions do not begin to capture the whole child, they do convey information about how a child is performing relative to developmental expectations based on what we know about children of the same age. They can also tell us if the child is making age expected progress according to their unique learning curve. Furthermore, most people are good at some things and not so good at others, and the pattern of their scores can often give us valuable information about their learning profile.
Question of Bias: The concern about bias is important, given that neuropsychological tests are often used to classify people and make decisions about providing or denying services. There are a number of ways in which we try to control for bias, starting with trying to make sure that the group of people that are used as test subjects when developing norms are representative of the population at large. Test makers are getting better at this, but we have a long way to go, which means that it is important that evaluators know how each test has been developed and normed. Test selection is also extremely important; some tests are not appropriate for some groups. Think about giving a Calculus test to someone who has not completed Algebra 1; this kind of mismatch is going to result in a spuriously low score on math ability.
The main way that neuropsychologists and psychologists try to control for bias is through what is referred to as standardized administration—giving the test in the same way to each child. A good deal of the training of graduate students, interns, and post-doctoral fellows involves learning and practicing these skills so that the test is given to every child in the same way, regardless of who gives it. At the same time, children are children, and sometimes they need something different. It is up to the evaluator to decide when to engage in “non-standardized administrative procedures.” One example of non-standard administration could be starting a child who has trouble catching on to novel tasks at a lower age starting point in order to help them master the task demands. Another example would be stopping a task before a ceiling of errors is reached because the child is very anxious and is having a hard time staying with the activity. It is important to make note of that break in protocol in the report; while it may somewhat reduce the validity of the scores, it also tells us something very valuable about the child’s learning style and tolerance.
Value of Having Previous Testing: Having the opportunity to review all previous testing is extremely valuable to neuropsychologists because it gives up some insight as to a child’s developmental trajectory. Scores that are higher than in previous testing may suggest improvement in a skill set. Scores that are consistent with previous testing indicate that a child is making age-expected progress along their unique learning curve. However, they may be falling farther and farther behind their same-age peers or progressing more quickly. Scores that are significantly weaker than in previous testing need to be closely examined. This could be a result of an imbalance between the environmental demands and the child’s internal resources. For instance, smart kids with executive function deficits are often not prepared for the organizational challenges of middle and high school. Significantly lower scores could also indicate stalled development due to ineffective educational interventions. It could also be a sign of emotional distress that is interfering with a child’s functioning. Rarely, it could be a sign of a medical or neurological problem. There are also some times when a change in average scores reflects a change in the exact tests or subtests used for the child. For example, when a teenager turns 16, it is common to begin administering adult intelligence scales and these tests may place higher value on slightly different skills (e.g., mental math). Without reviewing previous testing, a current evaluator may be able to provide a snapshot of a child’s current functioning, but might miss a critical developmental pattern important for understanding if/how the child is learning, what is needed to enhance their performance, and what can reasonably be expected over time for the child.
About the Author:
Formerly an adolescent and family therapist, Dr. Stephanie Monaghan-Blout is a senior clinician who joined NESCA at its inception in 2007. Dr. Monaghan-Blout specializes in the assessment of clients with complex learning and emotional issues. She is proficient in the administration of psychological (projective) tests, as well as in neuropsychological testing. Her responsibilities at NESCA also include acting as Clinical Coordinator, overseeing psycho-educational and therapeutic services. She has a particular interest in working with adopted children and their families, as well as those impacted by traumatic experiences. he is a member of the Trauma and Learning Policy Initiative (TLPI) associated with Massachusetts Advocates for Children and the Harvard Law Clinic, and is working with that group on an interdisciplinary guide to trauma sensitive evaluations.
To book an evaluation with Dr. Monaghan-Blout or one of our many other expert neuropsychologists and transition specialists, complete NESCA’s online intake form.
Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.
Formerly an adolescent and family therapist, 
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