Neuropsychological Assessment: What to Expect?

What assessment do the parents of a delayed and struggling internationally adopted child need, and what should they expect to see in the clinical report? Here are typical questions adoptive parents ask when calling for a free consultation or referral.

Question: I was told I should do a neuropsychological assessment of my child, but is there any difference between it and a psycho-educational evaluation?

Answer: You need to request a neuropsychological assessment when your child:

• Has a neurological condition (such as cerebral palsy, certain genetic disorders, or specific medical conditions related to a brain injury as a result of an accident or an infection of the brain);
• Had been exposed to toxins such as lead or had been exposed to alcohol prior to birth;
• Needs a differential diagnosis: The child was evaluated by a school multidisciplinary team, but interventions resulting from that assessment failed to help.

A neuropsychological assessment done for a school-age child will assess such areas as general intellect, achievement skills (such as reading and math), executive functions (such as organization, planning, attention, self-regulation), auditory and visual perception, memory (short-term and long-term), language, visual-spatial-motor integration, emotional/behavior patterns and social skills, learning style, and other psychological functions. Some abilities may be measured in more detail than others, depending on the child's needs. A detailed developmental history and data from the child's parents and teachers may also be requested. Observing your child in order to understand his or her motivation, cooperation and behavior is an important part of this evaluation. The goal of a neuropsychological assessment is not only to measure the level of functioning and separate skills, but to determine strengths and the ways these could be utilized to compensate for the child's weaknesses.

The neuropsychological assessment aims at understanding the roots and the specific nature of the child's disability(ies) - including those caused by deprivation, abuse, and psychological trauma typical for internationally adopted children - while a psycho-educational assessment tends to obtain a profile of the child's psychological and educational abilities and strengths/weaknesses in order to improve the student's overall school functioning. Although both types of assessments may use similar tests and procedures, the neuropsychological evaluation is more comprehensive and in-depth, while the psycho-educational evaluation is more focused on school issues.

Question: Will a large number of tests the clinician uses be a guarantee that the entire assessment is thorough and will not be a waste of time and money?

Answer: No. Tests, questionnaires and clinical procedures are just instruments, tools of the trade. Some are better than others and can provide more data, but it is up to the professional who uses these instruments to give an interpretation and explanation. Thus, it's crucial for the professional working with your child to have experience with, be knowledgeable of, and be sensitive to the issues related to institutionalization and international adoption in order to be able to interpret the data. Unfortunately, too often even good specialists in their disciplines are confused by post-institutionalized children and may either overlook or dismiss the important issues. When you bring your internationally adopted child to the office of a psychologist, the professional often sees a well-groomed and nicely dressed child accompanied by somewhat nervous but otherwise "regular" middle-class, well-educated parents. If the child has been living in the country over a year, his communicative English will be indistinguishable from that of his /her peers. In the perception of a psychologist, this will be a typical family with typical issues. (The issues may be serious, but still will be "typical"). Even when the history of the child is known, it is difficult for a psychologist who never dealt with post-institutionalized children to change his mind-set and re-examine his ways of assessing and interpreting the results. This is especially obvious in the assessment of developmental disabilities and issues related to language processing.

Question: What should be the outcome of the neuropsychological assessment of a school-age child?

Answer: In plain words, this kind of assessment must provide parents with a clear, structured and usable plan of how to work with your child at school and in the family over the next 12-18 months to address his /her developmental and educational needs. Some experts, though skillful clinicians, may still be unfamiliar with special-education procedures and the linkage between assessment and intervention in schools. They may end up with purely medical diagnoses and/or unrealistic, vague, and irrelevant recommendations, which will be rejected by your school as inappropriate. Other clinicians will give you an endless list of recommendations that are not structured, pretty much "one size fits all," and which would take up 25 hours of your child's day if indeed implemented.

Question: Will a neuropsychological assessment be covered by my health insurance?

Answer: It depends on your plan, but a neuropsychological assessment may be reimbursed under medical or mental health services coverage, particularly when a child is referred by a physician. Be aware that a neuropsychological assessment is usually covered if testing is conducted to establish a diagnosis as a basis for medical treatment, to evaluate the functional impact of medical treatment (baseline testing), or to assist in selecting treatment. For example, for some children the use of medication may be the best approach when behavior problems occur, while for other children the use of a behavior plan or psychotherapy is the best approach.

Neuropsychological assessment may be covered if your child has cognitive or emotional/behavior problems and has a history of brain injury or has a current medical problem that may be affecting brain development. Many insurance plans will require a letter from your physician indicating the medical necessity of an assessment that explains the need for additional information to help him/her provide care for the child. Please note that most insurance plans will deny coverage for an assessment used to establish an educational classification (e.g. learning disability). Medical insurance carriers view this as the responsibility of your school. However, coverage will often be provided if the assessment is done to substantiate a relationship between an academic problem and some other medical problem or medical treatment.

Question: What can be done to ensure that a clinical report resulting from a neuropsychological assessment is useful for the school and that the parents are well-informed about what has to be done after they receive the report?

Answer: As with everything else,

• Do good research before you commit to any assessment: The time lost on a useless procedure cannot be recovered for the child.
• Make sure that your chosen specialist is qualified for the job, experienced with the issues of internationally adopted children, and is capable and willing to analyze the developmental history of your child. (Sometimes it's really a sizeable amount of documentation). A lot of problems are rooted in this history; underestimating the child's history leads to direct misinterpretation of the existing problems.
• Get a clear and detailed explanation of what is going to happen and whether the goals you have in mind for this evaluation will be addressed by the professional. Look for details (such as referral issues, goals of an evaluation, expected outcome) in writing.
• Remember that the ultimate goal of an assessment is a recommendation plan that is tailored to your child's specific situation and can be implemented by the educational institution that your child attends. Ask your clinician if he/she has experience with school-related procedures and regulations and can write a report that will withstand the school's critical review.

For those who need to further educate themselves about specific psychological issues of international adoptees or are looking for native-speaking Russian professionals in this field, here are some recommended sites, publications, and online classes:

1. Gindis, B. (2006). Cumulative Cognitive Deficit in international adoptees: its origin, indicators, and means of remediation. The Family Focus, FRUA (Families for Russian and Ukrainian Adoption) newsletter, Spring 2006 (Part I) Volume XII-1, pp. 1-2; Summer 2006 (Part II), Vol. XII-2, pp. 6-7. Available online at: http://www.bgcenter.com/BGPublications/CCD_in_international_adoptees.htm.
2. The University of Washington (Seattle) FAS Center site at http://depts.washington.edu/fasdpn/htmls/whatisfasdpn.htm
3. A set of articles on assessment of internationally adopted children available online from the International Adoption Articles Directory
4. A list of bilingual (Russian/English) professionals in different adoption-related fields available online at: http://www.bgcenter.com/bilingualExtention.htm
5. Sites with useful information on Neuropsychological and Psychological Assessment http://cpancf.com/Psychological_Neuropsychological_Assessment.asp
6. Sites on Benefits of Neuropsychological Assessment (Neuropsychological Testing)
   at http://www.brain-injury-therapy.com/services/neuropsychological_testing.htm
7. Online classes:
   • SBG2-School Issues of internationally Adopted Children: Language, Behavior, and Academic Functioning. Available online at: http://www.bgcenter.com/CourseLibrary/Courses.shtml
   • BG3 - Initial Psycho-Educational Screening, Full Assessment, and Specialized Assessment of an Internationally Adopted Child Available online at: http://www.bgcenter.com/CourseLibrary/BG3M.shtml