Would a patient with severe stomach pain receive surgery or medication without obtaining an evaluation? Hopefully not. The patient probably wouldn’t consent to surgery unless the doctor had some tests to confirm its necessity. In the dental office, X-rays are considered fundamental in determining the extent of decay or deterioration. Most of us wouldn’t buy prescription eyeglasses without an eye doctor’s examination to determine correct visual needs. Doctors’ recommendations, research, and public service announcements routinely advise tests and screenings such as mammograms, colonoscopies, etc. Such tests are vital in early detection for potentially deadly diseases.
Yet in education, instruction and intervention without diagnostic assessment is the norm. Obviously, teachers give tests in subject matter and school districts administer standardized group tests for purposes of funding, ranking, and curriculum needs. I am referring to the value of individual assessment by a trained professional and the lack of routine recommendation, resources, and follow-through on this important preparatory intervention.
People routinely submit their children to years of education without the benefit of an individually administered evaluation to determine readiness, learning needs, styles, and limitations. When children are floundering in school or when there are obvious behavior problems, an astute healthcare provider may alert parents to the need for assessment (and this should be done before prescribing psychotropic drugs). But this is the exception. Physicians usually do not refer, nor do many of them have an adequate or reliable resource list or understanding of what a good assessment entails.
Everyone is skittish about the cost and the resistance or unavailability of insurance coverage. Under the aegis of public laws, and usually requiring persistent pressure from parents (who are often unaware of their legal rights and intimidated by the system), public schools may eventually assess problem students and occasionally provide appropriate special services. However, only the students who present flagrant difficulties are assessed within the public system.
This is astonishing, especially in light of the evidence that learning and developmental disorders afflict nearly 20 percent of the school-age population. In addition, many more children with differences struggle to meet curricular rigors or adult expectations that are inappropriate to their abilities, maturity, or neurological functioning. Every child should be individually assessed to monitor development, identify basic personality and learning styles, plan suitable instructional and motivational strategies and environments, and detect learning or emotional problems for early and effective remediation.
Assessment is a formal process for collecting clinical information from multiple sources in order to reach a diagnosis, make a prognosis, render hypotheses about the person’s condition, and determine recommended instructional or other interventions. Although it includes “tests,” assessment is a broader process that integrates numerous measurements with professional clinical interpretation specific to an individual. Assessment may result in a diagnosis, but its greater goal is to identify combinations and interactions of strengths and weaknesses in aspects of human functioning that have particular relevance to learning and problem-solving (academically as well as interpersonally).
Children (as with adults) are generally assessed only when there is a perceived crisis or when symptoms manifest that perplex others.
The lack of routine individual assessment is attributable to four factors:
For children at risk, off track, or in trouble, none of these factors justify the years of frustration, failure, and family heartache that competent assessment can avert.
California K-12 schools spend $18,020 per pupil ($106.9 billion annually). Expenditures are equivalent to 3.37 percent of taxpayer income. California K-12 schools receive $16.30 billion, or $2,750 per pupil, from the federal government.
The total per-pupil expenditure from all sources is projected to be $23,878 in 2024–25.
Given the thousands of dollars spent each year per pupil on education and the tens of thousands spent over the course of each child’s education, spending a small fraction of this sum on the individual assessment that provides direction and effectiveness for the time, money, and effort spent educating each child is a sensible expenditure. Would it be sensible to buy an expensive car and not afford insurance or good tires? This is the analogous paradox of spending vast sums to educate children without providing the guidance, direction, and preventive protection afforded by individual assessment.
Children must indeed submit to many tests in school; however, such testing rarely constitutes individual assessment. Most of the testing administered is pencil-and-paper group testing, which yields much information about the conformity of groups of students to a standard curriculum, but relatively little useful information about the capabilities, learning styles, motivations, and differences among individuals.
In general, schools give two types of tests: standardized achievement tests and teacher-made tests. Standardized achievement tests (e.g., CTBS, CAP, Stanford Achievement) are normed on large numbers of students in California or nationwide. They are curriculum-bound in content, yield general information about students’ mastery of curricular material, and are intended for use in comparing the relative standings in academic achievement among groups of studentsinschools.
Teacher-made tests are given to students to measure the extent to which the children have “learned” the material taught in class, and to provide feedback about students’ progress. Unfortunately, many teacher-made tests are notoriously unreliable, do not provide accurate and timely feedback to improve learning, are often used in coercive and punishing ways, and supply little (if any) diagnostic information targeted to help the student improve. Additionally, the group testing system uses only a pencil-and-paper format and has inherent biases that tend to reward good test-takers and penalize poor test-takers, irrespective of actual achievement or ability.
Public school districts employ trained specialists who can administer reputable and useful individual tests. Federal and state laws mandate that the schools identify children with exceptional needs and provide free and appropriate education. School personnel sometimes initiate the request for individual assessments; however, parents may also make the request. In either case, the school must legally follow through with assessments, written reports, and meetings within a specified time (usually sixty days). Although these services are available, it is important for parents to realize that mobilizing them requires a suspected disability that adversely affects a student’s education. There are many instances where parents want specific information on their child’s functioning; yet school districts have become more stringent and discriminating about the circumstances when they deem individual testing warranted.
This often leaves parents with the choice of struggling against the schools or obtaining a private assessment. An independent private assessment is a wise course of action on several counts.
Assessment has purposes beyond labeling and diagnosing. Comprehensive assessment uses a scientific methodology that compares thousands of data points to distinguish among conditions that would account for the same sets of data. The job of the examiner is to guide you and your child through this process and provide information that can alert you to difficulties and help you achieve defined goals.
The assessment should be done by someone appropriately trained and licensed (preferably a neuropsychologist or educational psychologist with a doctoral degree). Assessment involves clinical procedures and should investigate all areas of development relevant to your child’s functioning or suspected difficulties. Tests, observations, records, and interviews are tools—but there is no substitute for experienced clinical judgment. When a child manifests symptoms of significant underachievement or maladjustment, a differential diagnosis is necessary to pinpoint the source of the problem. Proper assessment (just like a medical diagnosis) uses scientific techniques to “rule out” different disorders that can present similar symptoms.
The assessment process should include a consultation with the parent/s, a written report of the results, and specific recommendations for implementation in the child’s learning and home environments. Never settle for test scores you don’t understand with a statement about whether or not your child qualifies for special services. Look for the following information in the child’s assessment:
• Intellectual capacity for school
• An equating of school achievement with intellectual potentials
• An alert to reading, spelling, arithmetic, listening, language, memory, or writing problems
• Measurement of perceptual-motor capacity
• Discovery of dominant learning modality—auditory, visual-spatial, kinesthetic, mixed
• Determination of developmental grade level and discrepancies in standard score terms
• Insight into cognitive style—convergent and divergent
• Assessment of factors affecting development, family/peer adjustment, and school performance—self-esteem, motivation, anxiety, depression, anger, and other emotional indicators
• An alert to developing attitude problems and contribution of stressors
• Identification of temperament, interpersonal strengths and weaknesses, and influences on learning
After the assessment is completed, the parent may want to apprise the child’s educators of the results and how they influence the child’s learning, development, and achievement. Getting school staff to implement the results and recommendations can be tricky, but advocating for your child is a major role a parent can play in modeling responsibility and ensuring a suitable environment for growth.
Tests can be intimidating to many people. Perhaps our culture and our professional community have erred in the interpretation and meaning often assigned to tests, as well as the agendas they have served. Regrettably, tests are sometimes used to exclude people or to weed out some from opportunities for which they are deemed unfit.
But when used appropriately and diagnostically, tests can save time, pinpoint areas of need, and greatly guide diagnosis, description, and meaningful interventions and recommendations. I have used tests strategically and invaluably for fifty years in providing assistance to children and adults. This is simply good professional practice.
However, most of the public and much of the professional community misunderstands or misjudges fundamental elements and principles of testing and assessment. Unfortunately, the competitive applications of testing have obscured the broader scientific bases for the measurement of individual differences.
Most testing (and the general perception of testing) is based on an expectation and familiarity with a mode known as level of performance. Though level of performance is only one facet of assessment, it is the aspect most people recognize.
Let’s review the larger picture:
Level of performance testing encompasses how well the subject (examinee) does. This is measured either in reference to a similar population (group of children the same age, for example) or to a criterion standard (e.g., number of words spelled correctly). The vast majority of tests yield information only in the level of performance domain. Norm-referenced, criterion-referenced, and mastery-referenced scoring systems all compare performance levels, though how they compare them varies. This information is basic and useful because it assesses competencies and shows them in reference to known or assumed standards.
Intelligence tests, academic tests, personality tests, etc., reveal information about how a person performs relative to the performance of others. Think of level of performance as measuring the height, for instance, of all fourth-graders, or measuring how many push-ups each child does, or the reading levels of all the students. One could then rank order the scores and judge a particular child’s demonstrated competency or position within the group.
What this information does not reveal is whether the performance shows abnormalities or anomalies with respect to the individual’s own self.
For this, we need to use other neuropsychological techniques.
Pathognomonic sign testing is concerned with errors and performance deviations that occur almost exclusively among certain populations. For example, as a medical analog, consider tuberculosis or HIV. Although the blood and skin of people differ, positive markers for HIV or tuberculosis would only be expected to occur in people carrying these diseases. In a population comprising people with and without these diseases, we could gather lots of measurements across which people with and without the diseases might differ. However, specific signs would distinguish the people with tuberculosis or AIDS because these signs do not occur in others.
Pregnancy is another example. Though it is not a pathological condition, pregnancy is a good example of the principle of pathognomonic sign testing. As far as pregnancy testing goes, the main consideration is whether the woman is or is not pregnant. Pregnant women have certain specific blood and urine characteristics.
Let’s take this a step further with regard to behavior. Would you ever expect to drive into your neighbor’s driveway thinking it’s your own? Or put your key into your neighbor’s door lock, mistaking it for your own apartment? Or confuse a sink with a toilet? Hardly. These examples give a sense of the breach represented by specific deficits. In neuropsychological testing, the breach occurrences are subtler, but they are highly significant.
As Mark Twain said, “There are liars, damn liars, and statisticians.”
Test scores alone can be misinterpreted. A scientific guard against this is the clinical and mathematical analysis of combinations of scores and patterns and relationships among the sores and performances. The old idiom, “Where there’s smoke, there’s fire,” must be subjected to the rigorous scrutiny of comparing performance variability with known profiles of deviations in brain function.
Does the examinee show striking variability in scores on different tests that fits a pattern with regard to the known functions of the two cerebral hemispheres or areas within the cerebral hemispheres?
An example: Two children the same age can have Full Scale IQ scores of 98. These are average IQ scores. However, these two children may be far from the same or even similar. Child A might have a Verbal IQ of 98 and a Performance (nonverbal) IQ of 99. His “scatter” or variability among the subtest scores could be minimal—no conspicuous weaknesses, strengths in moderation and balance. Child B could have a Verbal IQ of 78 and a Performance (nonverbal) IQ of 123 with variability ranging between the 5th and the 98th percentiles. Child B would probably have significant language learning and academic problems along with superior abilities at nonverbal learning. Such a child would undoubtedly excel at spatial and mechanical tasks, but would struggle with the codes of language that suffuse reading, spelling, writing, and listening. (Interventions for this child would likely include procedures and strategies targeting specific training of the left hemisphere.)
All composite IQs are not the same. Patterns and relationships among scores are critical in properly assessing brain function.
Neuropsychologists and neurotherapists focus their interest on the integrity of and relationship between the two hemispheres. Are they different in the way they function in a given individual? Do they work together to enhance performance? Are there specific deficits in either hemisphere that are correlated with compromised performance?
In neuropsychology, such findings are known as lateralization: disparities between left and right sides of the brain that go beyond expected limits for examinees with normal brain functions. When administered properly, even brief screenings contribute valuable information about a child’s neuropsychological makeup that can guide expectations and interventions, indicate deficits needing further attention, and provide predictive information on treatment length and outcomes. The process is complex, however. As wonderful and malleable as the brain is, we need to give it adequate information. Part of the sequence is to gather relevant information in a methodical and translatable manner. That is the essence of comprehensive and appropriate assessment.
Though this article elaborates the reasons and details for individually assessing children for educational and developmental guidance, it is also prudent and helpful for adults to be individually assessed.
Adults are sometimes referred for assessments (far too infrequently) in cases of head injury, suspected dementia, or when doctors are at their wits’ end in treating complex patients. From a neuropsychological perspective, all cases of significant head injury or concussions, strokes, chronic pain and headaches, chronic sleep disorders, and incalcitrant psychiatric conditions should be referred routinely for neuropsychological evaluation. This may be concurrent with medical treatment for symptoms or prior to treatment for data supporting or confirming what physicians recommend.
Many developmental and mental health conditions are comorbid—that is, more than one condition exists and interacts (e.g., ADHD and anxiety; ADHD and learning disabilities; depression and cognitive impairment, etc.). A skilled practitioner can differentially diagnose and shed light in how coexisting conditions interact. Even in the absence of a known injury or trauma, adults will benefit from a comprehensive assessment to learn more about themselves; uncover and validate gifts, strengths, and suspected deficits; and to assist in personal growth and as a useful evidentiary tool for more effective psychotherapy.
In providing neurofeedback treatment for my patients, I have found that an abbreviated and focused assessment is sufficient to choose treatment protocols and target symptoms for effective relief. Money is often a constraint—but where finances are not delimiting, more comprehensive assessment bears fruit for patients, their professional providers, and for any individuals who want objective and useful information about how they operate.
Neuropsychological assessment is not just for identifying pathology or avoiding life-threatening afflictions. It can be an enlightening, scientific gateway to self-discovery and personal development.
See the General Assessment Model below that describes the components of comprehensive assessment from the perspectives of diagnostic methodology and categorical information yielded as an outcome of the assessment.
—Sometimes people overuse their strengths or “go-to” abilities instead of using or developing other necessary skills.
—Are the abilities demonstrated during assessment purely native in response to test items or can the individual apply them in real world settings? For example, some people have strong vocabularies, but are less able to express themselves clearly.
—Does the person use capabilities in successful, goal-oriented ways rather than self-absorbed or ineffective outcomes?
—For example, does the individual use verbal explanations instead of applying hands-on follow-through?
—Does the person accomplish needed tasks and fulfill potential?
—Are the strengths adaptive to productive and helpful behavior (e.g., using verbal skills to make excuses or inappropriately negotiate or avoid rather than taking responsibility and completing tasks)?
—Are there deficits that limit or prevent functioning? For example, deficient linguistic or comprehension, sensory-motor deficits, visuospatial weakness that affects organization and planning, attention/executive control problems, slow processing or visual-motor delays…
—Are the courses or curricular material too advanced for the skills, achievement levels, and entering behaviors measured (e.g., trying to learn advanced math when basic computational skills are lacking; reading books that require reading levels much higher than the examinee demonstrated)?
—Can the person make up for deficiencies by using other skills, attaining environmental accommodations and modifications (such as more time allowed on tests, quiet workspaces, technological assists, etc.)?
—For example, does the person’s attention to detail help accomplishment or result in excessive delays or distractions to non-essential information? Does the person let emotional sensitivity get in the way?
—For example, is the person with a weaker right hemisphere trying to solve problems or tasks requiring good spatial skills such as engineering? Conversely, is a person with great nonverbal abilities and weak language skills endeavoring to do outside sales?
—Does the combined picture of strengths, weaknesses, motivation, emotional constitution, processing styles, and environmental challenges match equitably with desires, expectations, and responsibilities?
Feel free to contact me if you have questions or want an assessment.
— Mark Steinberg, PhD
