Glen A. Palmer, Ph.D.
Children with dual diagnosis provide unique challenges for parents, school systems, and mental health providers. Neuropsychological evaluation can provide valuable information regarding clarification of diagnosis, assessment of individual strengths and weaknesses, and recommendations for treatment.
This paper describes the benefits of neuropsychological evaluation for children with dual diagnosis. Two case studies are presented to demonstrate the role of evaluation in programming for children with mental retardation. The first case study describes the profile of a child with diagnoses of reactive attachment disorder and mood disorder. The second case study describes a child referred with an anxiety disorder. Comprehensive evaluation is recommended including the need for intellectual and achievement assessment as part of evaluation. A neuropsychological battery that includes the use of the NEPSY is presented.
The benefits of neuropsychological evaluation are recognized with respect to a variety of medical and psychiatric disorders, including traumatic/acquired brain injury (Anderson, Bigler, & Blatter, 1995), schizophrenia (Zakzanis, Leach, & Kaplan, 1999), depression (Zakzanis et al., 1999), and learning disabilities (Denkla, 1989; Pennington, 1991). Despite evidence that this specialized assessment is beneficial for diagnosis, treatment planning, and research with a variety of populations, there is a significant lack of information for children with mental retardation.
Neuropsychological evaluation is intended to assess a variety of domains, including intellectual functioning, attention, memory (including both visual and auditory components), language, executive functions, sensorimotor abilities, and personality factors. Both quantitative and qualitative aspects of these domains are assessed in order to identify relative strengths and weaknesses.
In this study, two childrens case studies are presented in order to demonstrate the use of neuropsychological assessment.
The first child (Case1) was a 9-year-old, right handed boy referred for neuropsychological assessment in order to provide clarification of diagnosis and recommendations for treatment. He had a number of previous diagnoses, including reactive attachment disorder, mood disorder, and attention deficit hyperactivity disorder, combined type. Intellectual testing revealed mild mental retardation (WISC-III Full Scale IQ SS = 66). The Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1998) revealed difficulties with mild elevations with aggression, conduct, and hyperactivity. At school, he received special education services, including resource classroom, speech therapy, and occupational therapy. The child was receiving vision therapy, and one eye reportedly tended to cross with fatigue. Achievement testing revealed deficits in mathematics and writing.
The second child (Case 2) was an 11-year-old, left-handed boy referred for neuropsychological evaluation in order to provide a detailed appraisal of his abilities. He had previous diagnosis of cerebral palsy with spastic diplegia. CT scan revealed presence of Dandy-Walker syndrome. Intellectual testing revealed mild mental retardation (WISC-III Full Scale IQ SS = 62). The BASC revealed difficulties with anxiety, depression, and somatization. At school, he received special education including resource classroom, speech therapy, and occupational therapy. Achievement testing revealed deficits in reading, mathematics, and writing.
Each child was administered the NEPSY (Korkman, Kirk, & Kemp, 1998), a developmental neuropsychological test battery. The battery is designed to assess children 3-12 years old. The NEPSY assesses several domains including attention/executive functions, language visuospatial abilities, memory, and sensorimotor abilities.
The NEPSY is a neuropsychological test battery that is based on Lurian theory (Palmer, Weinhaus, & Pohlman, 2001). Tests administered from the NEPSY included Design Copying (DC), Phonological Processing (PP), Memory for Faces Immediate (MEMFI) and Delayed (MEMFD) Recalls, Tower (TOWER), Auditory Attention and Response Set (AARS), Speeded Naming (SN), Arrows (ARROWS), Memory for Names Immediate (MEMNI) and Delayed (MEMND) Recalls, Fingertip Tapping Dominant (FTD) and Nondominant (FTND) Hands, Visual Attention (VA), Comprehension of Instructions (CI), Imitating Hand Positions Dominant (IHPD) and Nondominant (IHPND), Visuomotor Precision (VMP), Narrative Memory Immediate (NMEM) and Cued (NMEMC) Recalls, Repetition of Nonsense Words (RNW), and Verbal Fluency for Semantic (VFS) and Phonemic (VFP) Cues. In addition, Full Scale IQ scores (FSIQ), Vocabulary (VOC), and Block Design (BLK) were included in the assessment for comparison purposes.
The childs performance on a series of subtests is present in Figure 1. Standard scores on most subtests were expected to fall in the same range of functioning as his Full Scale IQ score. However, strengths were noted in areas of executive functioning, auditory attention, basic fine motor speed for the dominant hand, some areas of language, and memory for multimodal information. Verbal cues were also quite successful for assisting the child to remember verbal information. Behaviorally, The Behavior Assessment System for Children (BASC) revealed difficulties in areas of aggression, conduct, and hyperactivity. Although some moderate problems with attention were noted, his performance was better than expected given results of IQ testing.
Visuospatial abilities were a relative weakness for the child. Visual attention was slightly weaker than auditory attention, which was likely due to visual difficulties. Visual memory deficits were also noted.
This childs performance on selected subtests of the NEPSY and selected subtests of the WISC-III are presented in Figure 2. The child exhibited strengths in areas of executive functions, auditory attention, some areas of language, and many aspects of memory. Deficits were noted in areas of motor abilities and motor planning, visuospatial abilities, and some areas of language (i.e., Phonological Processing (PP) and Verbal Fluency for Phonemic Cues (VFP)). The Behavior Assessment System for Children (BASC) revealed difficulties with anxiety, depression, and somatic complaints.
Neuropsychological evaluation can be a valuable tool for identification of strengths and weaknesses of children with dual diagnosis. These strengths and weaknesses can be easily identified by development of a neuropsychological profile for the patient. Comprehensive neuropsychological evaluation is beneficial in that it can provide a highly individualized profile on the patients abilities. The NEPSY assesses several domains including attention/executive functions, language visuospatial abilities, memory, and sensorimotor abilities. In addition, assessment of Intellectual functioning, achievement abilities, and personality variables are recommended for complete evaluation.
Anderson, C. V., Bigler, E. D., & Blatter, D. D. (1995). Frontal lobe lesions, diffuse damage, and neuropsychological functioning in traumatic brain-injured patients. Journal of Clinical and Experimental Neuropsychology, 18, 900-908.
Denckla, M. B. (1989). Executive function, the overlap zone between attention deficit hyperactivity disorder and learning disabilities. International Pediatrics, 4, 155-160.
Korkman, M., Kirk, U., & Kemp, S. (1998). NEPSY: A developmental neuropsychological assessment. San Antonio TX: Psychological Corporation.
Palmer, G. A., Weinhaus, D. R., and Pohlman, C. (2001). Test review of the NEPSY: A developmental neuropsychological assessment. Journal of Psychoeducational Assessment, 19, 89-95.
Pennington, B. F. (1991). Diagnosing learning disabilities: A neuropsychological framework. New York: Guilford Press.
Reynolds, C. R., & Kamphaus, R. W. (1998). Behavior Assessment System for Children Manual. Circle Pines, MN: American Guidance Service, Inc.
Zakzanis, K. K., Leach, L., & Kaplan, E. (1999). Neuropsychological differential diagnosis. Lisse, The Netherlands: Swets & Zeitlinger.
For further information:
Glen A. Palmer, Ph.D.
Lanning Center for Behavioral Services,
Mary Lanning Memorial Hospital
(This material was included in a poster presentation at the 125th annual AAMR meeting in Denver, Colorado, in 2001.)