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Question #37


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Questions and Answers

 

Question # 37

Is a comprehensive neuropsychological assessment necessary to determine (a) if someone exhibits the syndrome of NLD, and (b) appropriate treatment programming for the person with NLD? Would the application of a simple checklist of assets and deficits or some other, less comprehensive, method do the trick?


Short answer to the first question: (a) yes, (b) this is the first necessary step; to the second question: no.

Rationale. There are many reasons why a comprehensive neuropsychological assessment is required if one aims to determine the presence of NLD and formulate a treatment programme for the person who exhibits NLD. (For the scientific basis of this view, the interested reader may wish to consult Rourke, 1995). The following are some of these reasons:

(1) The content of NLD (i.e., its neuropsychological assets and deficits; see NLD Content and Dynamics) is multifaceted. Leaving out any part of this content is less than adequate for classification and treatment planning (see Question #31).

(2) The systematic differential classification/diagnosis of NLD (e.g., Drummond, Ahmad, & Rourke, 2005; Harnadek & Rourke, 1994; Pelletier, Ahmad, & Rourke, 2001) requires much data regarding the NLD content exhibited by the youngster. Considerations regarding the intensity of the deficits (e.g., mild, moderate, severe) is also crucial.

(3) The neurodevelopmental dynamics of NLD (see NLD Content and Dynamics) are quite complex. Leaving out significant dimensions of NLD content renders confident inferences about such dynamics in the individual case very difficult, if not impossible.

(4) The treatment programme for youngsters with NLD is multifaceted and requires access to the content and neurodevelopmental dynamics operative in the individual case. But, even these data are not sufficient to formulate a potentially effective treatment plan (see Question #31).

Neuropsychological Assessment: From Tests to Interpretation to Treatment. For a battery of tests that constitutes an adequate basis for the measurement of the neuropsychological assets and deficits and the relevant neurodevelopmental dynamics of NLD, see Question #9. The systematic measurement of these dimensions of neuropsychological performance is likely to lead to a reliable and valid classification of NLD if (a) administered by (or under the supervision of) a qualified clinical neuropsychologist, and (b) interpreted by a qualified clinical neuropsychologist who is familiar with the neuropsychological and other relevant dimensions of NLD. In my practice with youngsters, I also add the administration of a behaviour rating scale(Hayman-Abello, Rourke, & Fuerst, 2003), a simple activity rating scale, and the Personality Inventory for Children (PIC). For a full description of the PIC and its application to children and adolescents, see Fuerst (1991); also of interest: Butler, Rourke, Fuerst, & Fisk (1997); Ralston, Fuerst, & Rourke, (2003). For a description of the neuropsychological test battery that we employ and examples of the modes of interpretation, individualized treatment plan formulations, and case applications, see Rourke, Fisk, & Strang (1986) and Rourke, van der Vlugt, & Rourke, 2002).

Some Observations. It has come to my attention that NLD is being "over-diagnosed" in some quarters. As pointed out in Question #17, one very important reason for this is the failure to conduct a comprehensive neuropsychological assessment (such as that described above) before arriving at conclusions regarding the presence of NLD. For example, the "shake-and-bake" application of a checklist of assets and deficits would be expected to lead to such errors rather frequently; so too, reliance of this method may lead to an unacceptably high rate of false negatives (i.e., "misses" with respect to the presence of NLD). The role of a reliable and valid checklist is quite specific and narrow: at best it may suggest that a comprehensive neuropsychological examination is or is not required. Even the systematic application of very sophisticated rules (e.g., Drummond et al., 2005; Pelletier et al., 2001) to render judgments of "definite, probable, questionable, or negative NLD" are no substitute for this type of examination. This is the case even though the application of these rules (e.g., Drummond et al., 2005) is 100% sensitive to the presence of definite/probable NLD versus BPPD (see Question #10). As with other "short cuts," such as batteries of tests and measures meant for screening but used for diagnosis, the fault lies with the person who uses the checklist, screening battery, or rules for classification in a manner for which they were never intended and will never be sufficient. The one who suffers most is the youngster and his caregivers. Indeed, having seen so many unprofessional, unscientific, and often unethical uses of checklists, screeners, and rules, I am reluctant to present our own NLD scale. The potential for misuse/abuse is, at present, unacceptably high.

That said, it should be borne in mind that a very large number of individuals with NLD are not being adequately assessed and treated. The legitimate and judicious use of reliable and valid checklists, screening instruments, and classification rules would be expected to eventuate in many persons with NLD having the opportunity to undergo a comprehensive neuropsychological assessment, with all of the benefits that can be derived therefrom.

Bottom Line. The only reasonable foundation for the determination of the presence and severity of NLD is a comprehensive neuropsychological examination. It is also necessary to gather much more information than that provided by such an assessment in order to formulate a potentially effective treatment plan. The injudicious application and use of checklists and the like is indefensible from a professional and ethical standpoint. Among other things, the potentially high levels of false positives and false negatives that may result from such applications are usually unknown, or at least unreported. The unprofessional and unethical dimensions of this practice have only one certain outcome: a failure to meet the needs of those who seek knowledge and effective assistance for persons who are thought to exhibit NLD. This may be especially important for the determination of the NLD phenotype and its implications for the treatment of youngsters suffering from various forms of neurological disease, disorder, and dysfunction (see NLD and Neurological Disease; Rourke et al., 2002).

References

Butler, K., Rourke, B. P., Fuerst, D. R., & Fisk, J. L. (1997). A typology of psychosocial functioning in pediatric closed-head injury. Child Neuropsychology, 3, 98-133.

Drummond, C. R., Ahmad, S. A., & Rourke, B. P. (2005). Rules for the classification of younger children with Nonverbal Learning Disabilities and Basic Phonological Processing Disabilities. Archives of Clinical Neuropsychology, 20, 171-182.

Harnadek, M. C. S., & Rourke, B. P. (1994). Principal identifying features of the syndrome of nonverbal learning disabilities in children. Journal of Learning Disabilities, 27, 144-154.

Hayman-Abello, S. E., Rourke, B. P., & Fuerst, D. R. (2003). Psychosocial status after pediatric traumatic brain injury: A subtype analysis using the Child Behavior Checklist. Journal of the International Neuropsychological Society, 9, 887-898.

Pelletier, P. M., Ahmad, S. A., & Rourke, B. P. (2001). Classification rules for Basic Phonological Processing Disabilities and Nonverbal Learning Disabilities: Formulation and external validity. Child Neuropsychology, 7, 84-98.

Ralston, M. B., Fuerst, D. R., & Rourke, B. P. (2003). Comparison of the psychosocial typology of children with below average IQ to that of children with learning disabilities. Journal of Clinical and Experimental Neuropsychology, 25, 255-273.

Rourke, B. P. (1995). The science of practice and the practice of science: The scientist-practitioner model in clinical neuropsychology. Canadian Psychology, 36, 259-287.

Rourke, B. P. (2000). Neuropsychological and psychosocial subtyping: A review of investigations within the University of Windsor laboratory. Canadian Psychology, 41, 34-50.

Rourke, B. P., Ahmad, S. A., Collins, D. W., Hayman-Abello, B. A., Hayman-Abello, S. E., & Warriner, E. M. (2002). Child-clinical/pediatric neuropsychology: Some recent advances. Annual Review of Psychology, 53, 309-339.

Rourke, B. P., Fisk, J. L., & Strang, J. D. (1986). Neuropsychological assessment of children: A treatment-oriented approach. New York: Guilford Press.

Rourke, B.P., & Fuerst, D. R. (1991). Learning disabilities and psychosocial functioning: A neuropsychological perspective. New York: Guilford Press.

Rourke, B. P., van der Vlugt, H., & Rourke, S. B. (2002). Practice of child-clinical neuropsychology: An introduction. Lisse, The Netherlands: Swets & Zeitlinger.


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