Neuropsychological or Language/Literacy: Which Assessment is Right for My Child?

Today I’d like to address the question which has been asked quite frequently in the past several years by parents. “Do I still need a comprehensive language/literacy assessment if my child is already getting neuropsychological testing done?”  The short answer is a definitive and emphatic “Yes“!  And now, allow me to explain why.

In order to answer this question thoughtfully, it is very important to compare neuropsychological and language/literacy testing in order to understand the purpose of these quite different assessments.

Neuropsychological Testing

First, here’s some information on neuropsychological assessments. Neuropsychological evaluations typically seek to establish a connection between brain and behavior. There are a number of reasons why they are performed including the determination of the child’s intellectual, emotional/psychiatric, and executive functioning. They may also be performed for differential diagnosis purposes to rule out confirm certain psychiatric diagnoses, learning disabilities, etc.  Testing is quite extensive and assesses a variety of areas including memory, processing, visuospatial abilities, fluid reasoning, executive function, learning including learning disabilities, giftedness, and much more. Classroom observation findings are integrated into the body of neuropsychological reports. Some neuropsychologists also add a battery of educational testing as well for further comprehensiveness. Typically such tests would then be considered to be neuropsychoeducational vs. neuropsychological.

Here’s just a very small sampling of tests included in neuropsychoeducational batteries administered to children that I have encountered during my report reviews (listed in alphabetic order):

• Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI)
• Behavior Assessment System for Children, Third Edition  (BASC-3) (Parent and Teacher Ratings)
• Behavior Rating Inventory of Executive Functioning-2  (BRIEF-2)(Parent and Teacher Forms)
• Bender Visual Motor Gestalt Test
• California Verbal Learning Test-Children’s Version (CVLT-C)
• Conners 3rd Edition (Parent and Teacher Forms)
• A Developmental Neuropsychological Assessment, Second Edition (NEPSY-II)
• Delis-Kaplan Executive Function System (D-KEFS)
• Gray Oral Reading Tests-Fifth Edition (GORT-5)
• Kaufman Test of Educational Achievement, Third Edition (KTEA-3)
• Phonological Awareness Test-2: Normative Update (PAT-2: NU)
• Purdue Pegboard Test
• Test of Auditory Processing Skills, Fourth Edition (TAPS-4)
• Test of Everyday Attention for Children Second Edition (TEA-Ch2)
• Test of Variables of Attention (TOVA) 
• Test of Written Language Fourth Edition (TOWL-4)
• Thematic Apperception Test
• Wechsler Individual Achievement Test-Third Edition (WIAT-III)
• Wechsler Intelligence Scale for Children – Fifth Edition (WISC-V)
• Wide Range Assessment of Memory and Language-2 (WRAML-2)
• Wide Range Achievement Test – 5 (WRAT-5)
• Woodcock-Johnson IV: Selected Achievement, Cognitive, and Oral Language Tests (WJ-IV)

After the completion of testing, neuropsychologists will summarize assessment findings. Typical summaries will include intellectual functioning, psychiatric diagnosis, learning strengths and needs, recommendations for in-school accommodations/modifications, special education placements, referrals to relevant professionals (speech pathologist, occupational therapists, etc.) for additional in-depth testing if needed. Recommendations for the utilization of particular programs/services may also be made at that time.

In the school system, the results of neuropsychological assessments are typically used in a variety of ways.  These include providing the students with appropriate educational classification,  providing the students with an IEP or a 504 plan, determining appropriate classroom placement, as well as establishing what type of accommodations and modifications will assist the child to succeed in the academic setting given his/her weakness areas.

Certainly, a quality neuropsychological assessment can accomplish a great deal for the child with respect to a number of benefits in the school setting. However, before you dismiss the notion of comprehensive language and literacy testing, allow me now to explain what a good quality language and literacy assessment conducted by a qualified speech-language pathologist, can bring to the table, in order for you to understand its value and worth.

Language and Literacy Testing 

The purpose of comprehensive language and literacy assessments is to determine the extent to which the child’s language and literacy weaknesses are impacting his/her academic performance.  Comprehensive language and literacy assessments are conducted in order to determine an appropriate educational environment, establish the present level of language and literacy functioning (strengths and needs), as well as to develop a comprehensive treatment goal hierarchy in order to improve social and academic functioning of the student in question. It is important to understand that while academic performance can be affected by impaired intellectual functioning, reduced working memory, processing abilities, etc., (neuropsychological testing), the vast majority of difficulties exhibited by children in school settings are language-based (language testing).  However, because not all language deficits are overt (e.g., reduced vocabulary and grammar), many subtle language difficulties (e.g., social communication, writing, etc.) may not be readily recognized without these in-depth assessments.

Consequently, the SLPs’ job is not only to perform a battery of standardized assessments but also to conduct a thoughtful clinical assessment of select deficit areas (discourse/narratives, reading, writing, and spelling) in order to tease out difficulties not picked up by standardized testing. This is another very important consideration that needs to be explicitly stated. All standardized assessments possess functional limitations.  Even some of the better ones are not without flaws.  From weak psychometric properties to a lack of sensitivity picking up certain higher-order deficits, all must be supplemented by clinical assessments which assess the child’s abilities to function academically at the grade level versus mere possession of basic language and literacy competency.

Below are some examples of tests included in batteries that focus on comprehensively assessing language and literacy abilities of school-age children (listed in alphabetic order).  Please note that this specific blog post does not cover speech and fluency testing and instead focuses only on tests of language, reading, spelling, and writing.

• Clinical Assessment of Pragmatics (CAPs)
• Clinical Evaluation of Language Fundamentals-5: Metalinguistics (CELF-5:M)
• Comprehensive Test of Phonological Processing-Second Edition (CTOPP-2)
• Executive Functions Test: Elementary (EFT-E)
• Expressive Language Test – Second Edition (ELT – 2)
• Gray Oral Reading Tests-Fifth Edition (GORT-5)
• Language Processing Skills Assessment (TAPS-4)
• Oral Passage Understanding Scale (OPUS)
• Phonological Awareness Test-2 (PAT-2: NU)
• Social Language Development Tests (A and E)
• Spelling Performance Evaluation for Language and Literacy-Second Edition (SPELL-2)
• Test of Early Written Language-Third Edition (TEWL-3)
• Test of Integrated Language & Literacy Skills (TILLS)
• Tests of Problem Solving (TOPS 2 & 3)
• Test of Reading Comprehension-Fourth Edition (TORC-4)
• Test of Written Language-Fourth Edition (TOWL-4)
• WORD Tests (Elementary and Adolescent)

As you can see, there are some overlaps with respect to several popular tests (reading, phonological awareness, and writing). Typically, when both professionals are doing assessments during the same time period, each provides a courtesy list of tests to the parents in order to avoid the practice effect (repetition of the same test in a short period of time).  Instead, they either substitute tests (CTOPP-2 instead of PAT-2: NU) or use different forms of tests (e.g., use form B instead of A on the GORT-5, TOWL-4, etc.).

Similar to the results of neuropsychological assessments, in the school system, the results of independent language and literacy assessments are also typically used in a variety of ways.  These may also include providing the students with appropriate educational classification (e.g., SLD),  providing the students with an IEP or a 504 plan, determining appropriate classroom placement, as well as establishing what type of accommodations and modifications will assist the child to succeed in the academic setting given his/her weakness areas.

Similar to neuropsychologists, after the completion of testing, speech-language pathologists will also summarize assessment findings. The Impressions section will provide a narrative review of a child’s language and literacy weaknesses, and provide subjective ratings of their deficits (below average, severely impaired, profoundly impaired) based on the combination of standardizing clinical assessments.  Here is a brief illustration of what that looks like:

“Comprehensive language and literacy assessment revealed that the student presents with previously undetected language and literacy deficits which are adversely affecting his/her social as well as academic functioning and require targeted remediation. These deficits include severely impaired metalinguistic comprehension, verbal expression, executive function, and problem-solving, as well as profoundly impaired social communication abilities. The assessment revealed that certain areas of literacy were a relative strength for the student as compared to his/her oral language skills. These included average phonemic awareness, basic reading fluency, nonword spelling as well as nonword reading skills. It is important to note that despite these relative strengths, the student presented with severely impaired reading comprehension and writing abilities, which require urgent remediation.”

These will be further broken down by all the tested areas and explained in further detail.  Here is another brief illustration of what that looks like:

“The student’s oral language deficits are characterized by difficulty defining concrete and abstract vocabulary words (e.g., snack, fever, subtract, poem, verb, sentence, compound word, question, etc.), explaining multiple-meaning words (e.g., order, season, fall, etc.), as well as interpreting figurative language and clarifying ambiguously worded sentences (e.g., The teacher told us to make a line, etc.). His/her narrative abilities are also judged to be significantly immature for his/her age and were characterized by deficits in the areas of semantics, pragmatics, syntax, word-finding, verbal reasoning, perspective-taking as well as social communication.”

After outlining all of the students’ difficulties in extensive details, and specifying ICD-10 diagnoses to relevant to the assessment, the SLP will also proceed to make recommendations for accommodations and modifications for the student.  Additionally, if the SLP performed the classroom observation, s/he will make a statement regarding whether the students present classroom placement is appropriate or requires any modifications.  If the classroom placement requires any modifications the SLP will provide a number of recommendations as pertaining to which classroom setting the student will function inappropriately and given what type of supports in the form of accommodations, modifications, as well as various therapies and additional services (e.g., reading, writing, etc.)

The SLP may also recommend select evidence-based, therapeutic approaches to remediation similar to the recommendations of the neuropsychologist.  But most importantly the SLP will list a suggested list of long-term and short-term goals that need to be addressed to the student in order to improve his/her performance in the school setting.  This is the most important recommendation that the SLP will make and this is an area in which an SLP differs from a neuropsychologist in a most crucial way. Here’s why.

Neuropsychologists typically do not make specific treatment recommendations in their reports. Even if they did (as some I am sure do), it creates a difficulty in the school setting, since there are no professionals there to follow through on them and executive them.  In other words, even if a neuropsychologist made specific treatment recommendations, these will not be implemented and executed in the school setting, because there are no neuropsychologists or psychologists for that matter there who will treat language and literacy difficulties.  Instead, these fall under the scope of practice of speech-language pathologists.  However, a speech-language pathologist cannot implement treatment recommendations of neuropsychologists without performing their own comprehensive testing.  In contrast, if a speech-language pathologist describes the students’ literacy abilities in extensive detail and then creates specific goals addressing phonemic awareness and reading, these can, in turn, be implemented by learning consultants and reading specialists in the school setting since the former have used relevant objective tests familiar to the latter.

More importantly, the goals and objectives created by speech-language pathologists to address language and social communication difficulties of the student can easily be implemented by fellow speech-language pathologists in the school setting upon the independent evaluation being accepted as part of the student’s record.  In sum, neuropsychologists make general recommendations to assist students with functioning in the academic setting.  Speech-language pathologists create specific, executable treatment goals which can be implemented in the school setting by fellow speech-language pathologists in order to actively intervene and improve the students’ abilities in the affected areas of functioning.

A neuropsychologist may recommend a particular program to address reading (e.g., Orton-Gillingham, Wilson, etc.).  But a speech-language pathologist will not only create specific goals for reading but may also specify the limitations of specific recommended programs (e.g., “Given the student’s excellent decoding but very poor comprehension abilities, currently the use of the Wilson program is not recommended at this time as it does not adequately address reading comprehension abilities”).

What a speech-language pathologist brings to the table, is a deeper analysis and the greater comprehension of language-based literacy deficits.  To illustrate, a neuropsychologist may recommend an application of particular writing approach/program to a child with difficulty in the area of writing.  However, a speech-language pathologist may recognize that a particular program is too advanced for the child’s present level of writing abilities. A speech-language pathologist will then adjust expectations and create more targeted hierarchical goals which are better suitable for the child’s present writing needs.

There you have it. This is just one of the many reasons why it is important to administer comprehensive language and literacy assessments to students struggling in the school setting even though they may not seem to present with overt language and literacy deficits, in the presence of decent grades.

I hope that I have answered the question, “Do I still need a comprehensive language/literacy assessment if my child is already getting neuropsychological testing done?” for any parents and referring professionals who read this post. While neuropsychological testing may be very relevant and needed for the student in question, it should never be preferred at the expense of forgoing a good quality comprehensive language and literacy assessment!