TYPES OF ASSESSMENTS

The purpose of psychological assessment is to discern the status of an individual in relation to an appropri­ate peer group. Jerome Sattler discerns four pillars of child assessment as norm-referenced tests, interviews, observations, and informal assessment (15).

In a discussion of cognitive testing, the issues of single tests versus batteries is an important consider­ation. Single tests are designed to tap a specific dimen­sion of cognition, like verbal learning or visual-motor abilities. As useful as they are for more in-depth exami­nation of a single construct, this strength is a source of limitation as well. Seldom is the question at hand to be answered by examining a single ability. Abilities are not the unitary concepts that evolve from theoretic models. The influence of other overarching cognitive abilities, such as attention or processing speed, is not addressed directly and is discernible only through observation. Normative samples for single tests can be restricted and not large enough or representative enough to draw firm conclusions as to standing within one's peer group.

Therefore, the use of a test battery is preferred. The best-known example of a test battery is the Wechsler batteries for intelligence assessment, comprised of a number of subtests. These collections cover an array of abilities. In neuropsychologic assessment, the concept of a fixed battery versus a flexible battery exists. A fixed battery is a group of subtests developed to tap a spec­trum of either a specific function—for instance, memory or attention—or a comprehensive view of cognition.

Fixed batteries provide for the strongest basis for comparison of a patient's performance across the sub­tests, as the norms are based on this arrangement of tests, given in the established order to the normative group. Because all subjects receive the same subtests, there can be an expression of both strengths (what a patient can do) and deficits. This is particularly use­ful in the construction of rehabilitation plans. A flex­ible battery is composed of a number of single tests, assembled with the patient's referral question or known medical condition in mind, with an eye to tap­ping tests most likely to explicate suspected deficits.

Lezak and colleagues (23) noted a survey of neu­ropsychologists where 70% responded that they use a flexible battery approach. They note the position that fixed batteries involve more testing than some patients need and can't accommodate the practice of adding tests either newly developed or needed to explicate a deficit seen but in need of further examination.

Automated or computer use in testing has increased substantially since the 1980s. Prior to that, automated and later computerized administration and scoring of tests was quite limited. Initially, comput­erized testing of attention was developed (Gordon Diagnostic System, Connors Continuous Performance Test). More recently, computerized tests have been developed for concussion diagnosis and monitoring (as noted in the prior section), but also for research purposes. Such techniques offer repeatability, sensi­tivity to subtle cognitive changes, and ease of admin­istration. Reliability, validity, and other considerations pertinent to general issues in more traditional so- called pen-and-paper tests are pertinent to this type of assessment as well.

Evaluation, then, is a robust and multifactorial process, not to be confined to a set of test scores or descriptions of test performance, but also to include natural setting data.

Maureen Dennis (24) captured the interaction of these factors in the following, which she calls an “outcome algorithm.” Though Dennis is specifically referring to disorders that affect the central nervous system, the same factors apply in understanding other medical disorders as well. She explains it as

...biological risk associated with the medical condi­tion, moderated by the child's development; by the time since onset of the condition; and by the reserve avail­able within the child, family, school, and community.

The interpretation of standardized tests must take these factors into account: issues about the course of a disease or injury recovery, the unique interface that the course of an illness or recovery has on the time­table of childhood development, and the actual length of the struggle with the medical condition. Her inclu­sion of the word “reserve” with which to respond and cope dovetails with the requirement of assessment that examines these factors as well.

Some of these elements are captured in a good history taking and/or record review. Reserve factors concerning coping and response are also gathered in history but can additionally be tapped by standard­ized questionnaires, whose responses are sought from a variety of sources. These encompass figures from the major settings in a child's life (ie, parents and teach­ers). The value of such instruments is that they can reference responses to those of a normative popula­tion such that the degree of divergence from standard development can be expressed.

Culture-Sensitive Assessment

Psychological assessments with culturally diverse chil­dren are challenging under any circumstances. Most measures have a culture bias in terms of content and validity, and normative data are seldom adequately representative of diverse groups. Not all examiners are sufficiently sensitive to the impact of cultural issues on test performance, and when interpreted without caution, results can be misleading. The assessment of English language learners, children who have reduced mastery of the English language because their parents' primary language is not English, is particularly chal­lenging. Use of interpreters or test translations carries limitations, such as lack of equivalent concepts in the two languages, minimal provision for dialectical vari­ations, and possible changes in the level of difficulty or meaning of translated words (15).

Several “culture-fair” tests have been developed to reduce culture bias by limiting the amount of ver­bal exchange, using more abstract content that is less grounded in culture and language, and using more diverse groups during the norming process. This represents an important step in culturally sensitive assessments, and some of these tests are discussed in following sections. However, there is no way to truly eliminate cultural bias from tests, and demographic data on normative groups must be carefully examined before assuming that it is any more representative of the specific patient than traditional tests. For example, many of the “culture-fair” tests are normed only on children in the United States. Their use for students with different backgrounds, such as children from ref­ugee camps in Africa with little to no formal school­ing, is clearly limited.

Culture-sensitive assessments in pediatric popu­lations are made even more complicated by the fre­quency of mild to severe motor impairment. Examiners assessing individuals with motoric impairment rely heavily on tests of verbal cognitive skills and try to reduce the number of tasks that require speeded or complex motor responses.