I’ve mentioned in past posts the necessity of neuropsychological testing in diagnosing schizophrenia spectrum and bipolar spectrum disorders. People often hear this, nod, and then walk away asking, ‘What the heck is she talking about? What is neuropsychological testing?”
Well, let’s talk about that. I finally have Grace’s written report in hand from her testing, and Eadaoin and I completed her intake for her round of neuropsychological testing yesterday. Why even bother with this sort of testing, and why is it necessary?
Let’s define it. What is it? There are a few definitions out there. Here’s a short one:
Neuropsychological assessment is a performance-based method to assess cognitive functioning. This method is used to examine the cognitive consequences of brain damage, brain disease, and severe mental illness.
Here’s the best one I’ve found:
Neuropsychological evaluation (NPE) is a testing method through which a neuropsychologist can acquire data about a subject’s cognitive, motor, behavioral, linguistic, and executive functioning. In the hands of a trained neuropsychologist, these data can provide information leading to the diagnosis of a cognitive deficit or to the confirmation of a diagnosis, as well as to the localization of organic abnormalities in the central nervous system (CNS). The data can also guide effective treatment methods for the rehabilitation of impaired patients.
NPE provides insight into the psychological functioning of an individual, a capacity for which modern imaging techniques[1, 2] have only limited ability. However, these tests must be interpreted by a trained, experienced neuropsychologist in order to be of any benefit to the patient. These tests are often coupled with information from clinical reports, physical examination, and increasingly, premorbid and postmorbid self and relative reports. Alone, each neuropsychological test has strengths and weaknesses in its validity, reliability, sensitivity, and specificity. However, through eclectic testing and new in situ testing, the utility of NPE is increasing dramatically. (online source)
One of the primary reasons why a person might get an NPE is to confirm a burdensome mental health diagnosis particularly if that person is a child. For example, if one suspects that a child has early-onset bipolar disorder, then evaluating the neuropsychology of the child should be part of the diagnostic process because there are specific neuropsychological markers, specifically executive function deficits, when bipolar disorder is present. It is irresponsible to diagnose a child with bipolar disorder and subject them to the medications without having included an NPE in their diagnostic process. The same is true for a schizophrenia diagnosis.
In the context of a schizophrenia spectrum disorder particularly in childhood-onset (COS), the NPE needs to be one of the tools used every two years until the disease process/prodrome settles which isn’t until after the first five years of onset and/or the child reaches eighteen to twenty years of age. COS is a severe form of schizophrenia. The earlier the onset, the harder the child is hit particularly in cognition. Recall that schizophrenia is defined as having three categories of symptoms: positive, negative, and cognitive. (See Clearing The Fog) This is where the NPE becomes highly valuable.
Grace had her first NPE when she was seven years-old. That can be unusual because most neuropsychologists won’t perform an NPE on a child so young, but I can be very persuasive. Grace was completely unable to read, and I was trying to convince a school board to grant her an IEP. I won because I had an NPE from a reputable hospital. Her next NPE was done when she was ten years-old at the very beginning of COS although we didn’t know that we were observing that. Her next NPE was a few months ago. The neuropsychologist was thrilled to have three data points to chart, and the results were indeed stunning. On the graph, starting from age 7, there was a decline in very specific cognitive functions. In certain areas, she is growing normally–verbal skills. In other skills, she is not just below average; she is impaired. That is a marker of disease progression known as regression. Remember, schizophrenia is a neurodegenerative/neurodevelopmental disease like MS. It isn’t like depression or even bipolar disorder in that the brain itself is largely unaffected in structure, size, or density. People with schizophrenia lose white matter, and they lose the most white matter in the first five years of disease onset. So, a child with COS is doubly hurt because their brain is growing and developing while degenerating at the same time.
The NPE is vital in a treatment plan because it allows parents, caregivers, educators, and clinicians to see exactly where the impairments and regressions have occurred. This allows for a very specific course of treatment and therapy to be created so that the parts of the child’s brain that are growing and developing normally can be taught to compensate for the impaired areas in addition to aiming treatment at the impairments. Knowing the exact nature of the impairments also elucidates the etiology of certain behaviors. What might look like panic attacks or tantrums may actually be a function of poor executive function and a deficit in working memory. A thorough NPE will reveal that.
Grace will receive another NPE in two years. Her neuropsychologist was very clear with me. She placed herself on Grace’s team and all but demanded that she see Grace again in 24 months for another round of testing. Because Grace’s results were so stunning and because Eadaoin is struggling with mood and working memory issues, the neuropsychologist made an exception for our family and insisted that she be evaluated as well.
The question that most people ask about the NPE is “Will insurance pay for it?”
That depends. If it’s solely for the purpose of diagnosing a learning disorder, then no. They consider this an educational issue and leave that to the schools to do. That’s what an IEP evaluation is for, so say insurance companies.
Grace’s NPE, however, was covered entirely by insurance because her neurologist ordered it, and it is being done for the purpose of tracking regression and disease progression. Due to family history and possible diagnosis of a mental health disorder, Eadaoin’s NPE is also being paid for by insurance. It will also help her obtain an IEP.
So, what kind of tests are involved in this so-called neuropsychological assessment?
For general intelligence, the WISC-IV, VCI Subtests, PRI Subtests, WMI Subtests, and PSI Subtests. For memory, WRAML-2 and CVLT-C. For Visual-Spatial/Visual-Motor, VMI. For social perception, NEPSY-II and CASL. For attention and executive function, Conners’ CPT-2, WCST, D-KEFS, Trail Making Test, Color-Word, Verbal Fluency. For achievement, WIAT-III. For motor, grooved pegboard. For adaptive behavior, ABAS-II (parent), ABAS-II (teacher).
Part of the NPE does involve teachers and parents answering questions, too. It is a long process. It takes a few months to complete, but it is worth the effort. The NPE is also useful for children, teens, and adults with autism spectrum disorders and even ADHD as ADHD affects working memory and executive function. There are many reasons to seek out an NPE, but, in the context of mental illnesses like schizophrenia spectrum disorders and bipolar disorder in children, the NPE becomes a vital tool in contributing to a solid treatment plan that not only brings stability to a child or teen but also provides direction into how to specifically treat a person so that they can thrive.