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Neuropsychological Assessment of Toddlers
and Pre-school Age Children

Early assessment of disorders is essential for effective intervention. This article will provide guidelines for comprehensive assessment with young children (2–5) to facilitate accurate diagnosis and appropriate recommendations for school placement and treatment. Toddlers and preschool-age children present with a diverse range of cognitive, attention and psychiatric difficulties that have far-reaching implications for their academic and social–emotional development. Thus‚ accurate assessment is a critical tool to guide their parents and facilitate maximizing their potential.

Common Reasons for Referral
Children are generally referred for assessment by a variety of professionals including pediatricians, day–care providers or teachers as well as parents. The most common reason for referral is language delays as children with motor delays are often picked up at a younger age as they fail to meet appropriate developmental milestones earlier. As there is a continuum of normal speech development beginning at nine months to two years‚ referrals are often made for children between ages two and three. Intense behavioral difficulties also tend to surface at this age as children develop motorically and cognitively. Thus‚ a placid‚ withdrawn infant causes little concern but a silent toddler rings a loud alarm.

Guidelines for Assessment

Informal (qualitative) assessment as well as formal (standardized) assessment is recommended to ensure that the evaluation captures the child's strengths and weaknesses. Young children often have a great deal of difficulty on standardized tests as they are not used to rigorous demands‚ may react poorly to the unfamiliar adult (examiner) and fatigue easily. Testing should be conducted over many sessions with a great deal of time devoted to informal play and rapport building. Observation of the child in a variety of settings affords a valuable opportunity to assess language and play skills in a relaxed atmosphere. Thus‚ school observations as well as observing the child on the playground with his or her peers are a crucial part of the assessment. The testing environment should be child friendly and well equipped with basic toys such as LEGOs‚ blocks‚ dolls and crayons.

Interviews with both parents and caregivers can yield a wealth of information. In addition, interviewing the therapists and teachers who work with the child is critical. A careful prenatal history should be obtained including prenatal history, family history and medical history. Difficulties during the pregnancy or birth may result in specific neurocognitive deficits. Family history can inform the evaluator regarding potential issues as learning and psychiatric difficulties often run in families. Traumatic events during infancy including separations, hospitalizations, marital conflict and loss of loved ones significantly contribute to child development. Eating and sleeping difficulties can predict or exacerbate cognitive or psychiatric issues. Careful inquiry of the child's daily routine is helpful to assess developmental level as well as environmental variables that may be contributing to the problem such as exposure to bilingualism‚ excessive television and multiple caregivers.

An informal play therapy assessment is an important tool for the evaluator to assess relatedness‚ spontaneous language, conceptual skills and ability to engage in fantasy. In addition, neuropsychological functions such as attention, memory and receptive language skills can be informally assessed using dolls, blocks and crayons. The assessment begins with observing how the child separates from his or her caregivers. If the child cannot separate‚ I encourage the caregiver to stay in the room but remain unobtrusive. Separation is generally encouraged as most children perform better alone with the examiner.

Assessment Instruments

Intelligence There are several assessments of intellectual functioning for preschoolers. The Stanford–Binet is a well standardized, reliable IQ test. It is “user friendly” as it is game-like in nature and assesses language skills‚ arithmetic, conceptual reasoning‚ social judgment and visual–spatial skills. The Stanford-Binet should be administered to very young children or children with significant cognitive difficulties. The WPPSI is more academic in its approach although is assesses similar skills and is effectively used with slightly older children who are experiencing more subtle academic issues. The McCarthy has a more comprehensive fine and gross motor section and can be used to supplement standard IQ testing.

Academic Skills Preschool readiness academic conceptual abilities can be assessed with the Boehm using pictures of familiar objects and conceptually oriented questions. Beginning math skills are assessed on the Stanford-Binet and the WPPSI. The Woodcock–Johnson is an important tool for assessing reading readiness and reading skills. Letter and word identification are evaluated on a variety of tasks. In addition‚ sound symbol association is assessed as a precursor to acquiring phonetic skills. The WIAT–II can also be used for older children who have some degree of academic proficiency to assess reading‚ math and spelling skills.

Language The Preschool CELF assesses receptive and expressive language skills in a comprehensive manner‚ better used for older or more conceptually sophisticated children. The TOLD is a similar language assessment which can be used for children in the younger range with cognitive delays. The Peabody Picture Vocabulary Test is a quick assessment of receptive and expressive language skills but it only assesses vocabulary as compared with the TOLD and the CELF that both assess complicated language functions including understanding of grammar and syntax‚ programmatic use of language, auditory memory and use of conceptual skills with language tasks.

Attention ⁄ Memory: The NEPSY is a well standardized and highly reliable assessment of neuropsychological functions including attention‚ language‚ sensory-motor function‚ visual spatial functions‚ and memory. Motor planning‚ auditory and visual attention‚ impulse control‚ distractibility and sequencing skills are assessed with a variety of game–like tasks.

The Continuous Performance Test (CPT) is a computerized assessment of attentional skills with norms beginning at age five. Memory: As mentioned above‚ the IQ tests assess visual and auditory short term recall. In addition‚ the NEPSY assesses memory for facts‚ names, stories, sentences and list words. The WRAML is normed for children ages five and older and assesses visual and auditory recall for contextual and non-contextual material.

Visual-Motor ⁄ Fine Motor Motor planning and programming can be assessed with the McCarthy subtests. In addition‚ the Beery assesses grapho-motor skills for the older children. The Dencla is a quick battery of motor activities including hopping‚ balancing‚ oro–motor coordination and fine motor movements.

Personality The Rorschach is normed for children and can be used to assess reality testing‚ impulse control, and ego functioning and defense mechanisms. The CAT is also normed for use with children and can help evaluate social skills‚ ability to resolve conflict‚ self esteem and perception of others. Figure drawings are used to evaluate graph-motor skills‚ relatedness‚ and self esteem and can be normed with the Hammer system.

Diagnostic Issues

Arriving at an accurate diagnosis for a preschooler is complicated as preschoolers change rapidly and their functioning is variable. Accurate and comprehensive assessment is vital for diagnosis and intervention. Re-assessment after one year is often recommended to obtain a true picture of the child's strengths and weaknesses. Common diagnoses include Autistic spectrum disorder‚ Attention Deficit Disorder, language-based learning disabilities‚ sensory integration disorder and psychiatric difficulties including the pre–bipolar and pre-psychotic child. These diagnoses are always tentative given the child's neuro–plasticity and capacity for change. In addition‚ environmental factors can cause a child to mimic symptoms and disturb functioning. For example, marital conflict can cause anxiety and withdrawal that is resolved with therapy and more appropriate parenting. A review of test results leading to common diagnoses will follow.

Autistic Spectrum Disorder Currently, autism is more widely recognized and evaluated earlier due to more sophisticated awareness of this disorder. Early detection can lead to successful intervention and significant progress for these children. Neuropsychological test results often indicate a profile of a highly verbal child with early recognition of letters and numbers and poor social relatedness. Stereotypical, repetitive behaviors may be observed. Often autistic children are nonverbal and internally preoccupied. These children are on the more severe range; however‚ Asperger spectrum children are often highly verbal and obsessed with one subject‚ e.g. subways‚ weather or other areas. They have a huge amount of information about the topic but cannot engage in mutually social reciprocal behaviors.

Thus‚ a high verbal IQ is often observed with lowered visual spatial skills. In addition, personality tests reveal poor reality testing‚ little or no awareness of others and poor affect regulation. Verbal preservative responses are also common. Intervention includes ABA treatment‚ placement in a center based program with special instruction and related services and referral to a therapist for parental counseling and adjunctive work with the child.

Attention Deficit Disorder Attention difficulties are especially difficult to diagnose in preschool children as their attention skills have not yet developed. As a rule, all preschoolers are extremely active‚ restless and lack focus. However‚ a careful assessment can reveal significant attention problems that require intervention. These children are motorically restless, extremely distractible and require a tremendous amount of structure to complete tasks (ADHD). The inattentive subtype is typified by inattentiveness, distractibility and difficulty focusing as well as poor organization and sequencing skills. Early history is usually significant for hyperactive behaviors‚ poor impulse control and short attention span. Performance on the neuropsychological assessment is often marked by difficulty with the attention tasks, poor memory (both long term and short term)‚ and poor impulse control on the personality tasks. Attention difficulties are often co-morbid with learning difficulties. Psychopharmacological intervention is often recommended. In addition, a neurological workup to rule out absent seizures is essential as inattentiveness may be due to seizure behavior.

Language-Based Disorders Expressive and receptive language disorders are often manifested during this age. Expressively, children may demonstrate a limited vocabulary‚ poor sense of pragmatics, impaired use of syntax and difficulty expressing information. These issues can lead to learning problems particularly in the areas of reading and writing. Receptively‚ children may demonstrate difficulty following direction‚ responding to verbal cues and processing auditory information. These deficits may indicate auditory processing difficulties and related learning issues. Interventions that are helpful include speech therapy‚ auditory integration training and use of visual cues with remediation.

Sensory Integration Disorder Children with sensory integration difficulties are often tactilely defensive and demonstrate fine and gross motor difficulties. Their lack of eye-hand coordination is illustrated by slowed speed on timed tasks involving puzzles and pictures‚ poor grapho-motor skills and impaired visual sequencing and organization. In addition‚ sensory processing may be an area of weakness in both the visual and auditory modalities. A history of sensitivity to stimuli including loud noises‚ bright lights and textures such as wool indicates sensory difficulties. Treatment includes Sensory integration therapy with a certified occupational therapist‚ auditory integration treating and developmental visual training.

Psychiatric Disorders Pre–psychotic children often present with social withdrawal, internal preoccupation and heightened fantasies. As mentioned above, the personality assessment profile includes impaired reality testing and confabulated responses on the Rorschach and disorganized stories on the CAT. In addition, the figure drawings are often highly distorted and immature. Pre–bipolar children’s personality responses are characterized by sex and aggression. A history of intense agitation and irritability at home is often reported including mood swings‚ temper tantrums and poor impulse control. Further‚ hyper sexual activity and inappropriate attachment behavior is often observed. Psychotherapy and psychopharmacological intervention are the treatments of choice.

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