Play-based neuropsychological assessment of toddlers.
Of IDEA (2004) calls for a multidisciplinary assessment of preschool children with potentially identifiable developmental needs to determine their eligibility for school-based services. Many of these children are referred through state-sponsored early intervention systems during their toddler years prior to age three to receive multidisciplinary assessments, and referrals for early-age assessments often request information addressing the neuropsychological status of these toddlers, i.e., cognition, attention, object permanence and memory, pre-language and language skills, visual-spatial perception, executive functioning as well as pre-academic skills. As such, preschool, early-age multidisciplinary assessment often involves neuropsychological correlates relevant to a number of presenting disorders commonly identified during these evaluations (e.g., Attention Deficit Disorder, Pervasive Developmental Disorder, Dyslexia, Tourette's syndrome, Neurofibromatosis, and Sensory Integration Disorder).
Observational measures of children's neuropsychological status. Although the traditional neuropsychological assessment batteries for children offer precise and reliable measures, they do not address the age range of children commonly referred for the early age assessment. Examples of these measures include the Halstead Neuropsychological Battery for Children (HRNB; Reitan & Davison, 1974a),the Reitan-Indiana Neuropsychological Battery (RINB; Reitan & Davison, 1974b), and the Luria-Nebraska Neuropsychological Batter--Children's Revised (LNNB-CR; Golden, 1984). The HRND is standardized for children ages 9-14,and the RINB is standardized for children 5-8, while the LNNB-CR is standardized for children ages 8-12. Given the importance of early age assessment and the types of questions presented at preschool evaluations, efforts to extend neuropsychological assessment downward to an early age population have been made through formal and informal methods.
Many of the formal and traditional neuropsychological assessment batteries are standardized on children above the age of three and allow for the direct observation of performance. For instance, the NEPSY is a standardized, individually administered procedure that provides information about attention and executive functioning, language, sensorimotor functioning, visuospatial processing, and memory and learning for children ages 3 to 12 (Korkman, Kirk & Kemp, 1998). The Cognitive Assessment System (CAS) is a standardized, individually administered procedure that provides a full scale estimate of cognitive functioning as well as subscale measurements of planning, attention, successive processing and simultaneous processing (e.g., PASS scales) for children and adolescents ages 5 to 17 years. PASS subscales allow for the identification of cognitive strengths and weakness (Naglieri, 1999).
Early age neuropsychological assessments with the NEPSY and CAS are based upon a Luria (1973) model of brain development. Brain functioning is looked upon as a complex functional system that combines in concert with many working brain structures, each of which contributes separately to a holistic functional system. Each specific brain structure introduces its own particular factor essential for performance, with removal of this factor making the total performance impossible. As such, brain functioning is looked upon as the concerted effort of independently functioning units, each of which having specific purposes, yet carded out in interconnection with these other units.
Luria's model, which was based upon adult brain functioning, identified three principal functional units necessary for mental process to take place (Languis & Miller, 1992). One unit regulates the tone and wakefulness of mentation, and is responsible for arousal and selective attention. A second unit is primarily responsible for receiving, analyzing and storing information, including the use of simultaneous and successive integration of sensory stimuli into an organized temporal or serial order. A third unit is responsible for executive planning and is useful for such activities as planning, organizing, programming, regulating, monitoring, and verifying activity.
Collateral reports of preschool children's neuropsychological status. Despite the specificity of brain functioning based upon the adult model, childhood brain functioning is much less specific. Brain development takes time, with different regions of the brain maturing at different ages. For instance, the prefrontal cortex of the brain is among the last regions to reach full structural development, which is essential for such activities as planning, response inhibition, and emotional regulation as well as the modulation of attention, working memory and goal-directed behaviors (Fuster, 2002). Nonetheless, neuropsychological assessment of the early age population provides measures of early brain-behavior relationships, which assist in making diagnoses of childhood disorders that interfere with subsequent cognitive development.
Other measures of neuropsychological status are based upon collateral reports (i.e., a parent or teacher observation). The Behavior Rating Inventory of Executive Function--Preschool Version (BRIEF) measures components of executive functioning for children 2 to 6 years of age, and includes a full-scale global executive component and three broad index scores: inhibitory self-control, flexibility and emergent metacognition. More specific clinical subscales are also reported: inhibit, shift, emotional control, working memory, and plan/organize (Gioia, Espy, & Isquith, 2003). Although not considered a neuropsychological assessment procedure, the Behavior Assessment System for Children (BASC) exemplifies a collateral report often used in neuropsychological assessment and includes a parent or teacher's report of the preschool child's behavior across four composite scales: externalizing problems, internalizing problems, behavioral symptoms index, and adaptive skills. Nine clinical scales relevant to neuropsychological status are also reported: hyperactivity, aggression, conduct problems, anxiety, depression, somatization, atypicality, withdrawal, and attention problems, as well as three adaptive scales that include adaptability, social skills, and leadership.
Play-based observational assessment of neuropsychological status. Despite the efficacy of the toddler's collateral reports of neuropsychological status, evaluation of neuropsychological functioning often requires the direct observation of behavior. Indeed, for the most part, multidisciplinary assessment of children's exceptional education needs requires evaluative information based upon an empirical and direct observation of that child's behavior. Yet, few standardized instruments are available for this direct measurement of toddlers' neuropsychological status. To this extent, alternative strategies are often needed to observe and evaluate the neuropsychological functioning of toddlers.
Play-based assessment is a developmental assessment process that involves observations of how a child plays alone, with peers, and with caregivers in free play or in special games. Play-based assessment represents one alternative when assessing the neuropsychological needs toddlers.
The literature indicates many different methods of play-based assessment, each of which varies in terms of process, structure and content (Belsky & Most, 1981; Fewell & Rich, 1987; Largo & Howard, 1979). However, all play-based assessment allows children maximal freedom to express their highest levels of skills in a natural and flexible environment. Play-based assessment meets the legislative mandate to provide alternative procedures for ongoing and naturalistic assessment required for special education placement. Children and their parents often find the process of play-based assessment less stressful and more reflective of the child's typical behaviors than more traditional, standardized procedures (Gagnon & Nagle, 2004).
Transdisciplinary play-based assessment (Lindner, 1993) represents one model of play-based assessment allowing for the evaluation of neuropsychological status for children birth through 6. Through play, children can be assessed in areas of cognition, social-emotional, communication and language, and sensorimotor functioning. As such, play-based evaluation can provide information relevant to a number of neuropsychological factors: (1) sensory stimuli--the ability to process visual, auditory, tactile, smell and taste sensations; (2) sensorimotor--the ability to relate information from sensory systems; (3) object use--the ability to use objects with developmentally appropriate actions; (4) problem solving--the ability to solve problems of daily living; (5) imitation--the ability to observe and emulate verbal and motoric actions; (6) memory--the ability to attend to and retain information, (7) causality--the ability to act on objects to produce a desired response; (8) concept development - the ability to grasp concepts and draw relationships among objects, (9) classification--the ability to differentiate and then categorize stimuli into groups, and (10) sequencing--the ability to order objects into a scheme.
Play-based evaluation requires astute observational skills and knowledge of childhood development, including an ability to infer brain-behavior relationships based upon observations of children's behavior. Lindner's (1993) developmental milestones often serve as a basis for evaluating the developmental status of preschool children. For example, classification skills can be assessed by observing the child's ability to discriminate between a circle and square on a form board typically found at 15 to 18 months of development; matching objects by color, shape and size found at 24 to 27 months; and sorting objects by one criterion (i.e., shape or color) typically found at 33 to 36 months. Problem solving skills can be assessed by observing the child's ability to use foresight to complete a puzzle (18 to 21 months), build blocks horizontally and vertically (24 to 30 months), and putting graduated sizes in order (36 to 48 months). Imitation and memory skills can be assessed by observing the child's ability to imitate drawing of a stroke (15 to 18 months), activating a toy in imitation of an adult model (18 to 24 months), and imitating the drawing of a face (27 to 30 months). These examples are not exhaustive, and Lindner (1993) provides many developmental milestones relevant to the assessment of attention, memory, cognition, language, and sensori-motor skills.
Unlike standardized testing, results from play-based assessment are often presented in terms of age-ranges derived from developmental tables. Consequently, test performance often appears less specific than results obtained from standardized tests. Nonetheless, scores derived from developmental tables lead to judgments about the developmental status of toddlers, which have direct relevance to such neuropsychological issues of cognition, attention, memory, sensori-motor functioning, visual-spatial perception, language, and executive functioning. Additionally, play-based assessment provides clinicians with observations of a broad spectrum of the behavior, which gives a fuller picture of neurological status than more specific measures found in standardized testing.
Conclusion. Child psychologists have often looked upon play as a treatment technique, rather than an assessment strategy. Yet, the naturalistic observation of play behavior has historically been referenced as a method by which to make judgments about cognitive development, i.e., sensorimotor, preoperational, concrete operations, and formal operations (Piaget, 1945/ 1962). More recently, play-based assessment has been used to evaluate children's social development, i.e., unoccupied behavior, solitary independent play, onlooker behavior, parallel activity, associative play and cooperative play (Rubin, 1989). Currently, play-based assessment provides a valuable addition to assessment strategies when evaluating the neuropsychological needs of toddlers. In this manner, play-based assessment provides an additional source of data when looking at the brain-behavior relationships of toddlers presenting with potential exceptional education needs.
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Bruce F. Dykeman, Associate Professor, Counseling and Human Services, Roosevelt University.
Correspondence concerning this article should be addressed to Bruce Dykeman at firstname.lastname@example.org.