The first thing to keep in mind when testing children with significant speech delays is that most standardized tests of intelligence will either be inappropriate or of questionable validity. Because language is such an important component of most tests of intelligence, it is nearly impossible to validly give those tests (such as the WISC-IV or WPPSI-III) in their entirety to children with significant communication disorders. That doesn’t mean that they aren’t given, and often they are given with good reason. However, the first consideration to keep in mind is that they would, at best, provide a crude comparison of a child’s ability in certain areas. The second consideration (and most important), is that these types of tests should never be used to make predictions about a severely language impaired child’s eventual functioning. We have evaluated countless children who were originally diagnosed with autism, mental retardation, or a pervasive developmental disorder because their scores on an intelligence test were impaired due to basic communication problems (either expressive or receptive or both).

Because language disorders vary widely in nature and are seen in a wide range of individuals from early childhood throughout adulthood, assessment is never simple and is often idiosyncratic. Keeping that in mind, there are some assessment considerations that can be somewhat generalizable. First, the examiner can modify the assessment to provide additional cues or assistance for the child (sometimes called “testing the limits”). Second, the examiner can pick certain tests that rely less on verbal skills.

“Testing the limits” occurs when an examiner goes beyond standard test procedures to gain additional information about a child’s abilities. Generally, examiners make few modifications when administering standardized tests because the tests are designed to be given in exactly the same way to each child. However, when a child has little or no speech or poor receptive language skills, we might modify instructions, modify the response format (e.g., allowing pointing instead of oral responses), or, in cases where the child’s speech is difficult to understand, allow the parents to serve as “translators.” Children with significant oral language problems should be allowed to use any means to communicate, including writing, typing, using a computer or another augmentative communication devise, pointing to letters, signing or gesturing. The information obtained when “testing the limits,” such as whether the child benefited from verbal cues, pointing, or repeating instructions, is often helpful in planning interventions. When tests are modified in this way, standardized norms can only be used as a rough guide and the results provide just an approximation of a child’s ability level.

In addition to these considerations, there are a number of assessment instruments that are designed for children with significant communication disorders. The Leiter-R, the Comprehensive Test of Nonverbal Intelligence, Raven’s Progressive Matrices, the Universal Nonverbal Intelligence Test (UNIT) and the Test of Nonverbal Intelligence (TONI-III) can be validity administered without having the child provide an oral response. The UNIT is administered using language-free gestures. Other good nonverbal tests include the Processing Speed and Perceptual Organization subtests from the WISC-IV, the Abstract/Visual Reasoning subtests of the Stanford Binet-IV, and the Spatial and Nonverbal Reasoning Clusters of the Differential Abilities Scale (DAS). Receptive language tests with multiple-choice picture responses include the OWLS Listening Comprehension Scale and some of the subtests from the Comprehensive Assessment of Spoken Language (CASL).

In general, when evaluating children with significant language impairments, the psychologist should tailor the assessment to the child’s individual functional needs or disabilities. Using a wide range of assessment instruments and using other sources of data such as observational and parent and teacher reports is crucial. While standardized tests are useful, more informal clinical judgments are important in these cases as well.

[Drs. Ellen Braaten and Gretchen Felopulos are the authors of Straight Talk About Psychological Testing for Kids. They are both on the faculty of Harvard Medical School and are child psychologists at the Massachusetts General Hospital. In addition, they have a private practice in Lexington, Massachusetts. Their web site, www.kidtesting.com, offers more information related to testing children with special needs.]

Clinical neuropsychology is the application of knowledge of brain-behavior relationships for assessment and treatment of a wide range of disorders. In children these disorders include outright neurological disease or injury, as well as conditions of presumed constitutional origin, such as learning disabilities, attention deficit hyperactivity disorder (ADHD), and speech and language impairment. Childhood apraxia of speech falls within the latter category of neurodevelopmental disorders. Neuropsychologists have a special interest in research on the neurological and genetic causes of these disorders. Their most unique clinical role is to examine childrens cognitive strengths and weaknesses. Although cognitive testing includes IQ, such global scores can hide important patterns of abilities and disabilities. For this reason, neuropsychologists evaluate a number of more specific abilities in the domains of language, perceptual-motor and spatial skills, memory, attention and executive functions, and problem solving. To determine how childrens cognitive abilities contribute to their learning and behavior, neuropsychological assessment also includes measures of academic achievement, behavior, and social adjustment.

Comprehensive neuropsychological assessment is useful in recognizing the deficiencies, as well as capabilities, that accompany apraxia. The pattern of childrens abilities, in turn, can help to account for the types of academic or behavior problems that children display at home and school. This information is valuable in fully appreciating the nature of childrens developmental problems, the reasons for these problems, and the types of interventions that will be needed to optimize childrens learning and day-to-day functioning. For example, children with apraxia frequently have weaknesses in academic achievement, attention, and organizational (executive) skills. By identifying these weaknesses, as well as strengths, and by examining behavioral and social adjustment, neuropsychological assessments provide a more complete picture of the childrens abilities and disabilities, as well as their efforts to cope with their limitations.

Because cognitive deficiencies identified earlier in development often forecast later learning difficulties, neuropsychological assessment is also useful in helping parents and teachers to anticipate future problems and establish longer-term educational plans. For example, deficits in remembering and manipulating phonological representations (as required, for example, to blend or segment spoken words or to rhyme) can lead to later difficulties in learning how to read. Similarly, early childhood problems in attention or executive functions can be manifest as poor study skills during adolescence, even in children who have functioned well in a structured elementary school program. Test findings that document such problems can make parents and schools aware of the need for preventative steps to reduce the impact of childrens deficiencies on future learning. Examples of these steps include additional academic instruction, efforts to teach the child organization skills, and accommodations that minimize frustration and encourage the development of compensatory strategies. At the least, anticipatory guidance can assist parents in monitoring development and in recognizing the signs of emerging problems, helping to insure that the problems can be managed in a more immediate and constructive fashion. Period neuropsychological follow-up may assist parents in tracking childrens development, but ongoing monitoring by parents and teachers is essential. The most critical times to be proactive are during transitions between educational settings, such as between elementary and junior or senior high, and between high school and entrance to post-secondary programs.

(Dr. Taylor is Professor of Pediatrics at Case Western University and in the Department of Pediatrics, Rainbow Babies & Childrens Hospital, University Hospitals of Cleveland in Cleveland, Ohio. His interests include both clinical neuropsychological assessments of children and research on the developmental outcomes of early brain insults. He is a Diplomate in Clinical Neuropsychology, American Board of Professional Psychology. He is supported by the National Institutes of Health to conduct research on the developmental consequences of childhood traumatic brain injury and low birth weight. He also collaborates with speech/language pathologist Dr. Barbara Lewis on an NIH-supported study of genetic influences on speech-sound disorders, including childhood apraxia of speech. Dr. Taylor is a member of Apraxia Kidss Professional Advisory Board.)

I am neither a psychologist, speech-language pathologist, or a lawyer. However, as a parent of an apraxic child I have had to make decisions about psychological testing and have had to deal with school officials seeking evaluations of my daughter. What I have learned about psychological testing and related legal issues has come from a variety of sources, including reading professional articles, discussions with psychologists and speech-language pathologists, and material I have gleaned from the Internet. Although I am not a health professional or attorney, I feel that I have learned a lot in my role as a parent and advocate for my child and would like to share what I have learned. Following are common questions regarding psychological testing of apraxic children and some information and opinions on each.

What is the purpose of psychological testing?

Psychological testing of young children is geared toward assessing several domains including behavior, communication, cognitive, adaptive, and social-emotional functioning. Cognitive assessment tends to get the most attention from parents and teachers, perhaps because of their familiarity with IQ scores. However, a good assessment should do more than just provide an IQ score.

Like any assessment, appropriate psychological testing can help identify areas of strength and weakness. By identifying specific deficits one can better target interventions and design teaching strategies that will maximize a child’s potential. In addition to identifying a child’s strengths and weaknesses, schools may also seek psychological testing for two interrelated administrative purposes.

First, a school may want to determine if a child is mentally handicapped for classification and placement purposes. Reliance on IQ scores to make long-term educational decisions for apraxic children is problematic, however. Love (1992) notes that the rate of mental growth is uneven in neurologically impaired populations and thus questions the predictive value of IQ exams for apraxic children.

Second, some schools use psychological testing to identify language impaired children. In the past, a common way of identifying language impairment was to look for discrepancies between IQ and performance on language evaluations. If language scores were significantly below a child’s IQ score then this was seen as evidence of language impairment. Children with both low language scores and low IQ scores were judged mentally handicapped. This “discrepancy approach” has been harshly criticized in the recent literature (Aram, Morris and Hall (1992) and Francis, et al. (1996)), yet remains part of the identification criteria in many state regulations (Casby (1992)).

What psychological tests are appropriate for apraxic children?

Most standard IQ exams are designed for children who do not possess any language or motor impairments. If someone has an overt specific language impairment, standard IQ testing will produce misleading estimates of intellectual functioning because of the verbal loading of instructions and the verbal nature of the tasks required. Many researchers agree that the performance of language impaired children on verbal IQ tests is hampered by poor communication skills and thus a standard IQ test may yield a biased assessment of the child’s general cognitive abilities (Swisher, Plante and Lowell (1994), Francis, et. al. (1996)). In particular, apraxic children will often score low on the verbal subtests of a standard IQ exam due to word finding problems and other expressive delays associated with apraxia.

While use of a single standard (verbal) IQ exam with an apraxic child is problematic, there are at least two alternative testing strategies. The best alternative strategy depends both on the goals of psychological testing and the presence of nonlinguistic disabilities, such as fine motor problems. If a single “IQ score” is not necessary for administrative purposes, then an eclectic approach to testing may be most appropriate. Love (1992) advocates employing selected measures from a variety of psychological batteries in order to evaluate various neuropsychological variables. Multiple tests, some of which differ systematically in their verbal, motor, or specific perceptual loadings, are used in combination in order to derive patterns of assessment findings. For example, one test might be used to evaluate higher cortical functions while parts of other tests could be employed to evaluate auditory and visual memory, fine motor and graphomotor skills, and academic achievement. An advantage of this eclectic approach is that language-laden components of particular exams can be avoided. Similarly, if the child has motor disabilities besides apraxia, subtests from different assessment batteries can be selected which will not be unduly influenced by the child’s motor deficits.

If a single “IQ Score” is deemed essential and the apraxic child does not have significant fine motor delays, a “nonverbal” IQ test may work well. Although nonverbal IQ tests are likely to give a more accurate measure of a language impaired child’s cognitive abilities than standard (verbal) IQ tests, no IQ test is completely language-free. For example, recent studies indicate that language-impaired children perform worse than non-impaired children on nonverbal IQ tests. Even among language impaired children, measured IQ varies across different nonverbal tests (Swisher, Plante, and Lowell (1994)). The nonverbal tests typically involve lots of fine motor skills (e.g. matching block patterns, manipulating puzzles, etc.) and thus would not be appropriate for a child with motoric problems.

In addition to direct testing of the child, psychological evaluations of children typically involve some sort of parental interview of the child’s behavior and abilities. Perhaps the most widely used is the Vineland Adaptive Behavior Scales. Others include the Child Behavior Checklist, Connor’s Parent Rating Scales and the Woodcock-Johnson Adaptive Behavior Profile. Such parental interviews can be an important component of the evaluation because they provide a much longer observation period than one or a few testing sessions with a psychologist.

Whatever the particular test or set of exams chosen, a crucial element is the judgment of the psychologist who performs the assessment and evaluates the test results. Any assessment, including intellectual, is only a sample of behavior. Particularly with younger children, test results can be affected by nontest factors like failure of preschool children to understand the test situation, fluctuating mood, etc. Similarly, some tests may allow questions to be repeated or permit additional response time, which could impact the scores of apraxic children. It is therefore crucial to have an experienced and competent practitioner who will thoughtfully administer tests and interpret the test results in light of relevant variables. A good psychologist should help a parent understand what the scores mean and why the child achieved the scores he or she received.

What nonverbal IQ tests are available?

While there are a number of nonverbal IQ tests, the three most popular tests seem to be the Kaufman Assessment Battery for Children (Kaufman-ABC), the Leiter International Performance Scale (Leiter), and the Test of Non-Verbal Intelligence 2 (TONI-2).

The Kaufman-ABC, developed by Alan Kaufman, is generally considered a measure of cognitive intellectual abilities. The Kaufman-ABC is intended for children ages 2.5 to 12.5 and is of relatively recent origin. The Kaufman-ABC emphasizes mental processing and provides an estimate of overall ability (Mental Processing Composite) as well composite measures of Simultaneous and Sequential Processing. The Kaufman-ABC has a nonverbal scale as well as an achievement section. The Kaufman-ABC has been examined in a number of different populations including speech-language impaired children. Psychologists say that the K-ABC is a fun test for children and seems to hold their interest. It appears to correlate well with standard verbal intelligence tests such as the WPPSI-R and Stanford Binet. A speech-language pathologist who has done research on IQ testing of speech-language impaired children thinks it is one of the fairest (assuming the child has no fine motor problems).

The Leiter has been around a long time and has a much narrower scope than the Kaufman-ABC. If anything, it may place language-impaired children overly high (see Swisher, Plante, and Lowell (1994)). The Leiter looks at conceptual ability but does not require speech responses. The child must solve puzzle type problems using visual, spatial, and some language based reasoning. Basically the examiner has a device on which they can put small squares with different images and the child is then asked to match the squares placed by the evaluator from the small squares placed in front of the child. The lowest level involves direct matching (e.g. red square to red square) and then the test proceeds to move to higher and higher levels of abstraction. There is some fine motor skill involved in that the child does have to place the square below the evaluator’s square. The test does not take long to administer, but does take some sustained attention from the child. A Leiter has recently been revised and a new, more substantial test, called the Leiter-R is now available.

The TONI-2 is designed for ages 5-0 and up. The items include problem-solving tasks that increase in difficulty. Each item presents a set of figures in which one or more components are missing. The test items include one or more of the characteristics of shape, position, direction, rotation, contiguity, shading, size, movement, or pattern. The subject must examine the differences and similarities among the figures, identify one or more problem-solving rules that define the relationship among the figures, and then select a correct response. The test requires a relatively short administration time, usually no more than 10 to 15 minutes. The TONI-2 was normed on a large, representative sample of more than 2,500 subjects. Evidence of both internal consistency and stability reliability are provided for normally achieving subjects and also for populations of persons who are mentally retarded, learning disabled, deaf, or gifted. Reliability coefficients exceed accepted standards at most age intervals. Substantial empirical evidence relating to the validity of the TONI-2 has accumulated and the relationship of TONI-2 scores to a variety of other tests has been established.

Should I Pay for a Private Psychological Evaluation?

As with speech-language evaluation, there are two potential advantages to having psychological evaluation performed privately, rather than relying on schools for testing. First, private evaluation gives the parent the choice of who is to perform the evaluation. Both school based and private psychologists vary in their experience working with language-impaired children. Finding a psychologist who has worked with apraxic or other neurologically impaired children is important. An experienced psychologist will have a better idea of what tests are appropriate and how a child’s disabilities can impact particular psychological tests. Second, with private testing a parent can control who sees the test results; the parent can choose whether results of a particular test are made available to school officials. Having a private evaluation performed is no guarantee that a school will not seek to perform their own testing, however. Schools are required to consider the results of any private evaluations when making decisions about special education placement and services. However, schools may still seek to have additional testing performed if they believe the private testing is inadequate.

What are my child’s legal rights regarding psychological testing for special education?

The federal law which governs special education is known as the Individuals with Disabilities Education Act, or IDEA. It was reenacted in the Spring of 1997. The Individuals with Disabilities Education Act Amendments of 1997 specify a number of safeguards that are relevant to psychological testing. First, parents must be notified of testing and give consent to administration of tests for either an initial special education evaluation or subsequent reevaluation (under the old law parental consent was only required for initial evaluations). Section 614 of the 1997 IDEA states:

“The local educational agency shall provide notice to the parents of a child with a disability, in accordance with subsections (b)(3), (b)(4), and (c) of section 615, that describes any evaluation procedures such agency proposes to conduct.”

“The agency proposing to conduct an initial evaluation to determine if the child qualifies as a child with a disability as defined in section 602(3)(A) or 602(3)(B) shall obtain an informed consent from the parent of such child before the evaluation is conducted. … If the parents of such child refuse consent for the evaluation, the agency may continue to pursue an evaluation by utilizing the mediation and due process procedures under section 615, except to the extent inconsistent with State law relating to parental consent.”

“Each local educational agency shall obtain informed parental consent, in accordance with subsection (a)(1)(C), prior to conducting any reevaluation of a child with a disability, except that such informed parent consent need not be obtained if the local educational agency can demonstrate that it had taken reasonable measures to obtain such consent and the child’s parent has failed to respond.”

Section 614 also outlines the procedures that must be followed when psychological or other testing is done. Specifically, a single IQ score can not be the sole criteria for a placement decision: “In conducting the evaluation, the local educational agency shall– use a variety of assessment tools and strategies to gather relevant functional and developmental information, including information provided by the parent, that may assist in determining whether the child is a child with a disability and the content of the child’s individualized education program … ; not use any single procedure as the sole criterion for determining whether a child is a child with a disability or determining an appropriate educational program for the child;”

Any tests, including psychological tests, must be fair and provide a valid assessment. Specifically, section 614 states that evaluations must:

“use technically sound instruments that may assess the relative contribution of cognitive and behavioral factors, in addition to physical or developmental factors. … Each local educational agency shall ensure that tests and other evaluation materials used to assess a child under this section … are provided and administered in the child’s native language or other mode of communication, unless it is clearly not feasible to do so; and … any standardized tests that are given to the child have been validated for the specific purpose for which they are used”

If a parent does not agree with the evaluations performed by a school, they have a right to have independent assessments performed. Section 615 of the IDEA states:

“The procedures required by this section shall include an opportunity for the parents of a child with a disability to examine all records relating to such child and to participate in meetings with respect to the identification, evaluation, and educational placement of the child, and the provision of a free appropriate public education to such child, and to obtain an independent educational evaluation of the child”

Suggested Further Reading:

• Aram, Morris, and Hall, “The Validity of Discrepancy Criteria for Identifying Children with Developmental Language Disorders,” Journal of Learning Disabilities, v. 25, pp. 549-554 (November 1992).
• Casby, Michael W., “The Cognitive Hypothesis and Its Influence on Speech-Language Services in Schools,” Language, Speech, and Hearing Services in Schools, v. 23, pp. 198-202 (July 1992).
• Francis, David J., et al., “Defining Learning and Language Disabilities: Conceptual and Psychometric Issues With the Use of IQ Tests,” Language, Speech, and Hearing Services in Schools, v. 27, pp. 132-143 (April 1996).
• Swisher, Plante, and Lowell, “Nonlinguistic Deficits of Children With Language Disorders Complicate the Interpretation of Their Nonverbal IQ Scores,” Language, Speech and Hearing Services in Schools, v. 25, pp. 235-240 (October 1994).
• Love, Russell J., Childhood Motor Speech Disability, New York: Macmillan Publishing Company (1992).