RESEARCH UPDATE REVIEW This series of 10-year updates in child and adolescent psychiatry began in July 1996. Topics are selecred in consultation with the AACAP Committee on Recertification, both for the importance of new research and its clinical or developmental significance. The authors have been asked to place an asterisk before the five or six most seminal references, MKD. Psychological Testing for Child and Adolescent Psychiatrists: A Review of the Past 10 Years JEFFREY M. HALPERIN, PH.D., AND KATHLEEN E, MCKAY, Px.D. ABSTRACT (Objective: To provide a review of psychological tests often used with chien and adolescents. Method: A description cf how psychological tests are used and how to interpret various types of scores is provided. Subsequently, psy- chological tests used to assess inteligence, academic achievement, naurepsychologieal functions, and personality are reviewed. Results: There are numerous woll-normed, rllable, and val inetruments that are availabe for assessing intellectual and academic functioning in children and adolescents. Nouropsychological tests, designed to assess ‘objectively a wide range of cognitive functions, are avaiable and extremely useful for designing treatment plans for patients with cognitive dificulties. Despite thelr populaily, most projective tests have relatively weak psychometric data ‘supporting their reliabity and/or validity. Conclusions: Psychological testing provides objective measures of behavior that are of considerable utility for evaluating children and adolescents, However, psychological test data, in isoaton, will rarely be adequate for providing a DSM diagnosis, and test scores are best inoxpreted inthe context of other clinical ata, Psychological test data can be very usetul for developing a comprehensive treatment plan that addresses the Patient's cognitive and emotional needs. J. Am. Acad. Child Adolesc. Psychiatry, 1998, 37(6)'575-584, Key Words: inteligence testing, academic achievement, neuropsychoiogical testing, personality assessment, projective tests This article will provide a review of psychological tests that are often used with children and adolescents, high- lighting more recently developed or revised instru- ments. The focus will be on tests of intelligence, academic achievement, personality, and neuropsycho- logical functioning. Space limitations preclude a com- prehensive review of all psychological tests or even an in-depth review of any individual test, but several books provide comprehensive reviews of psychological assess- ment instruments (e.g., Anastasi and Urbina, 1997; ‘Kamphaus and Frick, 1996). Accipied Ocrober 2, 1997. ‘Dr Halperin is withthe Pychlogy Deparment, Queens Cale ofthe City Univers of New Yr, Fishing and he Phe Deparment, Mount Sina Schwa of Medicine, Naw Yok, Dr McKay swith he Pyciary Department Mors Sinai Schl of Medicine Reprise requ 10 Dr Halperin, Pycholgy Department, Queens Calle (65-30 Kisena Bled, Pshing NY 11367. '0890-8567/98/3706-0575/S03,00/001998 by the American Academy (of Ohild and Adolescent Paychiatry J. AM, ACAD. CHILD ADOLESC, PSYCHIATRY, 37:6, JUNE 1998 Furthermore, this review will not cover behavior rating scales and personality inventories because the data they generate are qualitatively differenc from data derived from objective psychological testings. Unlike rating scales, which provide direct (although subjective) information about how an individual functions within his/her environment, psychological tests do not measure functioning in the natural environment and, only rarely, provide direct evidence about the presence or absence of psychiatric symptoms. Rather, psychological testing provides objective measures of behavior and/or func- tions derived in a “laboratory-like” setting. Psycholog- ical testing is particularly good for assessing current cognitive or emotional status, what someone has learned, and/or a person’ thinking process. Test data are best interpreted in the context of a comprehensive clinical evaluation and cannot, in isolation, provide DSM Axis I diagnoses. This is not to say that psy- chological resting cannot be useful for determining diagnosis or for clarifying etiological factors. However, 575HALPERIN AND McKAY such determinations generally require clinical inferences that go beyond the test data. Psychological testing is more often useful for assessing aspects of a child's cognitive ot emotional status that may have important tions for treatment planning rather than for differential diagnosis per se. UNDERSTANDING TEST SCORES Before discussing specific psychological tests, we will present a brief review of how to interpret test scores. Psychological testing reports rarely refer to raw scores, which indicate the number of items correct (or number of errors). Rather, they provide scores that indicate how performance relates to that of similar others on the same measures. For example, knowing that a 10-year- old child correctly answered 41 of 50 questions on atest means little unless you know how 10-year-olds in general perform on the same measure. ‘There are three common methods for reporting per- formance on psychological tests: developmental scores, percentiles, and standard scores. In somewhat different ways, each of these reflects performance relative to that of others. The most common developmental scores are “mental age” and “grade equivalents,” although many tests provide age-equivalent scores. The primary strength of developmental scores is their descriptive appeal. Hearing that Johnny has a mental age of 7 years, or a thitd grade reading level, provides what seems to be a vivid picture of where Johnny stands within these domains. Yer one must be cautious when interpreting developmental scores which, unlike chronological age, ate not on a ratio of even an interval scale of measure ment. The unit of measure on developmental scales systematically shrinks with age. A 5-year-old child functioning at the 3-year-old level might be quite impaired, whereas a 12-year-old functioning at the 10- year-old level might be only moderately behind. The -rence in functioning between a 19- and 17-year old. might be meaningless. Thus, at different ages, discrep- ancies in developmental scores mean different things. Furthermore, developmental scores provide little infor- ration about the variability of test performance, which often varies across ages. Thus, within a given measure, how much do normal 10-year-olds vary around a 10- year-old age score? Percentile scores provide an index of where one stands relative to others on a scale of 1 to 100. Importantly, a score at the first or 100th percentile does 576 not mean that the person got all of the questions on the test right or wrong. Rather, it means that the individual performed worse or better than everybody else in the ‘comparison group. If the comparison group is made up of children of similar age, percentile scores have the advantage over developmental scores of maintaining their meaning at different ages. Nonetheless, like devel- ‘opmental scores, percentile scores are on an ordinal scale, The unit of measure varies across the range. There is relatively litle difference between scores at the 40th and 60th percentiles (these are equivalent to IQ scores of approximately 96 and 104, respectively), but a 20- point difference near cither tal of the distribution will be substantial (eg., the Ist and 21st percentile equal IQ. scores of about 65 and 88, respectively) In contrast, not only do standard score scales have the advantage of being indicative of performance rel- ative to others, but the unit of measure remains con- stant across the range of scores. Standard score scales report scores in standard deviation (SD) units from the normative samples mean. Some tests report z scores, which ditectly indicate SD units. Thus, a z score of 0 ‘means that the child scored exactly at the mean of the normative sample, a score of +1.0 means the child scored 1 SD above the mean, and a score of -0.2 means that the child scored 0.2 SD below the mean as assessed via the normative sample. Most tests, however, do not present scores as z scores. Rather, a wide artay of stand- ard score scales are used which can all be interpreted in the same manner. Whereas a z score reflects perform- ance on a scale with a mean of 0 and SD of 1, an IQ. score is more likely to be on a scale with a mean of 100 and SD of 15 or 16. To follow the example above, someone who scored exactly at the mean of the normative sample would receive an 1Q score of 100. Someone scoring 1 SD above the mean would receive an 1Q score of 115 (or 116), and someone scoring 0.2 ‘SD below the mean would receive an IQ score of 97 .e., 0.2 X 15 = 3). Thus, to interpret standard scores, ‘one must know the mean and SD of the scale on which it is based. ASSESSMENT OF INTELLIGENCE Intelligence tests usually provide an estimate of global cognitive functioning as well as information about functioning within more specific domains. Compared to measures of virtually all other human trait, intelligence test scores are quite stable. However, J. AM. ACAD. CHILD ADOLESC, PSYCHIATRY, 37:6, JUNE 1998the degree of stability increases with age such that early childhood and preschool measures of intellectual function are far less predictive of later functioning than assessments taken during middle childhood. Further- more, despite their relative stability, intelligence test scores may change as a function of important environ- mental factors. Therefore, intelligence test scores are descriptive of a child’ Functioning at that point in time. This could change with alterations in the child’s psy- chiatric status, environmental conditions, or educa- tional program. The Wechsler Scales ‘The Wechsler intelligence scales are the most popular among intelligence tests (Watkins et al., 1996; Wilson and Reschly, 1996), and therefore they will be described in greater detail than others. There are three different ‘Wechsler intelligence tests that are structurally similar but differ with regard to the target age-range. The Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSLR) (Wechsler, 1989) is the most recent version of the test normed for ages 3 to 7.3 years; the Wechsler Intelligence Scale for Children-Third Edition (WISC-II}) (Wechsler, 1991) is normed for ages 6 to 16 years, 11 ‘months; and the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III) (Wechsler, 1997) is normed for ages 16 through 74 years, All three are well-normed rests with considerable data supporting their reliability and validity. ‘The Wechsler tests generate three major IQ scores: Verbal 1Q (VIQ), Performance IQ (PIQ), and Full Scale IQ (FSIQ). These are all deviation 1Q scores stan- dardized by age with a mean of 100 and SD of 15. Classification ranges are provided in the manuals such that the “average” range is considered to be between 90 and 109. “High average” is considered to be 110 to 119; “superior” is 120 to 129; and “very superior” is 130 and greater. Going downward, “low average” is between 80 and 89; “borderline” is 70 to 79; and the “intellectually deficient” range is below 70. These tests are not particularly sensitive to individual differences below the “mildly deficient” range (ie., 2 to 3 SD below the mean). Furthermore, as discussed below, mental retar- dation should not be diagnosed only on the basis of data from an intelligence test. The individual must also be assessed by a measure of adaptive function ‘The Verbal and Performance scales of all three ‘Wechsler intelligence tests are composed of subtests which are scaled with a mean of 10 and SD of 3, and J. AM. ACAD, CHILD ADOLESC. PSYCHIATRY, 37:6, JUNE 1998 PSYCHOLOGICAL TESTING they generate scores ranging from 1 to 19 (ie., #3 SD from the mean). All Verbal subtests are administered orally by the examiner and require a verbal response from the examinee. They require no reading or writing by the examinee, they do not involve manipulation of objects, and other than the Arithmetic subtest, all Verbal subtests are untimed. The Verbal subtests vary considerably with regard to the content of the material ascertained as well as the relative degree of receptive and expressive linguistic demands. For example, questions on the Information and Arithmetic subtests can generally be answered accurately with a one- or ewo- word response, whereas the Vocabulary, Similarities, and Comprehension subtests frequently require lengchy explanations. With regard to receptive skills, several questions on the Arithmetic and Comprehension sub- tests are semantically and syntactically complex, whereas those on the Vocabulary and Similarities subtests involve a single word oF two words, respectively. The Performance subtests primarily involve visual perceptual organization, motor speed and coordination, and visual-motor integration, along with reasoning abilities. All Performance subtests are timed. Importantly, Performance casks are not unaffected by poor verbal abilities. Instructions are verbally administered and many of the tasks can be best performed using verbal mediation. When interpreting Wechsler scores one typically looks initially at the FSIQ score, followed by VIQ-PIQ discrepancies, and finally patterns of subtest scater. The FSIQ may be the single best indicator of overall functioning, but this is only true when there is not a significant difference berween VIQ and PIQ scores. In the context of large VIQ-PIQ differences, the FSIQ may be of little utility. In general, large discrepancies between the VIQ and PIQ are suggestive of uneven development across domains of function. Although there is some variability across ages, for the WISC-III, differences of approximately 11 points are statistically significant at the .05 level. Yet large differences are not necessarily pathological. More than half of the children in the standardization sample for the WISC-III had VIQ-PIQ discrepancies greater than 9 points, and about 25% had discrepancies of 15 points or greater (Wechsler, 1991). Nonetheless, large differences may be indicative of language (where the VIQ is lower) or perceptual motor (where the PIQ is lower) problems. Further analysis of subtest scatter is often based on the factor structure of the subtests. The WISC-III sub- 577HALPERIN AND McKAY tests are best accounted for by a four-factor solution: Verbal Comprehension, Perceptual Organization, Freedom From Distractibility, and Processing Speed (Wechsler, 1991). While poor performance on one or more of these factors is not diagnostic, it may be indicative of difficulties within that domain. Typically, children with language disabilities perform poorly on the Verbal Comprehension factor. Children with attention-deficit/hyperactivity disorder and/or learning disabilities perform poorly on the Freedom From Distractibility and Processing Speed factors (Wechsler, 1991). Yer children may perform poorly on Wechsler subtests for a variety of reasons. Furthermore, the relia- bilicy (and thus the measurement error) of che subtests is not neatly that of the major scales. The reliability (averaged across ages) for WISC-III subtests varies from a low of 0.69 for Object Assembly, to a high of 0.87 for the Vocabulary and Block Design subtests. In contrast, the reliability values of the VIQ, PIQ, and FSIQ scores are 0.95, 0.91, and 0.96, respectively. Therefore, inter- pretations based on subtest patterns should be made with caution and only in the context of other sup- porting clinical and psychometric daca Stanford-Binet inteligence Scale The Fourth Edition of the Stanford-Binet (SB-IV) (Thorndike et al., 1986) represents several advances over previous versions of this first-of-all intelligence tests, Like the Wechsler tests, che SB-IV is an individ- ually administered test that requires extensive training to administer. Ie is well-normed for ages 2 through adulthood, thus allowing assessment of younger chil- dren than does the WPPSL-R. ‘The SB-IV is composed of 15 tests which are divided into four cognitive areas: Verbal Reasoning, Abstract! Visual Reasoning, Quantitative Reasoning, and Short- term Memory. However, all 15 tests do not span the SB-IV age/difficulty range. Thus, no individual is administered all 15 tests. The SB-IV no longer uses the term “IQ,” and instead it generates “Standard Age Scores” with a mean of 100 and SD of 16 for each of the four cognitive areas and a composite score. The Standard Age Scores for the individual subtests have a mean of 50 and SD of 8. The normative data for the SB-IV are quite good in that the sample characteristics closely represent U.S. census data, reliability coefficients are excellent, and validity data indicate high correlations with other 578 intelligence tests, with older versions of the Stanford- Binet, and with measures of academic achievement (Thorndike et al., 1986; Laurent et al., 1992). Ie is an excellent, well-normed test that is particularly useful for assessing gifted children in that its ceiling is quite high. However, similar to the Wechsler scales, there are floor cffects, rendering it less sensitive for assessing varying levels of mental retardation, especially in the younger age groups. Kaufman Assessment Battary for Children The Kaufman Assessment Battery for Children (K- ABC) (Kaufman and Kaufman, 1983a) was designed for uses similar to that of the Wechsler and Sranford- Binet tests. However, the K-ABC was designed from 2 theoretical orientation which posits a distinction between information that is processed via simultaneous versus sequential processing (Kaufman and Kaufman, 19836). Simultaneous processing is used on infor- mation that is presented in its entirety or as a whole. Sequential processing is used on temporal or succes- sively presented information. In general, the Simultan- cous subtests are visually presented perceptual tasks, ‘whereas che Sequential rasks are more likely to involve verbal processing, memory, and/or sequential move- ments. As such, it could be argued that the model does not hold up particularly well in practice and that the discinetion across scales may be mote modality- than process-related. The test, which is well-normed for ages 2 to 12% years, generates a General Cognitive Index along with separate scores for Simultaneous Processing, Sequential Processing, and Achievement. These scores are stand- ardized with a mean of 100 and SD of 15. Separate sub- test scores for the Simultaneous and Sequential scales are normed with means of 10 and SDs of 3, whereas the Achievement scale subtests are normed with a mean of 100 and SD of 15. In addition to ies distinct theoretical ‘orientation, the K-ABC differs from the Wechsler and SB-IV scales in several ways. Fits the items tend to be more colorful, child-oriented, and engaging for chil- dren, Second, an important difference exists in the manner in which the subtests are presented. Similar to other tests, each subtest is preceded by carefully worded instructions for the child. Unlike the others, however, the K-ABC manual instructs the examiner to use the initial items to teach the child what he/she must do if the task demands (as opposed to content of the material) J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 37:6, JUNE 1998are not clearly understood. Third, the nature of the sub- tests are different; they are more “neuropsychological- like.” That is, hey are more specific to specific processes. Finally, this tese distinguishes itself from the WISC-III and SB-IV in that its two cognitive scales (Sequential and Simultaneous) require minimal language skills on the part of the child. As such, scores are less likely to be influenced by cultural and linguistic factors. Two more recently developed Kaufman scales are the Kaufman Adolescent and Adult Intelligence Test (KAIT) (Kaufman and Kaufman, 1993) and the Kaufinan Brief Intelligence Test (K-BIT) (Kaufman and Kaufman, 1990). The KAIT, which was developed for ages 11 to 85 years, distinguishes between crystallized and fluid abilities. Crystallized abilities are presumably related to what one has learned, either through his/her environment or through schooling, whereas fluid abil- ities relate to one’s capacity to solve novel problems. To date only limited research on the validity of this instrument has been conducted. Yet one attribute of this testis the nature of the subtests and items, which are generally unique in character and of greater interest to most adults than items on other intelligence tests. The K-BIT is a screening instrument designed to estimate intellectual functioning for ages 4 through 90 years. It is composed of a Vocabulary test, which is divided into “Expressive Vocabulary” and “Definitions,” and a separate “Matrices” subtest. The limited scope of this test makes it less appealing as a clinical instrument. Yer it may be useful for research scudies in which a quick assessment of overall cognitive function is needed to characterize the sample. Infant Assessment Several of the tests described above are appropriate for assessing preschool children, but none are adequate for testing infants. The second edition of the Bayley Scales of Infant Development (Bayley-II) (Bayley, 1993), which is the most commonly used test for assess- ing infants (Wilson and Reschly, 1996), consists of three subsections: Mental Scale, Motor Scale, and Behavior Rating Scale. The Mental Scale assesses responsivity to environmental stimulation, as well as an array of sensory/perceptual, memory, learning, and early language/communication abilities. The Moror Scale assesses both gross and fine motor skills. The Behavior Rating Scale is not an objective psychological test, but rather a rating of several behaviors that the J. AM. ACAD, CHILD ADOLESC, PSYCHIATRY, 37:6, JUNE 1998 PSYCHOLOGICAL TESTING clinician bases on information gathered from the parent and from his/her own observations. ‘The Bayley-II has norms based on 1,700 children, broken down into 17 different age groups (50 boys and 50 girls) between 1 and 42 months. The Mental and Motor scales yield separate standardized scores with a mean of 100 and SD of 15. The Behavior Rating Scale yields a percentile score which gets translated into one of three categories: Non-Optimal, Questionable, or Within Normal Limits. ‘As mentioned earlier, the stability of cognitive func- tion increases with age. As such, the predictive ability of the Bayley-II is limited, This instrument should be used to assess current developmental level, not to predict later potential. Thus, for children within the “normal” range this test provides only limited utility. However, among the ever-increasing population of “high-risk” children (due to pre- and/or perinatal complications, substance abuse, prematurity), thi of substantial value for assessing current function and strument may be determining early intervention strategies. ‘Assessment of Mental Retardation Over the past few decades, conceptual and political changes have had substantial impact on the assessment of mental retardation, OF particular relevance to this review is the position that intelligence tests alone should not be used to diagnose mental retardation. Rather, ic is essential that a measure of functional ability is used in addition co an intelligence test. Although itis common, practice to consider a person scoring more than 2 SD below the mean on an intelligence test as mentally retarded, such individuals vary considerably in their degree of functional impairment. Furthermore, most intelligence tests have difficulties with floor effects. As such, they lack sensitivity to varying degrees of mental retardation. ‘Two instruments are particulaely useful aids for the assessment of mentally retarded people: the Vineland Adaptive Behavior Scales (Sparrow et al., 1984) and the second edition of the American Association of Mental Retardation Adaptive Behavior Scales (Lambert et al, 1993). These scales assess functional capacities in a wide array of domains including daily living skills, com- munication skills, and socialization. Several versions of these scales exist, but most are administered as semi- structured interviews to a caregiver. These scales have good norms, reliability, and validity, and they are 579HALPERIN AND McKAY generally far more useful for setting up a treatment plan for mentally deficient people than are standard intel- ligence tests. ‘Assessment of the Physically Handicapped Increasing societal awareness of the needs of hand- icapped persons has facilitated advances in psycho- logical testing for handicapped individuals. Assessment of hearing-impaired children is complicated not only by their sensory loss, which can be dealt with by admin- istering orally presented verbal items in written format, bur also by the language deficits that often accompany carly hearing loss. One approach to this complication is to use performance-type subtests from various intelli- gence tests. However, only limited research related to the validity of these scales with this population has been conducted (Maller and Braden, 1993). A more appro- priate method may be through the use of the Hiskey Nebraska Test of Learning Aptitude (Hiskey, 1966). This tese was developed and standardized on samples of hearing-impaired children and children with adequate hearing, and it is normed for ages 3 to 17 years. The test, which is untimed, assesses a wide range of cogni- tive functions. Instructions are presented primarily through the use of pantomime and practice exercises. ‘Assessment of visually impaired individuals is commonly done through the use of verbal—and elimination of performance—tests from standard intelligence tests. For example, the Wechsler scales have been modified for blind examinees through the elim- ination of the Performance scale and the few Verbal scale items that require sight. Several adaptations of the Stanford-Binet have also been developed and normed for visually impaired individuals. The most recent of these is the Perkins-Binet Test of Intelligence for the Blind (Davis, 1980). (Cross-Cultural Testing “The use of psychological testing with children from diverse cultures has increased in recent years. Although no test is free of all cultural influences, attempts have been made to make culture-fair tests. These tests limit or avoid completely the use of language, timing, reading, and stimuli chat may have greater familiarity in ‘one culture relative to another. As described above, the K-ABC uses less language than the WISC-III and may have greater validity with children of non—English- speaking backgrounds. However, it still uses speed and 580 several stimuli characteristic of American/Western cultures. In contrast, the Leiter International Performance Scale-Revised (Roid and Miller, 1997) is an untimed test, which is normed for ages 2 to 20 years, and is administered using essentially no verbal instructions. Each set of items begins with a simple example which is prompted through pantomime. This revised version covers four domains of functioning: Reasoning, Visuali- zation, Attention, and Memory. Unlike its predecessor, the revised Leiter generates standard scores rather than the cruder ratio IQ scores ‘Another test that is relatively free of cultural biases is the Ravens Progressive Matrices (Court and Ravens, 1995). This test comes in three forms, two of which are appropriate for use with children: the colored Progressive Matrices (normed for ages 5} to 11 years) and the Standard Progressive Matrices (normed for ages 6 to 80 years). The Ravens Matrices are administered in a multiple-choice format. The test begins with simple visual discrimination and gradually moves to more difficult perceptual analogies and reasoning problems. ‘The Ravens Matrices are untimed and can be admin- istered using virtually no language. ACADEMIC ACHIEVEMENT TESTS. ‘Academic achievement tests have a wide range of uses including the assignment of grades, identification of special needs for remediation, and assessment of progress. High-quality, group-administered general achievement batteries are typically administered by schools. Examples of these are the California Achieve- ment Tests, the Comprehensive Tests of Basic Skills, the IOWA Tests of Basic Skills, the Metropolitan Achieve- ment Tests, and the Stanford Achievement Tests. These tests have excellent norms and psychometric properties and are often quite useful for identifying children with educational deficits However, individually administered tests of academic achievement are generally warranted for children with cognitive, emotional, and/or learning problems because these characteristics frequently have a negative impact on the child’s performance within the group format. Furthermore, the individualized assessment, which is carefully structured and observed by the clinician, is likely to provide a more detailed assessment of the nature of the child's difficulties along with a profile of strengths and weaknesses. Finally, individualized assess- J. AM, ACAD, CHILD ADOLESC. PSYCHIATRY, 37:6, JUNE 1998‘ments are particularly useful for determining the pres- ence of a learning disability and to highlight specific achievement-related deficiencies that may be targeted for treatment. There are numerous well-normed individualized tests of academic achievement. Three of the most popular (Watkins et al., 1996; Wilson and Reschly, 1996) will be reviewed here: the Wide Range Achievement Test 3 (WRAT3) (Wilkenson, 1993), the Wechsler Individual Achievement Tests (WIAT) (Psychological Corporation, 1992), and the Woodcock-Johnson Psychoeducational Battery-Revised (Woodcock and Johnson, 1989). ‘The WRAT3 contains separate tests of rcading/ decoding, spelling to dictation, and arithmetic. The test is normed for ages 5 through 75 years and ranges in difficulty level from preschool skills (eg, recognizing/ naming letters, counting) through problems that are beyond high school level. Unlike most other tests, the ‘WRATS contains matched forms of each test, making it useful for retesting after remedial intervention. Whereas the WRATS is generally adequate for assessing a child’s level of function in the basic skills of decoding words, spelling, and arithmetic, and thus for assessing the presence of a learning disability, its narrow range of focus is limiting with regard to elucidating more subtle aspects of learning difficulties such as reading com- prehension, language difficulties, and writing problems. The WIAT is an individually administered achieve- ment battery that was developed and normed (for ages 5 to 19 years) along with the WISC-III. This facilitates the ability to draw comparisons between a child's intellectual and academic functioning, which is an important component of diagnosing most specific developmental disorders as defined by DSM-IV. The WIAT has two separate recommended formats for administration. The WIAT Screener consists of three tests: Basic Reading, Spelling, and Mathematics Reasoning. The Screener, which can usually be admin- istered in less than 20 minutes, provides limited infor- mation similar to that generated by the WRAT3. However, for a more comprehensive assessment of academic achievement, the full WIAT contains additional cests of Reading Comprehension, Numerical Operations, Listening Comprehension, Oral Expres- sion, and Written Expression. These latter tests, which may be necessary only for children wich known or sus- pected learning disabilities, provide a picture of the child's abilities in a wider range of academic domains. J. AM, ACAD. CHILD ADOLESC. PSYCHIATRY, 37:6, JUNE 1998 PSYCHOLOGICAL TESTING Among the most comprehensive individually admin- istered academic achievement batteries is the Woodcock- Johnson Psychoeducational Battery-Revised. This test battery, which was designed for ages 2 to 95 years, has 21 tests of “Cognitive Ability” and 18 Achievement Tests. Cognitive factors assessed by the Woodcock- Johnson include long- and short-term memory, auditory and visual processing, processing speed, com- prehension, and reasoning. Within the achievement domains, tests assess nor only level of functioning, but also underlying processes such as word atcack skills, reading comprehension, letter-word identification, and vocabulary. Similar subcomponents are assessed for writing and math skills. As such, this test battery is particularly useful for evaluating the underlying component skills that go into academic competency. Therefore, it can provide information necessary for developing remedial plans. NEUROPSYCHOLOGICAL TESTING Neuropsychological testing assesses a wide array of cognitive functions and interprets the data in the con- text of a comprehensive understanding of brain~ behavior relationships. Approximately 25 years ago, when neuropsychological testing began a rapid expan- sion in populatity, the primary goal of testing was to determine whether the patient had brain damage (e.g., “Is it organic?) and, if so, which part of the brain was damaged. Whereas this application is still used with cer- rain patient populations (e.g., closed head injury), this is rarely the purpose of neuropsychological testing in child and adolescent psychiatric patients. More often than not, the goal of neuropsychological testing in children and adolescents is to provide a detailed assessment of the individual’ cognitive functioning. Comparing per- formance across tests allows areas of strengths and weak- nesses to be identified, and a comprehensive assessment of how the individual encodes, processes, stores, and ourputs information is often provided. The data can then be examined to determine the ways in which the patient's “style” of information processing either impairs functioning or can be modified to improve functioning. Although rarely diagnostic by themselves, neuropsy- chological assessments may play a particularly useful role in understanding the deficits in many child psy- chiatric patients and in treatment planning. Neuro- psychological cesting is most useful in patients with a wide array of at least partially neurologically based dis- 581HALPERIN AND McKAY orders such as learning disabilities, Tourette’ disorder, autism, pervasive developmental disorders, and attention- deficit/hyperactivity disorder. Many neuropsychologists use standardized neuro- psychological rest batteries such as the Halstead-Reitan (Reitan and Wolfson, 1993) or Luria-Nebraska Battery (Golden et al, 1986). These test batteries have separate versions for children and adults. A more recently devel- ‘oped neuropsychological test battery, developed spe- cifically for children, is the NEPSY (Korkman et al., 1997). The NEPSY, which is normed for ages 3 through 12 years, was designed to detect subtle deficits that inter- fere with learning in five functional domains: language and communication, sensorimotor functions, visual- spatial abilities, learning and memory, and executive functions. This latter domain includes functions such as attention, planning, and problem solving. The use of a standardized battery is likely to ensure that the assessment is comprehensive with regard to the breadth of domains assessed. In addition, normative data for the individual tests that make up the battery are usually adequate, and comprehensive manuals facilitate interpretation of the test scores, which is generally done via various pattern analyses. Yet many neuropsycholo- gists contend chat the fixed format of test batteries requires excessive testing in some domains, which may not be necessary for certain patients, while lacking more in-depth measures in other domains when needed. ‘Thus, they lack che flexibility to tailor the assessment to the individual patient. Furthermore, they may not be ideal for comprehensively assessing the process by which individuals take in and use information. ‘Therefore, many neuropsychological evaluations comprise a wide array of tests which are “hand-picked” by the examiner. This approach may have several advantages for a skilled neuropsychologist, with regard to selecting the most appropriate test for assessing the process of interest for an individual patient. However, caution must be used because many smaller neuro- psychological rests do not have adequate norms, and the reliability and validity may not have been adequately assessed ‘Whether using a standardized or “self made” set of tests, a comprehensive neuropsychological battery generally assesses a wide array of sensory, perceptual, linguistic, cognitive, motor, and executive functions. ‘Table 1 indicates the domains that are generally asessed in a comprehensive neuropsychological assessment. In 582 addition, the table provides examples of several commonly used tests within each functional domain. PERSONALITY ASSESSMENT Personality assessment in children and adolescents involves several approaches including behavior rating scales, self-report inventories, and projective techniques. [As discussed above, behavior rating scales and self- report inventories differ from true psychological tests and will not be reviewed here. Projective testing is based on the notion that, when presented with a vague, unstructured, or ambiguous TABLE 1 ‘Components of « Neuropsychological Fraluation in Childzen and Examples of Tests (Overall cognitive function Standard intelligence rests Motor function (Fine, gross, apraxias) Purdue Pegboard Neurological Examination for Subtle Signs Perception (visual, auditory, somatosensory) “Hooper Visual Organization Test Motor-Free Visual Pereption Test “Two-point diserimination ‘Wepman Auditory Discrimination Test Visual-motor integration (construction, graphomotor) Bender-Gestale Beery-Bukrenica Developmental Test of Visual-Motor Integration Benton Visual Retention Test Lamping peice sa emesis “Token Test for Children Peabody Picture Vocabulary Test Bescon Naming Test Expressive One: Word Vocabulary Test ‘Tes of Language Development Memory (long-term/shoreterm; verballvisual;storagelrettieval) ‘Wide Range Assessment of Memory and Learning Buschke Selective Reminding Test California Verbal Leaning Test-Childrens Version Academic abilities Standardized achievement ests Executive functions (attention, inhibitory control, planning, organization) Stroop Color-Word Test Wisconsin Card Sort Trail Making, Continuous Performance Tess ‘Noie: A more complete compilation of neuropsychological ess, along with detailed descriptions and normative data, can be found in Lezak (1995) and Spreen and Straus (1991) J. AM, ACAD, CHILD ADOLESC. PSYCHIATRY, 37:6, JUNE 1998stimulus or task, the production of the individual will reflect aspects of the personality that might be otherwise unavailable to consciousness of for assessment. In most cases the examinee is unaware of what the examiner is looking for and thus the interpretation of the tes is dis- guised and less susceprible co faking. Yee this lack of structure, which results in a nearly infinite number of potential responses, creates psychometric problems for most projective tests. In general, normative data are sparse and interscorer reliability is problematic. Never- theless, these are extremely popular tools for assessing children. The most commonly used projective instru- ‘ments (Watkins et al., 1996; Wilson and Reschly, 1996) fall under one of three categories: drawings, inkblot techniques, and verbal/storytelling techniques. Drawings According to a survey by Wilson and Reschly (1996), the three most commonly used projective techniques are the Human Figure Drawing Test, che House-Tree- Person Test, and the Kinetic Family Drawing. The Human Figure Drawing Test (Koppitz, 1984), which is standardized for children aged 5 to 12 years, is scored for the presence of “emotional indicators.” While the frequency, or aggregate, of emotional indicators has been found to distinguish berween normal and patient populations (Naglieri and Pfeiffer, 1992), individual indicators cannot be used for diagnostic purposes. Furthermore, the data should only be interpreted in the context of other clinical material. The House-Tree- Person ‘Test requires the child to produce separate drawings of a house, tree, and person. Again, data should be interpreted with caution and should be used. primarily to generate, not confirm, hypotheses about the child. The Kinetic Family Drawing (Handler and Habenicht, 1994) requires that the child draw a picture of his/her family doing something together and is inter- preted in terms of the distances between individuals and the degree to which they are interacting. Inkblot Techniques ‘The most popular inkblot technique is the Rorschach (Watkins et al., 1996), which consists of 10 bilaterally symmetrical inkblots. The lack of adequate assessments of reliability and validity, as well as the absence of a single clear procedure for administration and scoring, led to a decline in confidence in the Rorschach through- out the 1960s and 1970s. However, the development of J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 37:6, JUNE 1998 PSYCHOLOGICAL TESTING Exner’s (Exner and Weiner, 1994) Comprehensive System for administration and scoring throughout the past two decades has begun to reverse that trend. By gleaning aspects of several previously described systems, Exner’ atheoretical Comprehensive System has begun to apply modern psychometric procedures to the Rorschach. There are now clear guidelines for admin- istration and scoring, as well as normative data for chil- dren and adults. Furthermore, several reliability and validity studies have yielded favorable results. Although Rorschach data must still be interpreted with caution and should never be used in isolation for making important decisions about diagnosis, etiology, or prog- nosis, this newly revived test may provide useful daca regarding aspects of thinking, perception, and affective responsivity in children. Storytelling Techniques Several techniques require the child co tell a story in response to a picture. Two popular tests (Watkins etal, 1996) are the Thematic Apperception Test (TAT) (Bellak, 1993), which is reported to be applicable for adults as well as children down to the age of 4 years, and the Children’s Apperception Test (CAT) (Bellak, 1993), which was designed for children aged 3 to 10 years. Whereas the TAT consists of sets of black-and- whire pictures depicting various scenes, the CAT depicts cartoon-like pictures of animals in human sieu- ations that relate to various developmental themes (e.g. toilet training, feeding, sibling rivalry). The task is for the examinee tell a story based on the picture. Despite the common use of the TAT and CAT, few clinicians use systematic procedures for administration (even varying which cards they choose to present), and true scoring of responses is rarely done. Rather, stories are generally interpreted in the context of what is known about the patient and inferences about social relation- ships and interpersonal interactions are often made. Because of the lack of standardized procedures and objectivity in scoring, these results must be interpreted with extreme caution. CONCLUSIONS Unlike other forms of clinical assessment, psy- chological testing provides standardized and objective ‘measures of behavior that can be of considerable utility for evaluating children and adolescents. While psy- chological testing data, in isolation, will rarely be 583HALPERIN AND McKAY adequate for providing a DSM diagnosis, the test data are likely to provide important information about intellectual/cognitive, academic, and personality char- acteristics of the patient. When interpreted in the con- text of other clinical information, these data are very useful for developing a comprehensive treatment. Furthermore, objective reevaluation using psychological tests is of considerable utility for determining the effectiveness of an ongoing treatment plan and to modify the intervention to coincide with the patients changing needs. REFERENCES Anat A, Uibina § (1997), Byebolpcal Ting, 7 ed. Upper Sade Rivet, NJ: Prentice Hall Bayley N (1993). Raye Sale of infent Development, Dd ed Mana. San ‘Antonio, TX: Psychological Carpestion Balak 1 (1993) The TAT. CAT, and SAT in Clinical Cie, Sh ed. Boston: All & Bacon CCoute JH. Raven J (1995), Manual forthe Raven Popesie Matrices end Vecublary Sale. OxSors, England: Oxiord Psychologists Pest. Davis C} (1980), Prine Tes of Ieligence forte Blind. Watertown, MA Peskin School forthe Blind Exner JE J: Weiner 1B (1994), The Rorchach: A Comprehensive Sytem, Vo 'S Asesment of Children and Adolcents, 2d ed. New Yor: Wiley Golden CJ, Parisch AD, Hammeke TA (1986), Luria-Nebraske ‘Newoparblogial Baer: Forms land If Manual Los Angee: Western Paychologial Services Handle L, Habeniht D (1994), The Kinetic Family Drawing echnique 3 review of the iteraure. J er Ass 62440-4684 Hiey MS (1966), The Hike Nebraks Tet of Learning Apitude, Lincoln TNE: Union College Press *Kamphaus RW, Frick P) (1996), Clinical Aseumen of Child and Adelent ‘esonli and Behavior, Boston: Aliya 8 Bacon Kaufman AS, Kaufman NL (19832), Kaufan Aseximent Basery for (Children: Administration and Scoring Manual. Cicle Pines, MN: ‘Armetcan Guidance Service Kaufman AS, Kaufman NL (19838), Kaufman Ascent Rarer for Children Thcerpeive Manual. Cie Pines, MN: Ameican Guidance Service -Kaufian AS, Kaufman NL (1990), Kannan Brief Tnligence Te: Mama Girl Pines, MN: American Guidance Service 584 Kaufman AS, Kaufman NL (1993), Kew Tnieligence Tet: Manual, Circe Pines, MIN: American Guidance Service Koppits EM (1984), Pcholepcal Enluacian of Human Figure Drawings by "Midis Shoal Papi Orlando, FL: Grune & Stratton Korman M, Kick U. Kemp § (1997), NEPSY. San Antoni, TX: Pycho- logical Corporation Lambert N, Nike Ky Leland H (1993), AMR Adgpsive Bebesior Seale. "Soo, 2nd ed: Eximiners Manual, Austin, TX. PRO-ED Lauren J, Swe M, Rybur M (1992), Review of vali esearch on the ‘Sanford Bune lnaligence Scale: Fourth Edition. Pychl Ass 4:102-112 Leak MD (1995), NewopoebolepzlAsesment ke New York: Oxford niversiy Press Maller §), Braden |P (1993), "The construct and crtron-reated valid of the WISC-III with deaf adolescents. J Pychoedue Aes 1105-113 (WISC-III Monograph) Nagle JA, Peller SI (1992), Performance of disruptive behavior dis: dered and normal simples on the Draw a Peon: screning procedure foremotional dstutbance.Pyobol Anes 4156-159 Pyychlogical Corporation (1992), Weller Individual Achievement Tes "Mansal San Antonio, TX: Pychologial Corporation Reitan RM, Wellin D (1993), The Haltead-Retan Newopaeholgical Tt “user Theory and Clinical nepretton, 2nd, Tucson, AZ: Neuro- pychology res oid GH, Miller L} (1997), Examines Manual forthe Leite international Peformance Scale Reied, Wood Dale, IL: Stocking Sparrow 85, Balla DA, Ciccheri DY (1984), Vineland Adaptive Bebesor ‘Sal Iteviw Edition Expanded Form Manaal. Cice Pines, MN: ‘American Guidance Service *spreen O, Sass E(1990)-A Compendia of Navspcolgial Tt: Adin. timation, Novms end Commentary. New York: Oxfoed Univesity Press “Thorndike RL, Hagen EP, Sater JM (1986), The Sanford Bins Inclignce “Seale, th ed: Teil Manual. Chicago: Riverside ‘Watkins CE Je: Campbell Vi, Nieberding R, Hallmark R (1996), ‘Comparative practic of psychalialaseszmene. Pf Pehol Res Prat 27316318 ‘Wechsler D (1989), Macher Prchol and Primary Sele of Itligene ‘Revised: Manual. San Anconio, TX: Pjchological Corporation Wechsler D (1991), WecherIneligence Seale for Children Third Eon "Manual. San Antonio, TX: Psychological Corporation ‘Weculer D (1997), Wechsler Adult InligenceSeale-ThindEdlvon (WAIS- “UD: Administion and Scoring Mana. San Antonio, TX: Pychoogial Corporation Wilkenton JS (1993), Wide Renge Achievement Tall: Administaion ‘Manual. Wilmington DE: Wide Range, Ine ‘Wilton MS, Reschly DJ (1996), Asesment in schoo! pycholoy taining, aud pace. Sh Pohl Rev 2529-23 ‘Woodcork RU, Jobson MB (1989), Woadeackobnion Pychaeducavonal ‘Butery Revie. Allen, TX: DLM Teaching Resources J. AM, ACAD. CHILD ADOLESC, PSYCHIATRY, 37:6, JUNE 1998