RATIONALES UNDERLYING NEPSY AND NEPSY-II

Theoretical Foundations

The theory of A. R. Luria has been one of the cornerstones of neuropsychology for more than 45 years (Luria, 1980). The basic concepts in Luria’s frame of reference are general principles, most of which apply to both children and adults. Some of them are adopted in NEPSY and NEPSY-II. Working with adults with focal, acute damage, Luria viewed the brain as a “functional mosaic,” the parts of which interact in different combinations to subserve cognitive processing (Luria, 1973). He contributed to delineating brain regions that are interactively responsible for specific functions. One area never functions without input from other areas; thus, integration is a key principle of brain function in the Lurian views.

Another level of the principle of integrated neural processes is the functional level. Luria viewed cognitive functions: attention and executive functions, language, sensory perception, motor function, visuospatial abilities, and learning and memory, as complex capacities. They are composed of flexible and interactive subcomponents that are mediated by equally flexible, interactive, neural networks. In other words, multiple brain systems contribute to and mediate complex cognitive functions. Multiple brain regions, for instance, interact to mediate attentional processes (Luria, 1980; see also Barkley, 1996; Mirsky, 1996).

Luria’s view of cognitive functions as complex systems based on interrelated neural networks is a general principle applicable to both children and adults. Yet the processes may differ in their composition. For example, in a young child reading involves more deliberate analysis of speech sounds and of the visual signs, more attention, and puts more demands on the not yet very strong working memory, as compared to the overautomatized glancing through a text with immediate sight recognition, of the printed words by an adult reader. Further, the relationship between brain anatomy and function is not clarified in children to the same degree as in adults. Thus, grounds for assuming which parts of the brain may be involved in complex functions are not as firm as they are for adult patients. For one thing, the child’s brain is still developing functionally. Further, brain abnormality in a child, whether congenital or acquired, may modify the functional development of different regions.

Lurian theory proposes that impairment in one subcomponent of a function will also affect other complex cognitive functions to which that subcomponent contributes. This is an especially important factor to consider in children, because an early-occurring anomaly or event may well affect the chain of development in a basic subcomponent that occurs subsequent to impairment. (See Rapid Reference 1.1, Summary of Lurian Theory.)

Rapid Reference 1.1

Summary of Lurian Theory

A. R . Luria, a Russian psychologist working with adults with focal, acute damage, viewed the brain as a “functional mosaic” (Luria, 1980).

• Luria’s concept of interactive brain function

• Multiple brain functions interact to mediate complex capacities.

• Complex capacities are composed of flexible interactive subcomponents.

• Also, the subcomponents are mediated by flexible interactive neural networks.

• Levels of impairment in neurocognitive functioning

• Impairment in one subcomponent of a function will also affect other complex cognitive functions to which that subcomponent contributes.

• An early occurring anomaly or event may well affect the chain of development in a basic subcomponent that occurs subsequent to impairment.

In correspondence with the assumption that impairments may have secondary effects, Luria’s clinical approach bases its diagnostic principles on identifying the primary deficit underlying impaired performance in a complex function (e.g., auditory phonological decoding deficit may underlie a language impairment). The language impairment would be a secondary deficit of the auditory decoding impairment. In severe cases this has secondary effects not only on comprehension but also on verbal expression—it is not possible to produce verbalizations without a corresponding verbal comprehension. Luria noted that both impaired performance and qualitative observations are necessary to identify underlying primary deficits (Korkman, Kirk, & Kemp, 1998; Luria, 1980). Therefore, qualitative observations were a part of the structure of NEPSY and, subsequently, became a part of NEPSY-II in the form of scored Behavioral Observations. (See Rapid Reference 1.2, Primary and Secondary Deficits; Behavioral Observations.)

Rapid Reference 1.2

Primary and Secondary Deficits; Behavioral Observations

Primary deficit(s) underlie impaired performance in one functional domain (e.g., auditory decoding deficit). Several different primary deficits can be present in different domains.

Secondary deficits are the effects of the primary deficit(s) on other functions in the same or different domains (e.g., verbal comprehension impairment = secondary deficit due to primary auditory decoding deficit). The deficit may be moderate or severe (e.g., in severe cases a primary deficit in auditory decoding has secondary effects not only on comprehension but also on verbal expression; it is not possible to produce verbalizations without a corresponding verbal comprehension).

Qualitative Behavioral Observations are quantified in NEPSY-II because Luria noted that both impaired performance and qualitative observations are necessary to identify underlying primary deficits (Korkman, Kirk, & Kemp, 1998 ; Luria, 1980).

Luria formulated a clinical assessment method that permits a comprehensive review and evaluation of disorders of complex functions by assessing subcomponents of these functions with specific tests. Thus, neurocognitive disorders are assessed by administering selective tests that represent the processes relevant for the function that was impaired (Christensen, 1984). In accordance with this approach, NEPSY-II is composed of subtests that assess, as far as possible, the range of basic subcomponents of important complex capacities. Similar to Luria’s clinical assessment, NEPSY-II provides great flexibility of assessment. It can be administered as a full NEPSY, a comprehensive, orienting survey of all domains of neuropsychological functioning followed by in-depth assessment in weak areas; or with the General Referral Battery, a briefer version of the full NEPSY-II comprised of the most sensitive subtests. It is also possible to use recommended subtests, Diagnostic Referral Batteries, to focus the assessment on specific referral questions (i.e., poor reading skills). Further, selected subtests can be used individually, if a clinician wishes to supplement other testing.

The NEPSY-II provides information both on basic, fundamental skills required to complete more complex tasks, and on higher-level cognitive processes. Examples of the former are tasks of visual perception or manual motor ability. An example of the latter could be clock reading that puts demands on visuoperceptual and visuospatial skills, and the concept of time. The scores provided in NEPSY-II are also combined with behavioral observations, error analysis, and task analysis. Together these findings provide a basis for evaluating both the nature of a child’s disorder by specifying the primary deficit(s) as well as its secondary consequences across other functional domains (Korkman, Kirk, & Kemp, 2007). Such an analysis may suggest the root(s)/primary deficit(s) of the child’s problem (often expressed in the referral question), and what other problems might arise in other areas from the presence of the primary deficit(s). These would be secondary deficits.

Neuropsychological Assessment of Children and NEPSY-II

Neuropsychological assessment relies on standardized, objective, reliable measures of diverse aspects of human behavior, allowing for the specification of each individual’s profile (Ivnik et al., 2001). Kaplan’s “process approach” to assessment taught neuropsychologists to appreciate the value of qualitative observations in understanding how an individual arrives at a response (1988). This approach, harking back to Luria, added another layer of clinical information to standardized assessments. Brain behavior relationships in a developing child are both qualitatively and quantitatively different from those of an adult (Baron, 2004, p. 5); therefore, it is essential that the clinician understand child development and the range of normal variation for each age level being assessed. One cannot assess the abnormal accurately until one knows the normal well. Otherwise, appropriate behavior may be misinterpreted as impairment, which may lead to misdiagnoses.

Because neuropsychological assessments are used for placement in special programs, or to formulate treatment/intervention plans, it is essential to understand the whole child, including the context in which the child must operate. The results of an assessment must be tailored to the context in which this information will be used—the child’s family, school, and professionals dealing with the child.

Those who see children in clinics may face the challenges presented by children with very diverse conditions. A child may be referred for evaluation due to traumatic brain injury (TBI), closed head injury, a neurological disorder (e.g., epilepsy) or disease (e.g., tuberous sclerosis, cancer), impulse control and behavior problems stemming from attention deficit hyperactivity disorder (ADHD) or autism; psychiatric disorders, such as bipolar disorder and depression, as well as learning disabilities (e.g., dyslexia). It is, therefore, essential that the neuropsychologist be able to weigh the effects of many different factors in assessing a child across a wide spectrum of insults, disorders, and diseases. He or she must have knowledge of and take the following into account: diagnostic clusters of symptoms for certain disorders, age at time of insult or at emergence of the disorder or the disease; location and severity of a lesion, whether or not it is local or diffuse; the role plasticity may play in recovery of function, and the possibility of a condition becoming chronic following an acute insult. Even when children present with signs of brain damage, inferences regarding brain-behavior relationships should be drawn with extreme caution. They should only be made by individuals whose training, expertise, and clinical skills qualify them for such inferences (Hartlage & Long, 1998, p. 5). (See Caution box, following.) Neuropsychological assessment is valuable in assessing the effects of damage on brain function whether the cause is known or not.

CAUTION

Inferences About Brain Pathology

Focal damage is more common in adults, whereas diffuse or multifocal damage is more common in children.

Lateralized or localized damage and neuropsychological findings in children are not usually evident in children with developmental disorders or early neurological insult.

Even with documented lateralized brain damage, the test profiles of children with left damage and with right damage do not differ enough to discriminate these groups.

Inferences concerning underlying brain pathology should be drawn with extreme caution, only by neuropsychologists who are trained in brain-behavior relationships.

Long-term follow-up for children with more severe problems is as essential as the initial evaluation, because cognitive impairment may change with age. For example, a young child with a language disorder may later have less notable language impairment but instead might have a reading disorder. Further, the child should undergo intervention and the clinician needs to follow its effects. For children with acquired damage, following the recovery of function is important in order to identify improved functioning, as well as persistent deficits, and to adapt interventions to changing needs (see also Korkman, Kirk, & Kemp, 1998).

Patterns of deficiencies in children with receptive and/or expressive language disorders and developmental disorders such as autistic spectrum disorders, nonverbal learning disabilities, and Williams syndrome, to name a few, can be detected with neuropsychological assessment. Neuropsychological assessments can, in such cases, assist in the diagnosis.

Subtle deficiencies in children with less severe developmental disorders such as dyslexia, ADHD, or graphomotor problems can be detected as well. It is quite frequent for children with some stated impairment to have problems in other domains as well—problems that are unrelated but coexist; that is, comorbid problems. For example, verbal learning disorders tend to overlap with attention problems, and motor coordination and visuomotor problems (Noterdaeme, Mildenberger, Minow, & Amorosa, 2002; Reinö-Habte Selassie, Jennische, Kyllerman, Viggedal, & Hartelius, 2005; Snowling, Bishop, Stothard, Chipchase, & Kaplan, 2006). Understanding the full spectrum of the child’s deficiencies is an important basis for the development of behavioral, educational, and cognitive interventions.

Advanced examiners are able to select NEPSY-II subtests that further clinical utility or that meet clinical or referral needs (Korkman, Kirk, & Kemp, 2008, p. 5). Whatever the clinician’s purpose in evaluating a child, the NEPSY-II is designed to be flexible enough to be tailored to specific referral questions. The NEPSY-II contains many traditional neuropsychological tests with appropriate norms for children and adolescents. Also, new tests developed specifically for NEPSY-II are included (e.g., Affect Recognition Theory of Mind, and Memory for Designs). Using the full NEPSY-II provides the additional advantage of conormed subtests, allowing scores to be compared to one another in a test profile.

Examiners who are not trained in neuropsychology can still make extensive use of NEPSY-II by interpreting it at the cognitive processing and more descriptive level. Such assessment is a good basis for developing modifications and interventions for children in the classroom. The test profile gives an idea of the child’s relative strengths and weaknesses, in addition to giving information about the child’s performance relative to the same-age peers.

Clinicians may use the NEPSY-II to understand children’s cognitive processing on both the level of a trained neuropsychologist and on a more descriptive level. In both cases, identifying and explaining the neurocognitive impairments of a child supplies, firm ground for making intervention recommendations to improve functioning in school, home, and social contexts.

Neuropsychological Assessment in Schools

Many school psychologists are obtaining additional training in neuropsychology to improve their neuropsychological assessment skills. The NEPSY-II is designed to aid in assessing school-based problems such as poor academic performance and behavioral control problems. While the use of neuropsychological tests in schools is increasing, it is important that examiners have training in administering and scoring neuropsychological tests and that they restrict their interpretation inferences to a level consistent with their background and training. In cases where the referral question is to determine cognitive consequences of neurological conditions, or to identify signs compatible with brain injury, the examiner should have training and experience in performing such evaluations. Otherwise, he or she should refer the child to a neuropsychologist with the appropriate background.

IDEA Implications for Assessment

The reauthorization of the Individuals with Disabilities Education Act (IDEA) in 2004 produced changes in the criteria used to determine classification of a student with a learning disability. Whether a neuropsychologist in a clinic or private practice is evaluating a child, or a school psychologist with a neuropsychological training is administering the assessment, it is essential that he or she be aware of the new requirements under this law.

The law does not require the use of an ability-achievement discrepancy, and clinicians may consider response to intervention (RTI) when making the determination of a learning disability. A comprehensive assessment is required for all eligibility determinations, but the law allows the clinician to make judgments about the presence or absence of learning problems based on a variety of procedures. Essentially, it is incumbent on the school to demonstrate that scientifically based interventions were provided to the child and that the child did not benefit from these interventions, in order for learning disability classification to be made. This requirement is meant to enable children to receive intervention services sooner, when they are most beneficial, and reduces the number of referrals associated with inadequate instruction. It also may increase the possibility that children will be placed in special education without a formal evaluation. It is strongly recommended that no child be placed in special education at Tier 3 without an evaluation, and it would be preferable for the child to receive an evaluation after Tier 1 at the latest.

The increased emphasis on RTI makes it essential for clinicians to focus the results of their assessment on informing instruction or intervention. It is not sufficient to diagnose a disorder or make a classification. The assessment should provide information relevant to improving services provided to the child. This may be a specific intervention, remediation, or accommodation to provide the best learning environment for the child.

The NEPSY-II is designed to assess cognitive functions not typically covered by general ability or achievement batteries. The NEPSY-II subtests may relate more closely to the source of processing problems manifested in a specific learning or behavior problem than general measures of ability. For instance, poor word reading (decoding) may be a function of impaired phonological processing. This would suggest the child needs intervention related to developing phonological skills; however, if the child has had extensive and appropriate phonological awareness or decoding training and has not improved, the intervention recommendation might suggest that a contextual or whole language approach may be best to improve word reading. (Rapid Reference 1.3 summarizes IDEA and RTI.)

Rapid Reference 1.3

Summary of IDEA and RTI

Reauthorization of the Individuals with Disabilities Education Act in 2004 produced changes in the criteria used to determine classification of a student with a learning disability.

• The law no longer requires the use of an ability-achievement discrepancy.

• A comprehensive assessment is required for all eligibility determinations, but the law allows the clinician to make judgments about the presence or absence of learning problems based on a variety of procedures.

• Clinicians may consider response to intervention (RTI) in establishing a learning disability.

• It is incumbent on the school to demonstrate that scientifically based interventions were provided to the child and that the child did not benefit from these interventions, in order for learning disability classification to be made.

• Meant to enable children to receive intervention services sooner, when they are most beneficial.

• Reduces the number of referrals associated with inadequate instruction.

• May increase the possibility that children will be placed in special education without a formal evaluation.

• The increased emphasis on RTI makes it essential for clinicians to focus the results of their assessment on informing instruction or intervention.

• It is not sufficient to diagnose a disorder or make a classification.

• The assessment should provide information relevant to improving services provided to the child. This may be a specific intervention, remediation, or accommodation to provide the best learning environment for the child.

NEPSY DEVELOPMENT

Twenty years ago, the scarcity of pediatric neuropsychological instruments led Marit Korkman, a pediatric neuropsychologist from Finland, to develop NEPS (Korkman, 1980), a brief assessment designed specifically for children 5.0 to 6.11 years of age. Various aspects of attention, language, sensorimotor functions, visuospatial functions, and memory and learning were each assessed with two to five tasks similar in content to the tasks in Luria’s assessment (Christensen, 1975). Although the method proved most useful, the narrow age range was problematic, as was the pass/fail criterion that was built on the medical model (Korkman, 2000).

The NEPS was revised psychometrically by adding more items so that the results could be expressed in graded scores. These were converted to z-scores (mean = 0 ± 1) based on age norms. During this revision new subtests were added, derived from tests that had proven useful in pediatric neuropsychology (e.g., Benton, Hamsher, Varney, & Spreen, 1983; Boehm, 1986; Reitan, 1979; Venger & Holmomskaya, 1978). To complement the test, the shortened versions of the Token Test (De Renzi & Faglioni, 1978), the Motor Free Visual Perception Test (Colarrusso & Hammill, 1972), and the Developmental Test of Visual-Motor Integration (Beery, 1982) were used in their original forms and standardized along with NEPSY. Norms were collected for ages 3.6 to 9.5. The assessment was called NEPS-U in Finnish and NEPSY in English (Korkman, 1988a, 1988b, 1988c). The Swedish NEPSY for children aged 4.0 to 7.11 was published in 1990 (Korkman, 1990), and the Danish version for the same age range was published in 1993 (Korkman, 1993).

In the spring of 1987, Marit Korkman, Ursula Kirk, and Sally Kemp began to collaborate on the American NEPSY, while keeping in mind international needs. It was planned to incorporate revisions and new subtests based on traditions and views central to contemporary neuropsychological traditions of assessment, as well as to expand the age range to ages 3 to 12. New subtests were designed to serve an extended period of development. The American NEPSY was developed in three phases: Pilot Phase (1987-1989), Tryout Phase (1990-1994), and Standardization and Validation Phase (1994-1996). During the early pilot phase, the original NEPSY subtests were adapted and revised for 3- to 12-year-old children. New items were added, new subtests were developed, and some subtests based on the work of others, such as Fingertip Tapping and Phonemic Fluency (Benton, Hamsher, Varney, & Spreen, 1983; Denckla, 1973), were included. A detailed account of the development of NEPSY is available in the previous volume in this series, Essentials of NEPSY (Kemp, Kirk, & Korkman, 2001)

NEPSY, A Developmental Neuropsychological Assessment was published in the United States in January 1998 (Korkman, Kirk, & Kemp). Just prior to its publication, a corresponding version of NEPSY was published in Finland (Korkman, Kirk, & Kemp, 1997). A corresponding version was also published in Sweden (Korkman, Kirk, & Kemp, 2000). After publication of the NEPSY in the United States, its validity was further demonstrated in a number of publications and it has been employed clinically in pediatric neuropsychological assessments in schools, clinics, and hospitals across the United States. (Rapid Reference 1.4 summarizes the history of NEPSY publication).

Rapid Reference 1.4

The History of NEPSY

NEPSY-II REVISION: GOALS AND DEVELOPMENT

Revision Goals

In the fall of 2003, the authors began work on the revision of NEPSY in order to incorporate new research in neuropsychology, neuropsychiatry, and education. Client and expert feedback on the NEPSY also needed to be addressed. From author experience and early pilots of revisions and new subtests, four primary revision goals were formulated to:

1. Improve subtest and domain coverage across the age span. The first task in order to improve coverage was to review the NEPSY subtests in view of the need to include subtests over a wider age range, from 3 to 16 years. Further, in response to changes and advances in the field demonstrating the importance of executive functioning, new tests were designed to assess executive functioning:

• Animal Sorting

• Clocks

• Inhibition

The Visuospatial Processing domain had the fewest subtests of any NEPSY domain; therefore, two new subtests were developed to assess mental rotation and visuospatial analysis. Further, a need to include nonmotor, perceptual tests was recognized. Two subtests without motor input were developed that tap spatial location, the ability to deconstruct a picture, and the ability to observe ecological visual details:

• Geometric Puzzles

• Picture Puzzles

The Social Perception domain was created to enhance the assessment of children with autism spectrum disorders or other social perceptual deficits. The domain includes two new subtests measuring:

• Affect Recognition

• Theory of Mind

2. Enhance clinical and diagnostic utility. In the previous version of the NEPSY, global domain scores often masked subtle deficits. Therefore, the domain scores were dropped from the NEPSY-II in favor of the more clinically sensitive subtest-level scores. On NEPSY-II, the clinician reviews the performance of the child at the level of specific abilities rather than at the global domain level. In this review the clinician may also score the performance for variations in the process of performance. Process scores may, for example, express types of errors. Other scores, called contrast scores, express a comparison of how the child performs on different conditions or complexity of a task. The child may, for example, find it easier to attend to local visual aspects than to global configurations, or may be able to carry out a simple version of a task but fail to accomplish the task when the instruction is made more complex. The number of behaviors for which base rates in the standardization population are provided has also been increased. These base rates allow the clinician to compare features that may occur as the child performs to average rates of such behaviors in same-age children. Such behaviors may include, for example, out-of-seat behaviors, rate changes, or asking the examiner to repeat the instruction.

Particular attention was paid to the study of how different children with different clinical conditions perform on the tests. To assess the clinical and diagnostic utility of the NEPSY-II, 10 special group studies were conducted during the standardization. The results of these clinical group studies were used as a basis for further modifications of the NEPSY-II. (See Rapid Reference 1.5 for special group samples and instruments used in concurrent validity studies on NEPSY-II.)

3. Improve psychometric properties. Scores used to determine eligibility for special programs and for diagnostic purposes should be based on normative data that are both current and representative of the relevant population. The NEPSY-II normative data were collected from 2005 to 2006 and were stratified on key demographic variables according to the October 2003 U.S. Census data (U.S. Bureau of the Census, 2004). However, the Design Fluency, Imitating Hand Positions, List Memory, Manual Motor Sequences, Oromotor Sequences, Repetition of Nonsense Words, and Route Finding subtests were not renormed and were not modified in any way from the 1998 NEPSY. Most of these subtests represent motor skills or other functions that are not sensitive to cultural factors and therefore are not subject to great changes in the population, as will be described in later sections of this chapter.

Increased attention was paid to the floors and ceilings of subtests to ensure adequate coverage across the wide range of abilities in children ages 3 to 16. Subtests were developed for subsets of the age range (e.g., a recognition trial was added to Body Part Naming) and easier and more difficult items were added to many of the subtests. Data collected on children with mild intellectual disability demonstrated improved floors across the subtests. Although ceilings were increased, the focus of the NEPSY-II, as with all neuropsychological assessments, is on identifying impairment in various domains, so the focus on improved floors was critical to the clinical utility of the NEPSY-II. Along with the special group studies described earlier, a number of concurrent studies were conducted to provide evidence of reliability and validity. Retest data are reported for all scaled scores for all ages and by smaller age bands. Evidence of convergent and discriminate validity was provided by correlation studies, with numerous instruments employed in pediatric neuropsychology (see Rapid Reference 1.5).

Rapid Reference 1.5

Concurrent Validity Studies for NEPSY-II :

Evidence for the Validity of NEPSY-II Scores in Special Diagnostic Groups

To assess the clinical and diagnostic utility of the NEPSY-II, 10 special group studies were conducted during the standardization. Special group samples included children with the following diagnoses:

• Attention Defi cit Hyperactivity Disorder

• Autistic Disorder

• Asperger’s Disorder

• Deaf and Hard of Hearing

• Emotionally Disturbed

• Language Disorder

• Mild Intellectual Disability

• Mathematics Disorder

• Reading Disorder

• Traumatic Brain Injury

Instruments Used to Establish Convergent and Discriminate Validity for NEPSY-II

The relationships between the N EPSY-II and the following external measures were examined:

• Pediatric Neuropsychological Instruments: NEPSY, Developmental Neuropsychological Assessment (Korkman, Kirk, & Kemp, 1998); Children’s Memory Scale (CMS ; Cohen, 1997); Delis-Kaplan Executive Function System (Delis, Kaplan, & Kramer, 2001; D-KEFS)

• General Cognitive Ability: Wechsler Intelligence Scale for Children—Fourth Edition ((Weschler, 2003; WISC-IV); Differential Ability Scales—Second Edition (DAS-II ; Elliot, 2007); Wechsler Nonverbal Scale of Ability (Weschler & Naglieri, 2006 ; WNV)

• Academic Achievement Test: Wechsler Individual Achievement Test—Second Edition (Harcourt Assessment, 2005; WIAT-II)

• Basic Concept Test, Receptive & Expressive: Bracken Basic Concept Scale—Third Edition: Receptive (BBCS-3R ; Bracken, 2006a); Bracken Basic Concept Scale—Third Edition: Expressive (BBCS-3E ; Bracken, 2006b)

• Behavior Rating Scales: Devereaux Scales of Mental Disorders (DSMD ; Naglieri, LeBuffe, & Pfeiffer, 1994); Adaptive Behavior Assessment System—Second Edition (ABAS-II ; Harrison & Oakland, 2003); Brown Attention-Deficit Disorder Scales for Children and Adolescents (Brown, 2001 ); and Children’s Communication Checklist—Second Edition, United States Edition (Bishop, 2006 ; CCC-2)

4. Enhance usability and ease of administration. Flexibility of subtest administration was enhanced by allowing a freer choice of subtests relevant to a specific clinical investigation. The flexible approach to assessment enables the clinicians to reduce testing time by tailoring the assessment to the child’s essential problems and the needs at hand.

Instead of fixed rules for subtest selection, referral batteries are proposed in the NEPSY-II that are tailored according to common referral questions. A General Referral Battery is proposed for a situation where the child’s problems are not known or fully identified, and to accommodate for the possibility for identification of problems that may be comorbid to a particular referral problem. Eight other Diagnostic Referral Batteries were based on eight of the many special group studies that were undertaken. Clinicians are also free to choose subtests to administer based on clinical, research, or child-specific needs.

Due to the multiple administration order possibilities, most of the NEPSY-II materials are presented in the Administration Manual in alphabetical order to make the subtests easier to find. The Administration Manual contains only the information required to administer the subtests and score subtest-level data. The normative data are contained in the Clinical and Interpretive Manual to allow for a streamlined Administration Manual that is not too thick to handle.

NEPSY-II SUBTEST DESCRIPTIONS ORGANIZED BY DOMAIN

Before considering the process of revision and standardization of the NEPSY-II, it will be helpful to the reader to be acquainted with the NEPSY-II subtests (Korkman, Kirk, & Kemp, 2007). Therefore, they are presented here in Table 1.1 by domain as they appear in the present revised NEPSY-II. For each subtest, the age range and a brief description is given. This review of the NEPSY-II subtests is followed by a detailed account of the development of NEPSY-II and modifications from NEPSY to NEPSY-II.

Table 1.1 NEPSY- II Subtest Description by Domain

Auditory Attention and Executive Functioning
Subtest	Ages	Description
Animal Sorting	7-16	This subtest is designed to assess the ability to formulate basic concepts, to transfer those concepts into action (sort into categories), and to shift from one concept to another. The child sorts pictures into two groups of four cards each using self-initiated criteria.
Auditory	5 -16	There are two parts to this subtest: Auditory
Attention and		Attention assesses selective auditory attention and
Response Test	7-16	the ability to sustain attention. Response Set assesses complex auditory attention and the ability to inhibit a previously learned stimulus in order to shift to a new set, while still controlling for selective attention to matching stimuli. The child touches a colored circle responding to matching or contrasting stimuli as required.
Clocks	7-16
5 -12
5 -16
3 - 6

3 - 4
3 -16
3 -12
3 -16
5 -12
3 -16
3 -16

7-12
3 -16
5 -16
5 -16
5 -16
3 -16
3 - 6
7-16

5 -16
3 -12
3 -12
3 -12

3 -16
3 -16

5 -16
3 -16
3 -16
3-16
7-16
5 -12