Neuropsychology Review, Vol. 9, No. 2, 1999

Applying Luria's Diagnostic Principles in theNeuropsychological Assessment of Children

Marit Korkman1,2

The first part of this article examines the theoretical justification for applying Luria's approach in theassessment of children. It is concluded that Luria's concepts of functional systems and the principleof specifying primary and secondary deficits may be applied to children. However, the selection offunctional components to assess should be based on traditions of child neuropsychology rather thanon Luria's assessment of adults. In addition, the tendency for comorbid disorders, mechanisms ofneural adaptation to damage, and the prevalent types of brain abnormality in children render brain-behavior relationships more complex in children than in adults. The second part of the article describeshow Luria's methods were adapted for use with children. An assessment, NEPSY, was developedby integrating Luria's views with contemporary child neuropsychological traditions. The NEPSYincludes 27 homogeneous and psychometrically developed subtests, standardized in the United Statesand Finland for the age range of 3 to 12 years. The rationale of analyzing disorders of cognitiveprocesses through a comprehensive and systematic assessment of their components, characteristic ofLuria's approach, was preserved, but more specific principles of diagnosis were modified. Researchfindings obtained with a previously published, Finnish NEPSY version are presented.

INTRODUCTION

Luria's theory and methods were mainly based on hisexperience of adult patients sustaining focal brain dam-age (Luria, 1973). Compared with children with devel-opmental or congenital neuropsychological dysfunction,who constitute the majority of the children referred forneuropsychological assessments, Luria's patients repre-sented the opposite pole on the dimensions of early ver-sus late and chronic versus acute brain damage. The firstpart of this article examines to what extent there is theo-retical justification for an application of Luria's conceptsand methods to children. The second part describes howLuria's methods have been adapted for the assessment ofchildren with developmental, congenital, or acquired braindysfunction.

1Helsinki University Central Hospital, Hospital for Children and Ado-lescents, Pediatric Neurology, Helsinki, Finland, and Abo AcademyUniversity, Turku, Finland.

2 All correspondence should be directed to the author at Avenue AlbertJonnart 89, B-1200 Brussels, Belgium.

APPLICABILITY OF LURIA'S APPROACHTO CHILD NEUROPSYCHOLOGY

Luria's Concepts and Methods

Functional Systems

The basic concept of Luria's theory is his view ofhigher mental activity, or, in more recent terminology,cognitive processes (author's remark), as dynamic func-tional systems. According to this view, cognitive processesshould be seen as functional systems characterized by aspecific aim but carried out by a system of interconnectedsubprocesses, or components, in a dynamic and variablefashion (Luria, 1973, pp. 26-30).

Verbal processes, for example, include at least the fol-lowing components: inner speech, comparable to a draftof a verbal formulation; oral articulatory motor series;kinesthetic feedback from articulatory movements; audi-tory phonemic analysis of speech; short-term memory al-lowing processing of the message; perception of spatial

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1040-7308/99/0600-0089$16.0/0 C 1999 Plenum Publishing Corporation

KEY WORDS: Luria; neuropsychology; neurocognitive; assessment; children.

90 Korkman

Table I. Components of Cognitive Processes According to Luna"

AttentionRegulation of vigilance, activity levelSelective attention to biologically relevant stimuliVerbal regulation, goal-directed attentionInhibition of irrelevant stimuli and impulses

LanguageInner speechMotor programming of successive articulemesArticulation based on kinesthetic feedbackAcoustic phonemic analysis of speechAcoustic memoryLexical-semantic retrieval, namingLogical-grammatical aspects: syntax and concepts

Movement and ActionIntention and planDynamic organization of motor seriesAfferent (i.e., kinesthetic, tactile, visual) feedbackOrientation of movements in space

Perceptual FunctionsVisual fieldPerception of surrounding space and own bodyVisual analysis and synthesisPerception of spatial coordinatesConstructional ability

Memory and LearningAuditory-verbal (short-termb) memoryVisual and spatial (short-termb) memoryCoding and long-term storagePreservation versus inhibition of memory tracesActive memorizing

Example of Complex Performance—Problem SolvingAnalysis of conditionsStrategy formationExecution of planEvaluation

aAfter Luria (1973).b Author's addition.

dimensions of language, inherent in logical concepts andsyntax; and semantic retrieval.

The composition of language, memory, attention, mo-tor performance, and thinking is described in detail byLuria (1970,1973). A summary of components of impor-tant functions is presented in Table I.

Developmental Aspects

Luria draws attention to some developmental changesto illustrate the dynamic structure of cognitive functions.For example, a young child copying a text needs to activelyidentify and produce the graphic characteristics of eachletter, whereas an adult automatically transfers the per-ceived written text into overlearned motor schemes. Thestructure of acquired skills may thus become more crys-tallized as a function of experience (Luria, 1973, p. 32).

Of special interest to child neuropsychology is Luria'sview, based on Vygotsky's (1965), of the development ofattention. The young child's attention is automatically at-tracted to novel or exciting stimuli, and the child tendsto react impulsively, in accordance with concrete stim-uli rather than verbalized rules and commands. It is, forexample, very difficult for a 2-year-old child to obey acommand to take off the shoes that he or she has just be-gun to put on.

The capacity for conscious attention and behavioralcontrol is formed in the child's interaction with the adult.The adult directs the child's attention by gestures, words,and instructions. The child gradually internalizes and takesover this control. By this mechanism, culturally medi-ated motives and behavior programs are transmitted to the

child. Verbal regulation becomes a particularly forcefulmedium for control of attention, behavior, and complexperformance (Luria, 1961a; 1961b; 1973, pp. 261-264).Luria's concept of verbal regulation is thus comparable tothe concept of executive functions.

Localization of Functions

The components of the functional systems reflect theactivity of specific brain regions. The brain is viewed as"a functional mosaic" the parts of which in various com-binations provide the neural basis of cognitive processes(Luria, 1963, pp. ix-x; 1973, pp. 11, 26-30). The func-tional organization of the brain is described in detail byLuria (Luria, 1970, 1973).

Clinical Assessment

The components of complex processes are repre-sented in the clinical assessment by specific tasks. Manytasks are designed so that they depend as much as possibleon a specific aspect of functioning; others are more com-plex. Disordered functions are analyzed one componentat a time, to determine which is the primary deficit in thechain of subprocesses.

The process of determining primary and secondarydeficits is, however, not entirely straightforward, becauseeven very focused tasks are complex and may depend onvarious contributing subprocesses. The interpretation isbased on logical deduction of what underlying deficit issufficient and necessary to explain the findings, a principlecalled syndrome analysis.

Applying Luria's Principles in the Assessment of Children 91

The way in which tasks are failed may also provideimportant clues as to the nature of the deficit. For example,difficulties in speech production, with relative preserva-tion of verbal comprehension, would point to some type ofmotor aphasia. Difficulties in production of phonologicalsequences and perseverative errors would point to a mo-tor programming deficit (efferent motor aphasia), whereasdifficulties articulating particular phonemes may indicatea problem with sensory feedback of articulation (afferentmotor aphasia).

Specifying primary deficits clarifies the nature of thepatient's cognitive disabilities and provides a basis forplanning rehabilitation as well as for the patient's abilityto cope with his or her problems.

Another aim of the neuropsychological assessmenthas been to aid in determining the localization of the dam-age. When the primary deficit underlying a patient's find-ings can be specified, the localization of the underlyingbrain dysfunction may also be determined. Modern brainimaging techniques have, however, replaced neuropsycho-logical assessments in the localization of brain damage.When the localization of damage is known, this may, in-stead, provide a source of verification of the interpreta-tion of neuropsychological findings. Findings indicatingdamage to Wernicke's area would, for example, support ahypothesis of a receptive aphasia with impaired phonemicanalysis as the primary deficit.

The syndrome analysis is facilitated by Luria's taxon-omy of aphasias, apraxias, agnosias, amnesias, and otherdisorders. The descriptions of syndromes include clinicalcharacteristics, primary and secondary deficits, and prob-able localization of damage (Christensen, 1984; Luria,1973).

The assessment is performed with the aid of tasksof a pass/fail type. An orienting, brief assessment is firstperformed across all domains of functioning: language,memory, sensorimotor functions, visuoperceptual func-tions, orientation and attention, and more complex skills.Thereafter, an in-depth analysis of selective domains isperformed in accordance with the findings on the orient-ing assessment, going from simple to more complex tasks.Tasks are selected in accordance with the hypotheses of theexaminer (Christensen, 1975,1984). The hypothesis-test-ing paradigm may be compared with the selection of testsand examinations in medical diagnosis. The examiner for-mulates, tests, and revises hypotheses concerning the typeof disorder, as a continuous process.

Contemporary Views in Child Neuropsychology

Many of the concepts included in Luria's theory areshared by most other neuropsychological views, includ-

ing those of child neuropsychology. Other concepts arespecific to Luria's theory or expressed in terms that makethem difficult to integrate with contemporary views (seeTable I). As was pointed out previously, children may dif-fer from adults with respect to the structure of functionsas well as the types and mechanisms of cognitive disor-ders. In attempting to apply Luria's theory and methods tochildren, the starting point has been Luria's general viewsof functional systems and his clinical approach. However,the specifications of the components to assess in chil-dren, as well as the detailed elaboration of clinical meth-ods, were based primarily on traditions of child neuropsy-chology.

Functional Systems

In agreement with Luria's views, contemporary childneuropsychology frequently views cognitive processessuch as attention (Barkley, 1988; Mirsky, 1989) and arith-metic calculations (Sokol et al., 1994) as complex pro-cesses consisting of several subcomponents. These pro-cesses may be disturbed in different ways, depending onwhich components are deficient, which leads to differentsubtypes of disorders—for example, language disorders(e.g., Rapin et al., 1992). Different authors may, however,emphasize different aspects. For example, some authorssee phonological analysis as crucial for reading acquisi-tion (Bradley and Bryant, 1985; Wagner and Torgesen,1987); others emphasize the role of semantic retrieval(naming) (Korhonen, 1991; Wolf and Obregon, 1992)andverbal memory processes (Benezra and Douglas, 1988;Siegel and Ryan, 1989). The following processes, manyof which approximate Luria's concepts, have been delin-eated as important aspects of complex functions.

Attention. In analyses of attentional processes in chil-dren, many authors account for the following components:selective attention, sustained attention, attention span ordivided attention, and inhibition and control of behavior(Barkley, 1988; Cooley and Morris, 1990; Douglas, 1984;Mirsky, 1989).

In empirical studies, children with attention deficithyperactivity disorder (ADHD) have been found to be im-pulsive (Barkley, 1988; Korkman and Peltomaa, 1993), tobe hyperactive (Matier-Sharma et al., 1995), and to havefluctuating attention on vigilance tasks, demanding sus-tained, selective attention (Kinsbourne, 1990; Penningtonet al., 1993).

Executive Functions. Closely related to attention areexecutive functions, that is, planning and strategy employ-ment, ability to maintain and shift set, organized search,and impulse control (Levin et al., 1991; Welsh et al.,1991).

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Pennington et al. (1993) found children with ADHDto perform poorer than children with learning disorderson tasks of executive functions: the Wisconsin Card Sort-ing Test (see Pennington et al., 1993) and the Towerof London test (see Levin et al., 1991; Shallice, 1982).ADHD children have also performed poorly on tasks de-manding maintenance and shift of set (Kemp and Kirk,1993).

Language. One component that has been found nec-essary for normal speech and articulation is oral motorprogramming and control of phonological sequences (Halland Tomblin, 1978; Rapin et al., 1992).

In addition to articulation problems, language-levelexpressive problems may be observed, for example, ontasks of narration of a story (Davenport et al., 1986; Norrisand Bruning, 1988). This type of task is, however, verycomplex because it involves executive functions and mem-ory, in addition to linguistic abilities.

An important component of language is the auditoryperception and analysis of the phonemic composition ofwords and speech. A deficit in this component may causereceptive language disorders (Rapin et al., 1977; Tallalet al., 1993). More subtle deficits of phonological analysismay lead to dyslexia rather than overt language disorder(Bradley and Bryant, 1985; Scarborough, 1990; Wagnerand Torgesen, 1987).

Comprehension deficits may also occur withoutany evident underlying phonemic decoding problem(Korkman and Hakkinen-Rihu, 1994).

Another deficit that frequently occurs in childrenwith language disorders and/or dyslexia is a deficit of se-mantic retrieval, that is, naming. Although most clearlyrelated to dyslexia (Korhonen, 1991; Scarborough, 1990;Wolf and Obreg6n, 1992), dysnomic problems may, bydefinition, be regarded as a language disorder. In addi-tion, they may occur in the context of more generalizedlanguage disorders (Korkman and Hakkinen-Rihu, 1994;Vellutino and Scanlon, 1989).

Sensorimotor Functions. Luria (1973) distinguishedbetween dynamic and kinesthetic motor organization(see Table I). A similar distinction was made in children byDewey and Kaplan (1994). These authors arrived at twosubtypes of motor coordination problems, one evident inimitating gestures and in motor coordination, and the otherin the production of motor series. In contrast, Korkman(1988c) did not find a dissociation between manual mo-tor series and imitating hand positions in a heterogeneousgroup of children with visual-motor problems.

Tactile discrimination is frequently included in neu-ropsychological assessments of children (Reitan, 1979;Rourke et al., 1983). In the study by Korkman (1988c), tac-tile, kinesthetic, and motor differentiations were stronglyintercorrelated in children with visual-motor problems as

well as in normal children, which suggested a dimensionof sensorimotor differentiation.

Motor manual speed may be an important aspect inthe assessment of children. Bawden and colleagues (1985)found children with head injury to be specifically im-paired on timed but not untimed perceptual-motor tasks.Slow performance on simple motor tasks has also beenfound characteristic of children with learning disorders(Denckla, 1985; Denckla and Rudel, 1978).

Visuospatial Functions. Visuospatial functions havenot been extensively studied in children with developmen-tal disorders. Factor analytic studies attempting to distin-guish between different types of perceptual-motor aspectshave not yielded uniform results (Francis et al., 1992;Williams and Dykman, 1994). A comparison of the resultsdoes, however, suggest that at least Visuospatial construc-tional capacity, psychomotor speed, and visual attentionmay be distinguished. In addition, assessment of visualand spatial perception is probably important in the assess-ment of children as well as adults.

Complex graphomotor production is frequently im-paired in various types of disorders, such as in develop-mental disorders involving motor clumsiness (Johnstoneand Garcia, 1994), hydrocephalus (Fletcher et al., 1992),and closed head injury (Thompson et al., 1991).

Memory and Learning. Beardsworth and Zaidel(1994) found short-term visual memory, in the form of apaired-associate facial memory task, to be specifically im-paired in children with right temporal lobe epilepsy. Chil-dren with learning disorders have been found impaired onshort-term verbal memory tasks in the form of word lists,verbal paired-associate learning (Benezra and Douglas,1988; Siegel and Ryan, 1989; Tarnowski et al., 1986), andverbal memory span (Siegel and Ryan, 1989). They havealso been susceptible to interference effects (Benezra andDouglas, 1988).

Learning supraspan auditory-verbal material proba-bly partially reflects efficiency in applying learning strate-gies (Delis, 1989). Douglas and Benezra (1990) foundchildren with attention disorder to be specifically impairedon such memory tasks, whereas children with learning dis-orders showed a more generalized verbal memory deficit.Impaired supraspan learning of names has been found im-paired in both children with learning disorders and thosewith attentional disorders (Korkman and Pesonen, 1994).

Specific problems on delayed retrieval of a word listas compared with immediate retrieval has been found inchildren with traumatic brain injury (Yeates et al., 1995).

Summary. The components of cognitive processesthat may be important to assess in children, as reviewed inthe preceding discussion, are summarized in Table II (fora more complete review, see Korkman, Kirk, and Kemp,1998).

Applying Luna's Principles in the Assessment of Children 93

One obvious reason for this is that brain abnormali-ties in children, whether in developmental disorders(Duane, 1991; Galaburda et al., 1985), in postasphyxialdamage (Truwit et al. ,1992; Volpe, 1992; Williams et al.,1993), or following teratogens (Miller, 1986; West andPierce, 1986), tend to be multifocal and/or diffuse, some-times affecting merely the microstructural, cellular level.Attempts to relate neurocognitive findings to underlyingbrain pathology are therefore not likely to be successful.The possibility also exists that children with learning dis-orders do not always have an underlying brain pathology.The problem for these children may simply be that part oftheir cognitive capacity does not meet the requirements ofmodern society.

In instances where de facto localized damage hasbeen found in children, such damage rarely leads to locali-zation-specific effects, such as aphasia or neglect, typicalof adult patients. Children with early left-sided damagedo not exhibit a significant verbal disadvantage as com-pared with nonverbal performance (Aram and Ekelman,1988; Korkman and von Wendt, 1995; Vargha-Khademand Polkey, 1992). Even in children with damage acquiredin childhood, aphasic signs tend to subside rapidly (He'caen,1983). In the young brain, development may adapt to fo-cal damage, and many mechanisms of neuroplasticity mayoperate on a neuronal and a functional level. Among thesemechanisms are the development of language in the righthemisphere (see, e.g., Strauss et al., 1990), double repre-sentation of functions that may serve as a reserve capacity(Kolb and Whishaw, 1990), and intrahemispheric func-tional compensation (Korkman and von Wendt, 1995). Thefunctional compensation may be related to a high degreeof neural redundancy in childhood, which may permit re-cruitment of uncommitted neural networks intra- or inter-hemispherically. This redundancy has been demonstratedin the form of an early surplus of neurons and synapses,which are gradually reduced to adult levels (Cowan, 1979;Huttenlocher et al., 1982). The elimination of neurons andsynapses seems to occur concomitantly in all brain regions(Rakic et al., 1986).

In contrast to such views, Lou et al. (1990) showedthat specific developmental disorders may, nevertheless,be related to dysfunctions that predominantly involve spe-cific regions. In their regional cerebral blood flow study,children with language disorders demonstrated left-sidedtemporofrontal hypoactivation, and children with ADHDdemonstrated striatal and periventricular hypoactivation.Similar conclusions may be drawn from autopsy studiesthat have shown minor anatomical abnormalities, indica-tive of disturbed migration, in persons with developmen-tal dyslexia. These abnormalities have been distributed buthave been particularly abundant in the left temporal region(Duane, 1991; Galaburda et al., 1985). Further, Levin et al.

Developmental Changes

The developmental changes in the structure of cog-nitive processes have not received much attention in childneuropsychology. Exceptions are studies on the develop-ment of graphomotor strategies in the production of com-plex designs. According to Waber and Holmes (1985) andKirk (1985, 1992), young children tend to use a part-oriented approach, copying the complex design piece bypiece, whereas older children apply a more efficient con-figurational strategy.

Changes that may be considered qualitative have beenfound in the form of a decrease in perseverative tendencyand in the susceptibility to interference effects on mem-ory tasks between the ages of 7 and 13 years (Fiduciaand O'Leary, 1990; Passler et al., 1985). Intrusion errors,caused by mixing different learning lists, have been foundto decrease with age, as have the number of words not onany list (Fiducia and O'Leary, 1990).

Although sparse, these studies are probably repre-sentative of a consensus that developmental changes mayoccur not only in the level of performance, but also in thestructure of performance.

Localization of Functions and Brain Dysfunctions

As mentioned previously, one of the initial aims ofLuna's assessment was to localize brain damage. With themodern possibilities of localizing brain damage by neu-roimaging techniques, the identified damage may insteadverify a neuropsychological interpretation of the adult pa-tient's findings. In children, however, neurological find-ings concerning brain abnormality do not always aid inattempts to understand the child's neurocognitive impair-ments.

Table II. Components of Cognitive Processes in Children

AttentionSelective attentionAttention spanActivity levelSustained attention

Executive FunctionsPlanning, strategiesFluencyShift of setInhibitionSearch

LanguageMotor productionVerbal expressionPhonemic decodingVerbal comprehensionNaming

Sensorimotor FunctionsSensorimotor differentiationProduction of motor seriesTactile perceptionPsychomotor speed

Visuospatial FunctionsVisual perceptionVisuospatial judgmentVisuoconstructive performanceGraphomotor production

Memory and LearningVisual short-term memoryVerbal short-term memorySupraspan learningName learningLong-term memory

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(1994) found children with traumatic frontal lobe injuryto be impaired on executive tasks, whereas children withinjury of other localization were not.

Indications of early lateralization of functions havealso been found. Examples of such findings are the anatom-ical asymmetries, corresponding to left-hemisphere dom-inance for language, that are visible already in the fe-tal brain (Witelson and Pallie, 1973). On a functionallevel, a right-ear advantage in discriminating phonemeshas been established in infants (Best, 1988; Molfese andBetz, 1988).

These studies would indicate that functions are local-ized and lateralized early in development. Nevertheless,the localization of functions may not necessarily be thesame in adults and children because functions can be car-ried out by different component processes depending onage, as stated previously. Early evidence of developmen-tal changes on the neural level was previously providedby Goldman (1978). She performed experimental abla-tions on infant monkeys and showed that lesions in thebasal ganglia impaired a learning task when the animalwas young, whereas the effects of frontal lesions on thesame task became evident when the animal had reachedadulthood. More recently, Duchowny and Jayakar (1993)showed that motor responses to brain stimulation may beelicited from focal areas of the brain. However, in youngerchildren, the responses tended to be less specific than thosein older children, involving, for example, the whole handinstead of separate fingers, or even bilateral oral reactionsto unilateral stimulation. This diffuseness of cortical rep-resentation may add to the plasticity and adaptability todamage of the young central nervous system.

In summary, brain abnormality and damage are typi-cally multifocal or diffuse in children, and many mech-anisms of functional compensation and adapted devel-opment also contribute to making their neurocognitiveconsequences diffuse. Nevertheless, functions do seem tobe localized and lateralized in children, but probably in amore dynamic and adaptable way than in adults. Clearly,conclusions concerning underlying brain pathology can-not be drawn from neuropsychological findings in chil-dren, and support for neuropsychological localizing find-ings from neuroimaging findings is not to be expected.

Clinical Assessment

Luria's principles of syndrome analysis are not uni-que. Rather, they are inherent in most neuropsycholog-ical diagnostic efforts, including assessment of children.For example, Pennington (1991) distinguished among pri-mary, secondary, and correlated symptoms in child-ren with learning disorders. Wilson (1992) advocated aconstruct-driven assessment by evaluating deficits or

constructs in a hypothesis-testing fashion. However, inthe assessment of children, determining primary deficitsis more complicated than in the assessment of adults.

First, children frequently have comorbid deficits. Forexample, learning disorders tend to overlap with attentiondeficit disorder (Cantwell and Baker, 1991; Dykman andAckerman, 1991).

Second, primary deficits may have other consequencesin children than in adults. For example, attention deficitsmay influence not only complex performance, such as ver-bal memory (Douglas and Benezra, 1990), but also rela-tively focused performances, such as naming (Korkmanand Pesonen, 1994; Narhi and Ahonen, 1995), the impair-ment of which may then be taken for primary deficits.

Vygotsky (1965) and Luria (1973, p. 33) recognizedthis difference when they specified that deficits in basicprocesses, such as blindness, may have more widespreadeffects on the child's cognitive development, whereasdeficits in more advanced processes, such as spatial syn-thesis, have more devastating effects in adults.

Third, we still lack generally accepted syndrome de-scriptions in the child neuropsychological literature thatcould serve as models for interpretation, comparable tothe taxonomy of Luria. Many important disorders, such asdevelopmental language disorder (DLD), have been clas-sified and described in disparate ways (American Psychi-atric Association, 1994; Rapin and Allen, 1988; Wilsonand Risucci, 1986).

Thus, in the assessment of children, conclusions con-cerning primary and secondary deficits may not alwaysbe achieved. A more realistic goal may be to describestrengths and weaknesses in the child's ability pattern.Descriptive interpretations also provide a useful basis forthe planning of interventions and special education.

ADAPTATION OF LURIA'S METHODSFOR CHILDREN

Development of the NEPSY

The adaptation of Luria's clinical methods for usewith children was based on the conceptualizations de-scribed in the preceding sections. The concrete format ofthe assessment was, however, developed through empiri-cal tryout.

The 1980 Version

For a long time, the neuropsychological assessmentof children had to rely on relatively sparse and variablystandardized tests. The need for comprehensive and si-multaneously standardized tests led to the construction of

Applying Luria's Principles in the Assessment of Children 95

a Finnish method, called NEPS (Korkman, 1980). Thismethod consisted of short series of two to five tasks, sim-ilar in content and psychometric elaboration to the tasksof Luria's assessment (Christensen, 1975). The subtestsrepresented various aspects of attention, language, sen-sorimotor functions, visuospatial functions, and memoryand learning. Test norms for 5- and 6-year-old childrenwere developed.

So that Luria's approach was preserved, most itemsof the NEPS were scaled as 0-1 or 0-2. Each item had apass rate (=scores of 0) of around 85 to 99%. Sum scoreswere not calculated.

The narrow age range of the normative data in com-bination with the pass/fail type of evaluation did, however,prove problematic. Bright 6-year-old children sometimespassed all items despite having learning disorders. Young,impaired children sometimes failed most tasks, yieldinglittle informative variation in the data. These experiencescalled for more psychometrically elaborated, graduatedscales.

The 1988 and 1990 Versions

The NEPS subtests were revised and expanded topsychometric scales by including more items. The resultsof the subtests were expressed as sum scores and convertedto z-scores (-3 to +1), based on age norms.

The need to revise the method psychometrically alsoprovided an opportunity for revisions of the content. Newsubtests were added, based on test ideas that had provenuseful in child neuropsychology (e.g., Benton et al., 1983;Boehm, 1969; Reitan, 1979; Venger and Holmomskaya,1978). Two tests, the shortened version of the Token Test(DeRenzi and Faglioni, 1978) and the Visual-Motor In-tegration (VMI) Test (Beery, 1983), were used in theiroriginal form as complements to the NEPSY.

Test norms were collected for the age range 3 years 6months to 9 years 6 months because this age range was themost prevalent in the population of child neuropsycholog-ical patients in Finland. Reliability and validity data werepresented. The assessment was called NEPS-U in Finnishand NEPSY in English (Korkman, 1988a, 1988b, 1988c).A corresponding version, NEPSY, was soon published inSwedish (Korkman, 1990). Interest in the NEPSY wasaroused in the other Scandinavian countries as well as inthe United States.

The 1997/1998 NEPSY

The decision to pursue an American version of theNEPSY provided possibilities for further revisions and

developments. The most important change was to expandthe subtests agewise to cover the age range 3 to 12 years, byincluding more items both for younger and for older chil-dren. Expanding the subtests, in turn, necessitated drop-ping some of the subtests to keep the testing time withinreasonable limits. Some subtests were also added or sub-stantially changed. Most subtests were renamed, evenwhen the content remained basically the same.

The revised NEPSY was standardized in Finland(Korkman, Kirk, and Kemp, 1997) and the United States(Korkman, Kirk, and Kemp, 1998). The NEPSY now con-sists of 27 subtests, divided into five functional domains.

I. The Attention and Executive Functions Domainincludes the following subtests:

Tower. This subtest of planning is an adaptation ofthe Tower of London test by Shallice (1982). The child isto place three balls on pegs to form specific patterns shownin pictures. Only a prescribed number of moves is allowedin each task, so the child has to think out a sequence ofmoves before performing the task.

Auditory Attention and Response Set. In part A ofthis subtest, a long array of words is presented on tape tothe child. Whenever the word red is said, the child shouldtake a red token from a pile of tokens of various colorsand put it into a box. The length and monotony of thetest invites attention lapses. In part B, the previous subtestis made more complex by having the child put a yellowtoken in the box whenever the word red is said, a redtoken whenever the word yellow is said, and a blue tokenwhenever the word blue is said.

Visual Attention. The child is given two sheets: onewith small figures placed in a random array, the other withfigures placed in a lined array. A target figure is at the topof the page. The task is to find and mark all figures similarto that one. Two versions with figures in a lined array areused, one simpler for young children and one complex,with two target pictures, for older children.

Statue. The child is to stand still, like a statue, witheyes closed, and inhibit impulses to open them or to movehis or her body despite noise distractors, such as the ex-aminer's knocking on the table and so forth.

Design Fluency. This subtest is an adaptation of the5-Point Test by Regard and colleagues (1982). The childis to draw designs by connecting dots arranged in smallsquares on a sheet. The design in each square is to beunique, and the child is instructed to come up with asmany unique designs as possible in 1 minute.

Knock and Tap. The child inhibits the impulse to dothe same thing as the examiner and performs instead anopposite action, for example, knocks on the table whenthe examiner taps and taps when the examiner knocks.

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II. The Language Domain includes the followingsubtests:

Body Part Naming. Nine body parts are pointed outin pictures, and the child is to name them.

Phonological Processing. This subtest of phonolog-ical awareness consists of tasks of sound blending, wordcompletion, word segment deletion, and changing wordsegments. In part A, the child responds by pointing out thecorrect picture from three alternatives. For example, theexaminer says, "Here you see children, chicken, kitchen.Now point to ki-tchen." In part B, the child is asked todelete one segment of the word or to exchange it foranother—for example, "Say 'changing.' Say it again, butchange '-ange' to '-omp.'"

Speeded Naming. The child is to name, as quicklyas possible, the size, color, and shape of 20 figures on asheet—for example, "Little red circle, big blue square,"etc.

Comprehension of Instructions. This subtest asses-ses comprehension of verbal instructions—for example,"Show me the figure that is above one cross and besideanother cross."

Repetition of Nonsense Words. The child is to repeatphonologically complex nonsense words, such as Incuse-ment or Pledgyfriskree.

Verbal Fluency. In the NEPSY version of the wordfluency test, the child is to name as many animals andas many things to eat or drink (semantic fluency), and asmany words beginning with S and F (phonemic fluency)as he or she can think of in 1 minute.

Oromotor Sequences. In this subtest of oromotor con-trol, the child is to repeat phonological sequences or tonguetwisters, such as "Scoobelly doobelly/scoobelly doobelly,"five times.

III. The Sensorimotor Functions Domain includesthe following subtests:

Fingertip Tapping. This subtest is an adaptation ofa procedure developed by Denckla (1973). The tappingspeed of each hand is assessed by asking the child to tap thetips of the index finger and the thumb together as quicklyas possible 32 times. A second task consists of tapping thetip of the thumb against the tips of the other fingers in asequence 8 times.

Imitating Hand Positions. The child imitates posi-tions of the hand, such as pointing outward with the thumband the little finger while keeping the other fingers in a fist.

Visuomotor Precision. In this paper-and-penciltest, the child is to draw continuous lines on curvilinearroutes. Crossing the edges of the routes is counted aserrors. The child performs two of three tasks of varyingcomplexity.

Manual Motor Sequences. The child is taught man-ual motor series and tries to repeat them five times in asequence. One of the tasks, for instance, is to knock right-hand knuckles on the table, then left-hand knuckles; tapright palm, then left palm.

Finger Discrimination. The child's hand is shieldedfrom his or her view by a cartoon shield. The examinertouches one or two fingers at a time. The child is to indicatewhich fingers were touched. The task is performed on eachhand separately.

IV. The Visual-Spatial Functions Domain includesthe following subtests:

Design Copying. This subtest consists of copying ge-ometrical designs of increasing complexity.

Arrows. The child is to evaluate orientations of lines.The material consists of pictures with arrows pointing toa target. The child is to indicate the two arrows that wouldhit the center of the target.

Block Construction. From models, both three-dimen-sional and two-dimensional, the child is to build blockconstructions.

Route Finding. Like the previous subtest, this subtestis designed to assess spatial perception. The child is tolocate houses on maps according to schematic drawingsof routes.

V. The Memory and Learning Domain includes thefollowing subtests:

Memory for Faces. The child is shown 16 black-and-white photographs of children and is asked to sort theminto boys and girls. After that, 16 pages are presented, eachshowing one of the previous photographs and two distrac-tors. The child is to point out the photographs previouslyseen. Half an hour later, the child is asked to point out thetarget photographs again among new distractors.

Memory for Names. Eight line drawings of children'sfaces are presented, and the child is taught and asked torecall the names of the children three times. Half an hourlater, the child is asked to tell the names of the childrendepicted in the line drawings again.

Narrative Memory. A story is told to the child, afterwhich he or she recalls the content. Additional questionsare asked concerning all details the child omitted in thefree recall.

Sentence Repetition. The child is asked to repeat sen-tences of increasing length.

List Learning. This subtest is an adaptation of theLearning Curve Test of Luria (Christensen, 1975) andthe California Verbal Learning Test (Delis et al., 1987).The child is read a list of 15 random words and is askedto repeat as many as he or she remembers. The learning

Applying Luna's Principles in the Assessment of Children 97

trial is repeated four more times, after which a new (in-terference) list is taught once. The first list is, thereafter,recalled once more. Half an hour later, the child is askedto say the words of the first word list again.

In addition to the subtest total scores, supplementalscores may be derived from different parts of the subtestsor different aspects of performance. For example, on theList Learning subtest, the effects of interference and ofdelay on recall may be derived. Error types are recordedin many tasks. Additional observations of specified behav-iors, such as motor overflow and pencil grip, are made.

The American standardization was performed ona geographically, ethnically, and socially representativesample of children, 100 children per age level. Only sub-tests with adequate reliabilities were retained.

Because a number of studies have been performedwith the 1988 NEPSY, the correspondence of this versionwith the revised NEPSY is presented in Table III.

Application

The indications for applying the NEPSY are all typesof cognitive or visuomotor disorders that need to be an-alyzed, as well as suspicions of neuropsychological im-pairment that need to be verified or specified.

The clinical application of the NEPSY differs some-what from that of Luria's assessment. In Luna's assess-ment, the selection of tests is based on hypotheses formedand revised in the process of the assessment. Such a hy-pothesis paradigm can also be applied in children. For ex-ample, a child presenting with dyslexia may be examinedby first presenting subtests relating to phonological aware-ness. If findings verify the hypothesis of a phonologicalawareness problem, related areas of, for example, namingand verbal comprehension may be added to delineate theproblem.

However, because children frequently have comor-bid disorders, a thorough orienting assessment, the coreassessment, across all domains is recommended. Two orthree subtests from each domain are first administeredto the child. After that, in-depth diagnostic assessments,called expanded assessments, are conducted in areas inwhich deficits have been observed, or in accordance withproblems in practice.

Other selections of subtests are possible, includingselective assessments, which may be restricted to somespecific referral question (e.g., what is the nature the child'sdyslexia?), or full assessments that include all subtests.

The interpretation is based on descriptions and classi-fications of cognitive disorders in children. Explanationsof disorders are tested against existing theoretical mod-

els of cognitive disorders in children. For example, a se-vere dyslexic problem will not be explained by attentiondisorders or spatial-constructional disorders, even if suchdeficits have been found, because such problems have notbeen found to cause severe dyslexia. In contrast, a findingof phonological awareness disorder will be accepted as amain causal factor; the other findings as additional deficits.

Studies performed with the 1988 NEPSY

Prediction of Attention Problems at School

A series of studies were performed to explore the testprofiles in various types of learning disorders and braindysfunctions. In addition, these studies provided evidenceof the validity of the NEPSY.

One study (Korkman and Peltomaa, 1991) was con-ducted to identify NEPSY test profiles that would predictattention problems at school. A heterogeneous group offorty-six 6-year-old kindergarten students at risk for at-tention problems was selected on the basis of various testfailures on school maturity assessments (in Finland, chil-dren start school at the age of 6 years 8 months to 7 years7 months).

The NEPSY attention subtests and the Matching Fa-miliar Figures Test (MFFT; Kagan, 1966) were adminis-tered. The test profiles were grouped into subgroups withthe aid of a Q-type factor analysis. This method is suitablefor studies in which the number of subjects is relativelysmall and the number of tests large (Nunnally, 1967). Afive-factor solution was chosen that explained 87% of thevariance.

Two subgroups had test findings that seemed to pre-dict attention problems at school. They had poor resultson the Inhibition and Control subtest, the Sustained Con-centration test, and the MFFT. The Inhibition and Controlsubtest is a combination of the Statue and the Knock andTap subtests of the revised NEPSY version (Korkman,Kirk, and Kemp, 1998). It consists of five tasks: keep-ing the eyes closed despite noise distractors, standing stilllike a statue for 45 seconds, and two tasks of inhibitingechopraxic reactions (i.e., the child should knock whenthe examiner taps on the table and tap when the examinerknocks, and he or she should show the fist when the ex-aminer shows the index finger and show the index fingerwhen the examiner shows the fist). In the fifth task, thechild should point to certain objects but inhibit impulsesto point to other objects when the examiner names them.The Sustained Concentration test is simply a measure ofthe mean time in minutes that the child was able to workon the assessment sessions.

98 Korkman

Table III. Corresponding Subtests of 1997/1998 NEPSYa and 1988 NEPSYb

Revised NEPSYC

OrientationHandedness

Tower

—Auditory Attention and Response SetVisual AttentionStatue

Design FluencyKnock and Tap

———

Body Part Naming

—Phonological ProcessingSpeeded NamingComprehension of Instructions

————Repetition of Nonsense Words

—Oromotor SequencesVerbal Fluency—

Fingertip TappingImitating Hand Positions

——Visuomotor PrecisionManual Motor SequencesFinger Discrimination—

Design CopyingArrowsBlock ConstructionRoute Finding

——

Memory for FacesMemory for NamesNarrative Memory

free recallfree + cued recall

Sentence Repetition

——List Learning(Included in Memory for Faces)

—(Included in Memory for Names)

1988 Finnish NEPSY

Optional SubtestsGeneral OrientationHandedness

Attention and Executive Functions

—The Sorting TestSelective Auditory Attentiond

—Guarde

Keeping Eyes Closede

—Knock and Tapd,e

Finger and Fiste

Pointinge

Sustained Concentration

Language FunctionsNaming Body PartsNaming ColorsAuditory Analysis of SpeechNaming TokensThe Token Test (DeRenzi and Faglioni, 1978)d

Comprehension of Simple InstructionsComprehension of Complex InstructionsRelative ConceptsComprehension of Syntactic StructuresRepeating Words and NonwordsOral Kinesthetic PraxisOral Dynamic PraxisVerbal Fluency (semantic only)Reading Readiness

Sensory-Motor Functions

—Kinesthetic PraxisKinesthetic Feedback from PositionsKinesthetic Feedback from MovementsVisuomotor PrecisionDynamic PraxisTactile Finger DiscriminationTactile Perception of Forms

Visual-Spatial FunctionsVMI (Beery, 1983)d

Slopes of LinesBlock ConstructionVenger's Map Test (Venger and Holmomskaya, 1978)Left-Right DiscriminationNeglect

Memory and LearningMemory for FacesName Learning

StorytellingLogical Learning

—Digit SpanWord Span

—Delayed Recall of FacesDelayed Recall of StoryDelayed Recall of Names

a Korkman, Kirk, and Kemp (1997, 1998).bKorkman(1988a, 1988b).cMost subtests of the revised NEPSY were expanded and include more items than the corresponding tests fromthe 1988 NEPSY.

dSubstantially different from 1997/1998 NEPSY subtest.eIncluded as parts of the same test called Inhibition and Control.

Applying Luna's Principles in the Assessment of Children 99

Half a year later, at the end of the first school semester,the attention of the children was assessed with the aid ofthe Conners Teacher Rating Scale (CTRS; Goyette et al.,1978) and an all-round evaluation of the ability to concen-trate on schoolwork, provided by the teachers.

Of the 22 children belonging to the attention deficitsubgroups, 15 (68.2%) were categorized by the teachersto have attention problems. In contrast, only 5 (22.7%) ofthe children from the other subgroups were categorized inthis way.

Thus, test profiles characterized by poor results on theInhibition and Control test, the Sustained Concentrationtest, and the MFFT seemed to be predictive of attentionproblems at school.

Test Profiles of Children with ADHD and/or LearningDisorder (LD)

In a study by Korkman and Pesonen (1994), the testprofiles of children with ADHD, specific LD, and bothdisorders (ADHD + LD) were compared. Sixty 8-year-oldsecond-grade students in normal classes were selected onthe basis of an evaluation of attention (American Psy-chiatric Association, 1987) and a spelling test. SpecificADHD was found in 21 of the children. Specific LD wasfound in 12 children, and ADHD + LD was found in 27children.

Significant group differences emerged on sevenNEPSY subtests. Moreover, the test profiles differed amongthe groups, as revealed by a repeated-measures analysisof variance. Children with specific ADHD had a relativelygood overall performance level, but they performed sig-nificantly poorer on the Inhibition and Control subtestthan did the children with LD. Children with specific LDperformed significantly poorer than children with ADHDon the Auditory Analysis of Speech test, the Digit Spantest, and the Storytelling test. Children with ADHD + LDhad the same deficiencies as both the ADHD and the LDgroups. In addition, they were impaired on the SelectiveAuditory Attention test, which indicated even more per-vasive attention problems than were evident in the ADHDgroup. Further, their performances on the Visuomotor Pre-cision test and the VMI were poor, which may indicate anadditional problem with motor precision as well. In ad-dition to the differences between groups, performance onthe Name Learning and the Naming Tokens tests was pooracross groups (see Table III).

These findings confirmed previous findings of impul-sivity in children with ADHD and phonological awarenessand verbal learning problems in children with LD. In ad-dition, the results indicate that name retrieval is impairednot only in children with LD, but also in children with

ADHD, perhaps as a result of poor rehearsal strategiesand poor active memorizing. Finally, the findings indi-cated that children with ADHD + LD were also impairedon graphomotor tasks.

Preventive Treatment of Dyslexia in Children withDevelopmental Language Disorder (DLD)

In a study by Korkman and Peltomaa (1993), the ef-ficiency of a treatment program, developed to reduce therisk of reading and spelling problems in preschool chil-dren with language problems, was evaluated. The studyalso demonstrated the utility of the NEPSY for follow-upstudies and evaluation of the treatment effects.

Sixty-three 5-year-old preschool children with lan-guage problems were selected as suitable for the treat-ment. Thirty-three children participated in the treatment,but 7 children were later excluded because of placementin special classes. A control group of 20 children receivedother forms of treatment.

The treatment was performed in small groups (2-6 children), with one 45-minute session weekly duringthe academic year before the children started school. Thetraining was designed to reduce problems caused by im-paired phonological awareness and dysnomia, character-istic of the included children.

After the treatment, the children completed their firstschool year. At the end of the year, follow-up assess-ments were performed. The experimental group signifi-cantly outperformed the control group on three of the fourtests of reading and spelling measures. On pre- and post-treatment comparisons, the experimental group had im-proved significantly on two attention tests (the SustainedConcentration and the Selective Auditory Attention sub-tests) and on two language tests (the Auditory Analysis ofSpeech and the Logical Learning tests), whereas the con-trol group had deteriorated on one measure (the VMI). Theresults thus indicated that preschool training of phonolog-ical awareness and grapheme-phoneme conversions mayreduce the risk of reading and spelling problems at school.

Delineating Subtypes of DLD

In a study by Korkman and Hakkinen-Rihu (1994),two groups of children with DLD were evaluated so thatwe could see whether test profiles suggestive of subtypesof DLD could be obtained and cross-validated.

Group 1 (N = 40) consisted of kindergarten studentswho had been diagnosed with DLD and/or were attend-ing special kindergarten groups for children with DLD.Group 2 (N = 40) consisted of children who had been

100 Korkman

referred for language assessments. A medical diagnosisof DLD or a special kindergarten group placement wasnot required.

The NEPSY results of Group 1 were used to per-form a Q-type factor analysis. A five-factor solution wasadopted that explained 67% of the variance. The resultingclassification was somewhat modified to facilitate clini-cal applications. It included a Global subtype; a SpecificComprehension subtype with impairments on the NEPSYreceptive language subtests and some impairment on nam-ing subtests; and a Specific Verbal Dyspraxia subtype,characterized by specific deficits on the Oral DynamicPraxis test and the Repeating Words and Nonwords test(see Table III).

To evaluate the predictive validity of the classifica-tion, we predicted that the children from the Specific Ver-bal Dyspraxia subgroup would not develop learning prob-lems in school, whereas the children from the other groupswould. This hypothesis was verified, as indicated by a hitrate of the predictions of 80.5% at follow-up 3 years later.

To evaluate the coverage of the classification in anew sample of children with DLD, we applied the clas-sification to Group 2. Of the 40 children, 32 (80%) fitthe criteria for the subtypes. Two children had normalNEPSY test results. Five children seemed to form an addi-tional subgroup with specific impairments on the NamingBody Parts, Naming Tokens, and/or Name Learning tests.A Specific Dysnomia subtype was added to the classifica-tion, which increased the coverage to 97.5%. This subtypeappeared only in children in Group 2 who had relativelymild language disorders.

The study thus proposed and validated a classificationof DLD including a Global subtype, a Specific VerbalDyspraxia subgroup, a Specific Comprehension subtype,and a Specific Dysnomia subtype.

Studies of Children with Neurological Conditions

Three studies were performed to see whether specifictest profiles would be obtained in different neurologicalconditions. First, in a study by Korkman and von Wendt(1995), 5- to 12-year-old children with left-sided braindamage (n = 17) and right-sided brain damage (n = 16)were compared. Children with hemiplegia and with nosigns of bilateral brain dysfunction and normal psycho-metric intelligence were included.

On the NEPSY subtests, no significant lateralization-specific deficits were seen. Both groups performed withinnormal limits, although the children with right-sided braindamage had a tendency toward impairment on a visuocon-structive parameter consisting of the Slopes of Lines test,the Block Construction test, and the VMI.

The children were also regrouped so that one groupwas formed of children with left-sided brain damage, with-out signs of transfer of language to the right hemisphere,as determined by ear advantage and visual half-field ad-vantage. The other group was formed of children withleft-sided damage and signs of transfer, as well as chil-dren with right-sided damage. No significant lateralizationeffects emerged on this grouping either, even though wetook possible transfer and crowding into consideration.

Second, in a study by Korkman et al. (1996), 5- to9-year-old children exposed to different types of risks forperinatal asphyxia were compared. The groups were asfollows: (1) children with very low birth weight (< 1500 g)who were born small for gestational age (VLBW-SGA;n = 34); (2) children with very low birth weight whowere born appropriate for gestational age (VLBW-AGA;n = 43); (3) children born at term with signs of birthasphyxia (n = 36); and (4) control children (n = 45).Children who were moderately and severely disabled wereexcluded.

The groups differed with respect to degree but nottype of impairment, as measured with the aid of the NEPSYsubtests and with intelligence measures. The VLBW-SGAgroup had the poorest results. The VLBW-AGA group wassomewhat less impaired, whereas the birth asphyxia groupperformed at a control group level. Group differences wereseen on the IQ measures, the VMI, the Sustained Concen-tration subtest, the Auditory Analysis of Speech subtest,the Naming Body Parts subtest, and the Tactile FingerDiscrimination subtest (see Table III). When present, im-pairment tended to be diffuse.

Finally, in a study by Korkman, Autti-Ramo et al.,(1998), an assessment using most NEPSY subtests wasperformed with forty-six 5- to 9-year-old children exposedto alcohol in utero for varying durations. The children weredivided according to duration of maternal alcohol abuseas follows: during trimester I (n = 16), during trimestersI and II (n = 16), and throughout pregnancy (n = 14). Acontrol group (n = 26) consisted of unexposed children.Fetal alcohol exposure throughout pregnancy had signif-icant, relatively diffuse effects on the development of thechildren, whereas exposure only during early pregnancydid not. Group differences were seen in the followingsubtests: Naming Body Parts, Sustained Concentration,Naming Tokens, Auditory Analysis of Speech, Repeat-ing Words and Nonwords, Dynamic Praxis, Word Span,and Inhibition and Control, in this order. In contrast, tac-tile discrimination and kinesthetic discrimination were notimpaired. Of the nine measures of memory, only one wasimpaired.

The studies indicated that different types of neurolog-ical impairment may be associated with different types of

Applying Luria's Principles in the Assessment of Children 101

neuropsychological effects. Children with unilateral dam-age seemed to have a tendency to visuoconstructive im-pairment. Children with left- and right-sided brain damagedid not seem to be characterized by significantly differ-ent types of cognitive impairment. VLBW children haddiffuse impairment. Children exposed to alcohol in uterohad problems in naming and receptive language, attention,manual motor series, and visual-motor functions, whereasverbal and visual memory and manual motor precisionwere less impaired.

Discussion

The NEPSY is the result of a long development thatstarted with attempts to apply Luria's methods directlyto children and evolved into an instrument that integratessome important aspects of Luria's approach with contem-porary approaches to neuropsychological assessment ofchildren.

The most characteristic feature of the NEPSY is di-rectly derived from Luria's methods: the rationale of ana-lyzing disorders of cognitive processes through a compre-hensive and systematic assessment of their components.Such a comprehensive analysis has necessitated the inclu-sion of almost 30 subtests in the NEPSY.

This comprehensiveness is unique to Luria's tradi-tion. Some other assessments of children do utilize thesame type of systematic component-by-component as-sessment, but they are less comprehensive (e.g., Reitan,1979) or are restricted to some specific domain of perfor-mance, such as scholastic achievement (e.g., Jastak andWilkinson, 1984) or language functions (Semel and Wiig,1980). In Golden's (1987) assessment for children, de-rived from Luria's assessment, the subtests are collapsedinto 11 scales. The subtests are heterogeneous and includeitems of various types and varying degrees of difficulty.As a consequence, children may fail the same subtest fordifferent reasons.

A comprehensiveness similar to that of the NEPSYmay be achieved by using tests from various sources (e.g.,Mattis, 1992; Wilson, 1992). However, a test profile basedon separately standardized tests may reflect differencesin test norms, such as when test norms are collected atdifferent time periods, and not just an individual's strengthsand weaknesses (Russell, 1986; Wilson, 1992). TheNEPSY offers the advantage of providing simultaneouslycollected test norms.

In the development of the content of the NEPSY,concepts and subtests that were found both in Luria's tra-dition and in contemporary traditions of child neuropsy-chology were favored. In case of conceptual or method-ological differences, child neuropsychological traditions

were more frequently adopted as models than were Luria'sconcepts and test ideas. The most important difference isthe psychometric elaboration of the NEPSY subtests intohomogeneous and standardized scales, which permits anevaluation of each type of performance against the normaldistribution at different age levels.

Concerning the more detailed content of the NEPSY,a comparison of Tables I and II reveals that many ofthe functional components proposed by Luria—for ex-ample, components of verbal processes—correspond tothose applied in child neuropsychology and selected forthe NEPSY. Other components differ or are differently or-ganized or formulated. Examples are the processes relatedto attention and regulation/execution of performance.

Similarly, some subtests of the NEPSY correspondboth to Luria's test ideas and to prevalent child neuropsy-chological assessment traditions. Such subtests are thosemeasuring comprehension of verbal instructions, confron-tation naming, articulation of complex words, narration,imitation of hand positions, tactile discrimination, and listlearning. Other subtests were based on specifically Luriantest ideas, for example, the Knock and Tap subtest of ver-bal regulation, the Manual Motor Series subtests, and thememory interference procedure in the List Learning sub-tests. Many subtests were based solely on ideas derivedfrom child neuropsychological traditions. Examples arethe attention subtests of a continuous performance and avisual cancellation format, and subtests of figural fluency,planning, phonological segmentation, graphomotor preci-sion, copying of designs, memory for faces, and sentencerepetition.

With respect to the principles involved in the clinicalapplication of the NEPSY, some aspects are similar to,others dissimilar from, those of Luria's assessment. Thereview presented in the first part of this article may besummarized as follows:

As compared with Luria's hypothesis-testing para-digm, test selection in the NEPSY is more of a two-stepprocess. Characteristic to the former is that tests are se-lected concomitantly with forming and revising hypothe-ses in the process of assessment. In children, however, thetendency for comorbidity of cognitive disorders empha-sizes the importance of a thorough survey of all domains,after which an in-depth analysis of affected domainsmay be performed to further analyze the nature of theproblem.

In the interpretation, the general idea of specifyingprimary and secondary deficits is adopted as far as pos-sible. This process is, however, complicated by the highdegree of comorbidity of deficits in children and by thewidespread secondary consequences of primary deficits.Therefore, it is often possible only to clarify individualstrengths and weaknesses.

102 Korkman

Another limitation to interpretation is that contempo-rary child neuropsychology still lacks generally acceptedclassifications and analyses of various types of disorders,which could serve as models for interpretation. Clinicalinterpretations may thus come to vary according to theorientation of the clinicians. As results obtained with theNEPSY accumulate, they may provide a more uniform ba-sis for diagnostic conclusions. For example, the classifica-tion of language disorders into dyspraxic, comprehension,naming, or global subtypes may be used as a diagnosticmodel (Korkman and Hakkinen-Rihu, 1994). Other re-sults, such as those obtained by Korkman and Peltomaa(1991, 1993), may aid in directing efforts of early identi-fication and intervention of attention disorders and verballearning disorders that predispose to dyslexia. Empiricalresults with the 1988 NEPSY also demonstrated that inchildren who are neurologically impaired, the test pro-file typically does not show lateralization effects. Instead,different neurological conditions—congenital hemiplegia(Korkman and von Wendt, 1995), VLBW (Korkman et al.,1996), and fetal alcohol exposure (Korkman et al., 1998)—tend to produce specific patterns of neuropsychologicalimpairment.

A final modification of the Lurian tradition is that dataconcerning brain-behavior relationships in adults may notbe directly applicable to children. First, cognitive func-tions in children may rely on different networks of neuralprocesses. Some findings indicate that functions and theirneural substrates may become both more crystallized anddiversified during development. Second, evidence fromchildren with lateralized damage show that the functionalorganization of the brain may be modified following earlybrain damage. Third, children tend to have diffuse or mul-tifocal rather than focal brain dysfunction (see precedingreview).

However, on a research level, specifiying the brainmechanisms underlying normal and disordered cognitivedevelopment, as well as the mechanisms of neural adapta-tion, is not an unrealistic aim, considering recent advancesin brain imaging techniques. By providing a comprehen-sive and systematic scanning of functional components,the NEPSY may aid in specifying the functional mecha-nisms of disordered and normal cognitive development.

ACKNOWLEDGMENTS

This article was initially prepared and submitted in1996. Portions of this material were previously presentedat a workshop of the International Neuropsychological So-ciety in Bergen, June 1997. Financial support was receivedfrom the Academy of Finland.

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