week 8 assignment
Solovieva Yu., & Rojas L.Q. (2017). Syndromic
analysis in child neuropsychology: A case study. Psychology in Russia:
State of Art, (4), 172. https://doi-org.ezp.waldenulibrary.org/10.11621/pir.2017.0415
Psychology in Russia: State of the Art
Volume 10, Issue 4, 2017
Lomonosov
Moscow State
University
Russian
Psychological
Society
Syndromic analysis in child neuropsychology: A case study
Yulia Solovieva*, Luis Quintanar Rojas
Faculty of Psychology, Puebla Autonomous University, Mexico, Mexico
*Corresponding author. E-mail: yulia.solovieva@correo.buap.mx
Background. Neuropsychology is a science with its own specific concepts, terms, and
methods of analysis of disturbances in psychological development. One of the essential
concepts of neuropsychological methodology, according to A.R. Luria, is that of a neuropsychological syndrome, which takes into account both the functional organization
of the brain and the behavioral system. However, this concept isn’t mentioned in the
majority of his publications, and thus is not well known by neuropsychologists. There is
no clear understanding of this concept within the works of modern neuropsychologists.
This omission has a strong influence on the way analysis and interpretation of developmental difficulties is carried out today.
Objective. The objective of this study is to present an example of the successful application of qualitative syndromic analysis to the case of a Mexican preschool child with
developmental problems and learning disabilities.
Design. The clinical analysis was applied to the case of a 6 year old girl with learning disabilities, whose difficulties had been attributed primarily to a low level of general
brain activation.
Results. The authors assert that the advantages of A.R. Luria’s syndromic approach
to clinical cases of difficulties in development and learning disabilities, are that it opens
up the potential for finding the general causes on different levels: neuronal maturation,
brain mechanisms, activity and personality.
Conclusion. The authors conclude that the topic of syndromic analysis in child neuropsychology requires further scientific discussion. The necessity for revising levels of
analysis of clinical cases should be taken in account.
Keywords: neuropsychological syndrome, child neuropsychology, assessment of development, qualitative assessment, Luria’s approach, developmental problems, subcortical
levels
Introduction
One of the essential concepts of neuropsychological methodology, according to
A.R. Luria, is that of a neuropsychological syndrome, which takes into account the
functional organization of brain (functional brain units) and the behavioral sysISSN 2074-6857 (Print) / ISSN 2307-2202 (Online)
© Lomonosov Moscow State University, 2017
© Russian Psychological Society, 2017
doi: 10.11621/pir.2017.0415
http://psychologyinrussia.com
Syndromic analysis in child neuropsychology: A case study 173
tem as a whole. However, this concept is not mentioned in the majority of Luria’s
publications in languages other than Russian (Luria, 1970, 1973). Tsvetkova (2004)
wrote that a neuropsychological syndrome represents “selective deficits of groups of
psychological functions, which structure includes the same damaged factor along
with the conservation of other functions, which do not include this factor.” Clinical
application of the concept of neuropsychological syndrome means to consider the
common reason (cause), or common base, of all the difficulties observed in each
case. This base or level should be considered a link between the level of material
brain structures and the level of psychological actions.
According to Luria, such a reason (cause), base, or “factor” could be understood
as the psychophysiological mechanism responsible for all the observed symptoms,
developmental difficulties, and problems in school, intellectual tasks at any age, and
day-to-day behavior. Such a cause could not be identified solely by quantification
or assessment of isolated cognitive functions such as language, memory, attention,
and so on.
Another consequence of utilizing Luria’s analysis is that the cause or “factor”
not be confused with symptoms or diverse expression of patient’s behavior. We
remind readers that, in all modern classifications of clinical developmental syndromes, each syndrome is understood as the combination of symptoms and features of external behavior.
The difficulty in finding the precise neuropsychological factor or common
cause responsible for each child’s difficulties, is that usually it is isolated cognitive
functions which are measured during neuropsychological assessment (Tsvetkova,
2004). For followers of A.R. Luria, isolated evaluation of cognitive functions is inadequate (Vigotsky, 1991). Qualitative assessment has to provide specific information for the specialist to identify the predominant reason or “factor” causing the
difficulties, from the point of view of the functional participation of central nervous
system (Quintanar & Solovieva, 2008).
At the same time, the “factor” is not merely the level of development of the
child’s anatomical brain structure itself, but the result of participation of this structure or structures in the child’s psychological actions. We understand psychological
actions not as isolated “cognitive functions,” but acts driven by goals (Solovieva,
2014; Solovieva & Quintanar, 2016a). In early infancy such actions are types of
communication and play activity. At school age they are learning skills, such as
writing sentences, repeating words spoken by the instructor, reading, etc. It is important to provide detailed analysis of the level of development of the child’s psychological actions relative to his/her specific psychological age (Solovieva & Quintanar, 2016b). Then it’s possible to establish the relationship between the child’s
psychological actions (functional) and the structural levels of participation of the
child’s central nervous system.
In child neuropsychology, the relationship between the child’s psychological
actions and the central nervous system might mean establishing the level of maturation of his/her subcortical or cortical functional relations (or the existence of a lesion on the system). It is important to separate cases where there is a lack of neurophysiological maturation at different subcortical levels, from the kinds of cortical
difficulties which appear in adults as a consequence of brain damage. One specific
feature of clinical assessment in infancy is that the effects of brain damage or im-
174 Yu. Solovieva, L.Q. Rojas
maturity can be expressed in a very generalized and diffuse way, compared to its
effects on adults. The whole personality and activity of the child suffers (Slepovich
& Poliakova, 2012), and there may even be no progress in psychological development. It is also possible to speak about developmental risk situations at an early age
(Katona, 1988) from a global point of view (Muñóz-Ledo, 2003), and the potential
for preventing difficulties in development during the first year of life (Pelayo, Solovieva, Marroquín-Andrade, Corona & Quintanar, 2013).
The concept of a neuropsychological syndrome was proposed especially for
cases of adults with brain damage (Luria, 1970). Luria’s colleagues and followers
have also used his concept for developing different clinical pictures for adults and
children (Simernitskaya, 1985), (Xomskaya, 1987), (Santana, 1999), (Tsvetkova,
2001), (Solovieva, Lázaro, & Quintanar, 2008), (Tsvetkova, 2004).
The functional or qualitative idea of the existence of a specific neuropsychological syndrome differs from syndromes established in DSM-IV (American Psychiatric Association, 2000). A neuropsychological syndrome should never be reduced
only to one “cognitive dysfunction,” such as “attention deficit disorder,” dyscalculia, dyslexia, or dysgraphia. The syndrome always includes difficulties with diverse
kinds of school activity or play, according to the age of the child. Even separate
identification of some aspects of cognitive functions, such as language, memory,
and attention, could not help identify the common factor of child’s difficulties
(Glozman & Potanina, 2004).
Instead of the psychometric method of assessment, or the assessment of isolated cognitive functions corresponding to various features of behavior, we propose
another scheme for syndromic analysis. In this scheme we include psychological
mechanisms as neuropsychological factors, which have to be evaluated functionally during a process of assessment. Assessment is understood as involving interaction with the child, with the possibility of providing help and different tasks which
may be more accessible for the child. Such a conception differs from the rigid presentation of tasks to be performed on established tests (Solovieva & Quintanar,
2015). Other levels of analysis are intellectual or through play. Such activities are,
for example, classroom learning or, at a preschool age, playing games.
As a consequence of the qualitative analysis and conclusions drawn after the
completion of syndromic analysis, we obtain a judgment based on four possible
levels:
1) the neuroanatomical structure or level of neuronal maturation;
2) the neuropsychological “factor” or base of difficulties;
3) actions corresponding to the child’s psychological age and personality;
4) speech production or the neurolinguistic level.
Each level should be characterized according to the positive and negative aspects of development and learning of each child. Such levels could be studied in an
interdisciplinary manner, including by specialists in neuroimaging or electrophysiology (Solovieva, Machinskaya, Quintanar, Bonilla & Pelayo, 2013). The authors
are aware of the fact that the first level, involving neuroanatomical structures or
the level of maturation, might be the hardest level to identify precisely during neuropsychological assessment. The identification of this level requires other meth-
Syndromic analysis in child neuropsychology: A case study 175
ods and techniques, such as electrophysiological or neuropsychological methods,
which are rarely accessible for all clinical cases attended by neuropsychologists.
Nevertheless, it is possible to speak of hypotheses on the level of participation of
neuroanatomical structures and level of maturation.
The second level, or level of “factor,” is the level of central interest for neuropsychological assessment. Identifying this central factor permits us to determine
which activities are well developed and which are disturbed. Such a “factor” might
be the “level of general brain activation,” as we show in this article, but other examples are also possible.
The third level, or the level of psychological actions, permits us to develop a
detailed analysis of the types of difficulties which have arisen in the child’s school
activity, play, overall behavior, and even his/her personality. For example, this level
includes identifying specific mistakes in writing and reading as the consequence of
a low level of general brain activation.
Finally, the fourth level is the level of verbal interaction, with linguistic analysis of different difficulties in the development, production, and comprehension of
speech at different psychological ages, in relation to the identified neuropsychological factor.
Objective
The objective of the study is to present an example of successful qualitative syndromic analysis in the case of a child with developmental problems and learning
disabilities.
Method
The authors present a case of a child channeled into neuropsychological assessment
because of her serious learning disabilities.
Syndromic analysis was carried out by qualitative comparison of all the data
obtained from the clinical picture, the child’s school productions (drawings, writings, tasks in mathematics), and the results of the neuropsychological qualitative
assessment. Verbal production, kinds of verbal and non-verbal communication,
tastes, aspects of personality, and commentaries by parents and teachers were also
taken into account. The neuropsychological assessment was carried out during four
individual sessions of 50 minutes each.
The patient
A 6 year old girl, a pupil in the last year of a private preschool institution in the
city of Puebla (Mexico), was being seen by the Social Services department of Neuropsychological Assessment at Puebla University Hospital, which is run by Master
in Neuropsychological Diagnosis and Rehabilitation on the Faculty of Psychology
at the Autonomous University of Puebla. The girl is right-handed; her parents are
employed professionals with high levels of education (16 years within the formal
Mexican educational system). The reason for the Neuropsychological Assessment
was the recommendation of the school psychologist, due to the child’s poor school
performance and behavioral problems (impulsiveness, problems with attention
and concentration).
176 Yu. Solovieva, L.Q. Rojas
The clinical history did not reveal any pathological data, no pregnancy complications, and no risk data, as there was an adequate course of postnatal development. The parents mentioned the lack of independence in the girl’s behavior; she
was not able to fulfill day-to-day tasks of bathing, dressing, eating, and so on, alone.
The preschool institution noted her constant difficulties with communication and
the learning process. The girl was not able to fulfill school tasks, showed impulsiveness, and got low marks. Neither medical reports nor other clinical studies were
available.
Neuropsychological assessment
The neuropsychological assessment was directed to identifying the strong and
weak functional areas of neuropsychological functioning, or brain mechanisms, in
relation to her cortical (and subcortical) brain levels (Table 1).
Table 1. Relation between brain functional mechanisms and cortical-subcortical levels
Neuropsychological level
(brain mechanisms)
Neuronal anatomical or level of maturation
(cortical and subcortical zones and connections)
Programming and control Frontal cortex and connections with frontal thalamic
regulation system
Sequential organization of movements and actions
Premotor cortex, secondary motor (partially primary
motor) zones
Phonematic and phonemic analysis
and synthesis
Temporal secondary zones
Kinesthetic tactile analysis and
synthesis
Parietal somatic zones, subcortical posterior zones
Audio-verbal retention Temporal medial zones, subcortical structures including hypothalamic structures
Visual retention Secondary occipital zones, parietal-occipital zones
including subcortical hypothalamic structures
Spatial analysis and synthesis Posterior complex associative zones (PTO)
General energetic brain activation
(Cortical tone)
Subcortical structures, including reticular formation
(diencephalon level)
General emotional activation (participation in activity)
Profound structures, including at the level of the
limbic system
In order to obtain information about the level of functioning of these mechanisms, specific tasks were used.. The tasks were selected according to their potential for identifying the positive or negative functioning of each mechanism.
We stress that there is no one task which could “measure” only one mechanism.
Clinical evidence was obtained during the whole assessment and was based on
identifying various kinds of mistakes (difficulties), external help, and verbal communication.
During assessment, different tasks were used to determine the level of functionality of various factors. The tasks were selected from the Brief Neuropsycho-
Syndromic analysis in child neuropsychology: A case study 177
logical Assessment for Children (Solovieva & Quintanar, 2013). Intellectual activity appropriate to the child’s psychological age was assessed with tasks selected
from the Assessment of Voluntary Activity (Quintanar & Solovieva, 2010) and
from the Assessment of School Success (Solovieva & Quintanar, 2012). All these
instruments are based on a qualitative methodology created for Spanish-speaking
children (Table 2).
Table 2. Types of tasks used for assessment
Neuropsychological mechanisms Tasks of assessment
Programming and control Verbal conflictive task, dynamic praxis, copy and
continuation of graphic sequence, all drawing tasks,
writing by dictation, free writing, copy of complex
image “house”, constructive tasks (cubes of Kohs),
comprehension of stories and verbal instructions.
Sequential organization of movements and actions
Dynamic praxis, copy and continuation of graphic
sequence, all drawing and writing tasks. Quality of
speech production and syntactic organization.
Phonematic and phonemic analysis
and synthesis
Repetition of words and syllables with opposite
sounds, identification of phonemes in words and in
series of sounds. Comprehension of oral and written
language. All verbal tasks.
Kinesthetic tactile analysis and
synthesis
Repetition of words and syllables with proximate
consonants according to precise point and mode of
articulation. Comprehension of oral and written language. All verbal tasks. Reproduction and retention of
tactile stimuli. Tactile recognition of objects, imitation
of articulation positions, etc.
Audio-verbal retention Repetition and retention of two series of 3 words each.
Oral comprehension of long sentences. Comprehension of texts.
Visual retention Free drawing of animal, vegetables, human figures.
Reproduction of series of letters and complex figures
after copying. Recognition of visual stimuli in series of
distractors.
Spatial analysis and synthesis All kinds of visual and perceptive tasks including
drawing and writing. Comprehension of instructions
and sentences with complex logic grammar structure
(temporal, possessive, cuase and consequence effects).
Constructive tasks.
General energetic brain activation
(Cortical tone)
The overall assessment, especially graphic and written
tasks. Tasks for retention in all modalities (visual,
tactile, audio-verbal).
General emotional activation (participation in activity)
The overall assessment, especially significant activity
according to the age.
178 Yu. Solovieva, L. Q. Rojas
Results
Th e results of the clinical assessment pointed to poor levels of acquisition of voluntary activity, of development of graphic activity, and of preparation for school
learning in general. A functional defi cit in self-regulation and control, and an insuffi cient level of tone of general activation were identifi ed. Th e signs of such defi -
cits were observed in all tasks used for the assessment. A functional immaturity
of subcortical profound structures could be the neurophysiological reason for the
diffi culties observed in this case.
Figure 1. Task of copying and continuing a graphic sequence
Figure 2. Writing by copying
Figure 3. Writing by dictation
Syndromic analysis in child neuropsychology: A case study 179
Figure 4. Free drawing of a table
Figure 5. Free drawing of a “round” watch.
Figure 6. Free drawing of a house.
Th e kinds of errors, diffi culties, and lack of executive stability, ability to follow
a proposed orientation, and verbal production obtained from all the applied tasks,
all of which led to such a conclusion, may be seen in the examples of the girls’ performance in various tasks during neuropsychological assessment (Figures 1, 2, 3,
4, 5, 6).
Table 3 reprises all the types of mistakes and diffi culties which appeared during
the qualitative neuropsychological assessment.
180 Yu. Solovieva, L.Q. Rojas
Table 3. Qualitative observations, according to brain mechanisms
Neuropsychological
mechanisms Tasks of assessment
Programming and control Difficulties in independent execution of verbal conflictive tasks
and constructive tasks, absence of perseverations, positive response to external help of an adult, possibility of comprehension
of stories with external help of guidance by questions, good understanding of verbal instructions.
Sequential organization of
movements and actions
Adequate motor fluency in dynamic motor tasks for hand and for
fingers, absence of perseverations. Absence of expressive syntactic problems. Executive difficulties and fluctuation of tone in elements of graphic sequence. Constant repetition of last elements
in stage of fatigue, constant changes of size, and some difficulties
with precision of elements (Figure 1).
Phonematic and phonemic analysis and synthesis
Perfect identification of phonemes, syllables according to sound
oppositions of Spanish phonetics
Kinesthetic tactile analysis and synthesis
Absence of difficulties in articulation; adequate stage of oral and
manual praxis
Visual retention Possibility to reproduce 5 of a series of 5 elements in reproduction of letters; 4 of 5 elements in reproduction of visual figures,
noticing the lack of one figure in own execution. In conditions of
homogeneous interference, manage to reproduce 3 of 5 elements
of letters and figures. In conditions of heterogeneous interference,
cannot reproduce stimuli. In memory tasks with usage of external
signs (pictograms), manages to fulfill the tasks correctly.
Audio-verbal retention Possibility to reproduce 1 of 6 elements of the series for involuntary memory. For voluntary memory manages to reproduce 2 of
6 elements. In conditions of heterogeneous interference, cannot
reproduce stimuli.
Spatial analysis and
synthesis
Some problems with distributions of elements. Fluctuation of executive tone, some tendency to asymmetry, lack of proportionality, losing of the basic line in drawings and in writing. Writing
with difficulties in finding right distribution of elements, execution in blocks (figures 2 and 3). Neither rotations nor inversions
are observed. Difficulties with precision of lines, unstable lines in
all graphic tasks (figures 4 and 5). General lack of development of
graphic activity, imprecise images.
General energetic brain
activation
(Cortical tone)
Reduction of volume of reproduction in memory and retention
tasks. Good results in all voluntary and mediated memory tasks.
In all tasks during assessment constant fluctuations, disorganized
execution, necessity for constant orientation and guidance, usage
of external language as orientation. Separation of pencil during
drawing and writing, impulsive execution in tasks for identification of phonemes and words, difficulties in verifying executions.
Bigger difficulties in a situation of saturation (fatigue) and in long
tasks with presence of multiple elements. Frequent changes from
wrong to right answer. Better responses in conditions of external
verbal and emotional orientation.
General emotional activation (participation in
activity)
Positive emotional contact, interest in playing and communication with the adult
Syndromic analysis in child neuropsychology: A case study 181
Discussion
According to the results of the neuropsychological assessment, it was possible to
draw conclusions about four levels of syndromic analysis. We include personality
in this analysis in order to specify certain features of behavior (Table 4).
Table 4. Levels of neuropsychological syndrome in the studied case
Level of nervous
system
Subcortical immaturity, adequate level of functioning
of cortical zones.
Neuropsychological
level
Insufficient functioning of cortical tone or of general brain activation.
Lack of executive stability in all tasks, difficulties with verification and
planning of activity. External help of adult is useful and permits to fulfill the tasks correctly. Tendency to perseveration as reaction to tiredness and in complex tasks.
Psychological level Different types of games are attractive for the girl, which is typical for
her age. Symbolic games and complex games with social roles are accessible. Insufficient acquisition of graphic and visual perceptive activities. Forced introduction of writing and reading with poor voluntary
activity makes a negative general effect on school success and intellectual activity. Possibility to respond positively to external regulation
and helps from an adult.
Linguistic level No specific particularities were found in speech production or comprehension.
Personality Impulsivity, extreme dependence on adults and constant emotional
approval of all actions. Positive acceptance of all external orientation
and help during assessment (zone of proximate development). Preschool does not use any strategies of external help, which leads to a
lack of satisfaction and negative relationship with learning.
The case was analyzed in relation to a variety of aspects of activity and personality appropriate to the girl’s age. Systemic observation of the functional
stage of brain mechanisms, which conform to functional systems for all school
behavior, permitted us to establish central mechanisms as the cause or “factor”
of the learning disabilities. Both strong and weak aspects of the girl’s development were identified. Among the strong aspects we can mention phonemic,
tactile and spatial analysis and synthesis; motor sequential organization; and
general emotional level. Among the weak aspects is insufficient development of
voluntary activity due to a low general activation (subcortical structures, possibly including reticular formation and other levels). As we have mentioned,
the presence of characteristics of both strong and weak aspects is a necessary
component of the syndromic analysis model proposed by Luria and his followers (Akhutina & Pilayeva, 2012).
We understand that the logic of syndromic analysis is not common in neuropsychological practice, and that the use of the psychometric perspective is much
more popular. Nevertheless, we assert that it might be useful and interesting for our
colleagues abroad to know about such a methodology and its use in cases of Mexican children with developmental difficulties and learning disabilities. Future studies would allow us to identify other specific syndromes and to improve the whole
182 Yu. Solovieva, L.Q. Rojas
qualitative methodology. Such a methodology differs essentially from the quantitative approach, and could be not easily applied in statistical analysis or psychometric
assessment of large populations (Plaisted, Gustavson, Wilkening & Golden, 1983),
(Teeter, 1986), (Rosselli, Matute, Ardila, Botero, Tangarife, Echevería, Arbelaez,
Mejía, Méndez, Villa & Ocampo, 2004).
The usefulness of the qualitative approach lies in its providing the potential for clinical-personalized assessment of unique cases of developmental difficulties, which is helpful for strategies of correction and development. It is also
useful for establishing a clear relationship between the level of the individual’s
central nervous system, neuropsychological mechanism or factor, psychological
activity, and personality. Besides the significant advantages of such a complex
integrated approximation in clinical cases of children’s difficulties in development and learning, we can mention the possibility of discovering their general
causes on different levels: neuronal maturation, brain mechanisms, activity, and
personality.
Conclusion
1. Syndromic analysis represents a qualitative method in child neuropsychology.
2. Syndromic analysis is the subject of recent qualitative clinical work and includes
diverse levels of assessment: neuronal anatomic (level of cortical and subcortical maturation), neuropsychological (brain mechanisms), psychological (dominant activity), and personality (features of behavior).
3. Syndromic analysis helps to establish the relationship between learning activity
and personality of a child with difficulties, with the level of maturation of cortical and subcortical functional stage.
4. Syndromic analysis offers a new integrative vision in psychology and neuropsychology, and implies identification of the central reason (factor or cause),
which explains or combines different symptoms of difficulty in development
and learning.
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Revised manuscript accepted February 14, 2017
First published online November 30, 2017