Developmental Asymmetry And Asynchronicity

In right-handed individuals and approximately 94% of left-handed individuals, the left cerebral cortex is specialized for language functions and sequential information processing, whereas the right hemisphere is specialized for spatial functions and wholistic or intuitive information processing. Just as children demonstrate growth spurts or uneven patterns of physical growth, the evolutionary functions of given brain areas tend to show asymmetric, nonlinear growth patterns in what some child development specialists have referred to as brain growth period-ization. A child may show delayed language production with accelerated motor skills and then demonstrate accelerated language growth corresponding to dominant hemisphere growth acceleration. The importance of this asymmetry and asynchronicity in pediatric neuropsychological assessment is obvious: over-reaction to such false positive indices of abnormality leads to over-diagnosis of abnormality, whereas failure to account for these phenomena may miss important clues to emerging problems and the opportunity for timely intervention. Over-diagnosis of the presentation of normal variations in central nervous system developmental symmetry and synchronicity can lead to unnecessary parental concern, initiation of costly and unnecessary interventions and treatment, and even precipitate spurious lawsuits for damages when none have occurred. Conversely, under-diagno-sis can produce problems resulting from lack of timely intervention, whether from early stages of arteriove-nous malformations or neoplasms or from language delays wherein critical periods for intervention may be missed. Issues of asymmetry and asynchronicity tend to be more pronounced during younger ages when brain growth is most rapid and tend to become less critical as children approach the end of the pediatric period and segue into young adulthood. However, at this stage the evolution of anterior cortical brain areas—heavily influenced by gender differences as previously noted—begins to represent an increasingly important facet of pediatric neuropsychological assessment. Factors such as impulse control, consideration of alternatives and consequences, monitoring and self-evaluation of responses, and executive functions become progressively important foci of pediatric neuropsychological assessment. Adolescents with delayed frontal maturation may present on examination with findings of abilities spuriously depressed due to impulsive responding or failure to consider attenuators. Knowledgeable and sophisticated examiners recognize the possible effects of such determinants and will structure the examination to detect such possible confounds and correct for their impact on findings.

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