Comments on "Development of a Battery to Assess Perceptual-Motor, Cognition, Language, and Scholastic Skills among Bengali Children with Neuro Developmental Disorders".

We read with great interest the study published by Mukhopadhyay et al.[1] The article is interesting and promising in the lagging field of pediatric neuropsychological assessment, especially in the Indian context. This study addresses an important and growing area of enquiry in our field related to the identification of learning-related difficulties in children with neurodevelopmental disorders (NDDs). The developed battery appears to be comprehensive, with relevant domains.

Given the foregoing, it is unfortunate that Mukhopadhyay et al.[1] did not document the theoretical framework used to generate culturally appropriate items, method, and criteria for (sub)domain selection, the time required to complete the task, and its ecological validity.

NDDs include a variety of conditions that are unique in terms of clinical features, comorbidity, and neurocognitive correlates. Therefore, developing culturally appropriate items and tasks that could be sensitive across different NDDs with varying ages is a challenging task. Information regarding the theoretical framework used to generate culturally appropriate items and item validity is missing from the article, and this piece of information could be useful for conducting similar research in the future.

Cognitive skills are systematically and differentially correlated with academic skills in the six domains of learning disabilities (LDs).[2] Similarly, a differential neurocognitive profile has been reported in autism spectrum disorder (ASD),[3] attention deficit hyperactivity disorder (ADHD),[4-5] communication disorder (CD),[6] and specific learning disorder (SLD).[2] It is apparent from the article that several core cognitive skills have not been incorporated/included in the battery, such as processing speed, rapid naming speed, verbal working memory, approximate number skills, executive functioning, fluency, social cognition, and episodic memory. Therefore, we might not be able to tap these crucial cognitive components while using this battery and probably miss certain vital information that is preserved or more impaired in children with NDDs. Deficits in working memory and processing speed are found to be shared across different LDs as well as ADHD.[2, 7] Further, social cognition and encoding-related problems could be affected differently in children with various NDDs including ADHD, ASD, and SLD.[8-9] Deficits in social reciprocity and organizational resources such as encoding might tax perceptual and executive resources in children with certain NDD.

Further, the variability in the nature of the tasks (i.e., open-ended, semi-open-ended, and closed-ended), as well as the number of items included in respective domains, might pose further complications in establishing the sensitivity and specificity of the developed tool. Several crucial cognitive skills are grouped under a single subdomain, and their descriptions appear to be overinclusive. For example, auditory attention also assesses response inhibition; visual reasoning includes perceptual reasoning, concept formation, and problem solving. In NDDs, using the same task to assess multiple brain functions will adversely affect the profile analysis, whereas domain-specific sensitive tasks will be more useful to assess neurocognitive and academic functions.

Several other important features of this paper are of concern, such as the total time taken to administer the task and the smaller sample in the clinical groups. This battery will be used to assess scholastic backwardness in children with NDDs. The majority of these children will have marked difficulty in expressive and receptive speech, socialization, and attention and concentration, in addition to sensory impairment. In this regard, it is crucial to use a quick and easy method to evaluate cognitive and scholastic skills in these children. Further, it is difficult to generalize the obtained findings due to the small sample size, as in this study, the age ranged from 4.5 to 9.5 years and the children were from five different categories, such as typically normal developing, ADHD, SLD, LD, and ASD. Therefore, a larger sample (including normal and clinical subjects) is required in order to assess the usefulness of the tool in different NDDs.

Considerable attempts have been made to develop culture-specific tools to identify learning difficulty in Indian contexts.[10] However, the majority of these tools cannot be used judiciously due to a lack of normative data. Therefore, future studies are warranted to develop robust normative data for these tools. There is a pressing need to connect knowledge across studies and achieve consensus regarding their specific usefulness in the Indian context. In our opinion, developing culture-specific tests for scholastic problems is a long and tedious process that involves challenges in training and research, especially when we have an acute shortage of mental health services in the country. In this regard, we appreciate the efforts of the investigators. However, the several issues we listed need to be considered to make this tool more useful.