Most people know Edvard Munch’s The Scream: the blood-red sky, the long bridge, the figure with its hands pressed to its face. Fewer people know what Munch said he was painting. He described walking along a road at sunset with two friends when the sky turned red. He stopped, exhausted, and sensed an endless scream passing through nature. His friends walked on.
Look again and the figure isn’t screaming. It is covering its ears against a scream it can hear. Behind it, the two friends carry on walking, unaware.
Many people with neurodevelopmental or neurological differences live a version of this. They appear calm, compliant and “fine”, while privately struggling to keep up with the information, noise and demands around them. Because the struggle is not visible, it is often missed.
It doesn’t always look like struggling
Hidden difficulties look different at different ages.
A girl nods at every instruction, then copies her classmate because she lost track after the second step. A boy is described by his teachers as “lovely, but slow”, copes all day at school and falls apart once he gets home. A teenager needs four hours for homework that should take forty minutes.
An adult manages for years with lists, alarms and late nights, until burnout. Someone recovering from a head injury keeps hearing “but you look fine”. A child’s absence seizures are mistaken for daydreaming. A young person with Fetal Alcohol Spectrum Disorder has difficulties that others don’t see.
In each case, the difficulty lies in how the brain processes information: how quickly it works, how much it can hold in mind at once, how well attention is kept and shifted, and how plans are made and followed through. The effort it takes to compensate is not visible either. Teachers, employers and family members may see someone who is calm, difficult or not trying, and the underlying difficulty goes unrecognised.
What a neuropsychological assessment looks at
Neuropsychology is the study of how the brain shapes thinking, learning, behaviour and everyday life. Neuropsychologists assess, diagnose and support people whose functioning may be affected by a neurodevelopmental, neurological or medical condition.
A neuropsychological assessment uses standardised tasks to measure these abilities. It shows what a person can do, how they approach a task, and how much effort it takes them. Depending on the reason for the assessment, it may look at:
- Attention and processing speed
- Learning and memory
- Executive functions: planning, organising, starting, shifting and self-monitoring
- Language, visual-spatial and reasoning skills
- Academic skills such as reading, spelling and maths
- Social cognition, emotional wellbeing and day-to-day functioning
Test results alone are not enough. The testing room is quiet, predictable and one-to-one, with breaks when needed, which are the conditions in which many people perform best. A good assessment therefore also uses developmental and medical history, reports from parents, partners and teachers, and the person’s own description of daily life. Results are interpreted with the person’s language, culture and schooling in mind, so that they are compared fairly.
Thandi and Daniel
Thandi, 9, was born prematurely and has epilepsy. At school she was the “good, quiet one” who drifted off and forgot instructions, and her teachers wondered about ADHD. Her neuropsychological assessment showed solid reasoning, but slow processing speed and weak working memory that worsened after seizures. Her teachers had not realised how much effort keeping up took. Her school began giving instructions in short steps with visual reminders, allowed extra time, and stayed in touch with her neurologist about seizure patterns. Thandi is now keeping up in class, and she understands how she learns best.
Daniel, 34, was diagnosed with ADHD as an adult and later identified as autistic. After a promotion, he became exhausted, missed deadlines and began to doubt his memory, privately convinced something was seriously wrong. His assessment showed that his memory was strong. The difficulty was with executive functioning (planning, prioritising and switching between tasks) when he was constantly interrupted, made worse by years of masking his autistic traits. He did not receive a new diagnosis. He received a clear explanation of his difficulties and specific workplace changes that he and his manager could put in place.
Thandi and Daniel are composite stories. Names and identifying details have been changed to protect confidentiality.
When to think about an assessment
- When several conditions may be present at once, such as autism, ADHD, a learning difference or a language difficulty
- When there is a gap between someone’s ability and how they manage at school, university or work
- When a medical or neurological factor may be involved, such as concussion or brain injury, epilepsy, functional neurological disorder, prematurity, a genetic condition, prenatal alcohol exposure or the effects of treatment
- When something has changed, and an adult wants to understand new difficulties with memory, attention or thinking
- When an older adult notices changes in memory or thinking, or lives with a condition such as dementia or Parkinson’s disease
- When a baseline is needed before surgery, a change in medication or a developmental transition
- When a detailed profile is needed to support exam concessions or workplace accommodations
Part of a bigger team
Neuropsychology works best as part of a wider team. The ESSENCE approach (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations) recognises that neurodevelopmental conditions often occur together, and that a person should be assessed as a whole rather than one diagnosis at a time. For autism and ADHD, neuropsychology adds depth to a broader diagnostic process rather than replacing it. After brain injury or with a neurological condition, neuropsychologists often lead, and may offer cognitive rehabilitation as well as assessment.
The aim of assessment is not to label someone or to help them hide their difficulties more effectively. It is to identify specific changes to expectations, teaching, work and support at home, so that the people around the person understand what is happening and can respond.
What the assessment is like
Assessment can feel daunting, especially for anyone who has spent years feeling tested and judged. A good assessment is clear, predictable and comfortable, with information in advance, breaks when needed, adjustments for sensory and energy needs, and a feedback session in plain language. It should end with a detailed report and practical recommendations for home, school, work or recovery.
Where to start
If you recognise yourself, your child or someone you work with in this article, a good first step is to talk to your GP, paediatrician, school or another professional you trust, or to contact a registered neuropsychologist directly. You don’t need to know which assessment is right before you ask. You can read more about neuropsychology at the Neurodiversity Centre on our Neuropsychology page.
