One of the great divides in the 20th century philosophy is the distinction between essentialism and relativism. At one conceptual endpoint, the relativist argument of writers, such as Rorty or Baudrillard, is that knowledge is a socially constructive narrative, a political and economic rhetoric; however, it takes on a reality that defines daily life in real ways. The construct of “Iowa” does not exist as you drive through it. The boundaries neatly delineated on a map are nowhere to be seen. Iowa is “made up.” It is a collective fiction that has become meaningful through persuasion and, if all else fails, punishment (e.g., failing to pay state taxes has consequences). As Gertrude Stein put it, “there is no there there.” While reading Donder and Hunter's Lifespan Developmental Neuropsychology, I was persistently reminded of the attempt to capture an idea through defining language usage. Words define what is real and what is “true.” In this case, it is the idea of a development as a lifespan model and that neuropsychologists can both appreciate and master this whole. The former seems plausible and admirable, the latter seems recklessly bold.
“Culture is passed along with language.”
Farmer and Vega (2010)
The concept of development, as in growth, advancement and refinement appears less applicable over time. Story and Attix's chapter attempts to define the accumulation of vascular damage and intracellular wear and tear as “development” (p. 42). This is a challenging concept to accept since, by that definition, my car has been evolving door dings over the past decade and I am growing wrinkles. While the profession of neuropsychology has a grasp of neurocognition across the lifespan, it is less convincing that the “practice” of neuropsychology is enhanced by this lifespan developmental model.
The tension was articulated in a different context within Farmer and Vega's chapter on “Multicultural considerations in lifespan neuropsychological assessment.” In a book ostensibly supporting a breadth model, the authors argued the importance of specific expertise, such as ensuring that a neuropsychologist is deeply familiar with the regional culture and language (e.g., Mexican Spanish vs. Guatemalan Spanish). Yet, the cognitive and “cultural” divide between adults and children is arguably wider and more dynamic—without adding the complication of a neurological condition. It is unlikely that the neuropsychologist shares the patient's belief in animism or preference for being paid in pennies. Children's culture is as disparate from the neuropsychologist as a potlatch.
Language is the vehicle for transmitting culture and, in this case, a small vehicle attempting to tow our profession toward this particular version of neuropsychology as a lifespan model. The trepidations about this lifespan model solidified while reading Farmer and Vega's chapter, which is perhaps unsurprising. The debates within multiculturalism highlight the role of culture, philosophy, and politics. Given our general focus on the intracranial world, it is an expansiveness that we rarely appreciate. As Farmer and Vega wrote:
One of the strengths of the book was a reminder that ignorance about our specialties does patients a disservice. Jane Bernstein has persistently reminded those of us working in pediatrics that our endpoint is not success in the third grade and there is no great virtue in Balkanizing our professional lives to the degree that we have “difficulty identifying colleagues who can provide care for adult patients … who were supposed to ‘graduate' from pediatric care” (p. 214). The chapters were often thoughtful, practical introductions to a disorder or a theoretical approach, but sometimes the references to other age groups seemed forced, like an intellectual garnish interrupting the often elegant prose and expertise of the authors. For example, it seemed only marginally helpful to have a paragraph on a disorder during infancy discussing the psychosocial aspects of the parents, but omitting how to assess the disorder in that infant or where one might find that information. Similarly, a thoughtful chapter on neuroimaging over the lifespan failed to mention that lack of myelination during infancy means gray and white matter are isodense and cannot easily be differentiated. The chapter also discussed the anxiety children might feel during the MRI itself, revealing the authors’ lack of familiarity with pediatric procedures. Children generally do not feel anxious in the MRI because they are anesthetized to prevent movement artifact. An MRI of a child involves primary management of wiggling not anxiety.
APA describes culture as “the embodiment of a world view, through … learned and transmitted beliefs, values and practices …. It also encompasses a way of living informed by historical, economic, ecologic and political forces on a group.” As one can see by following these definitions, culture encompasses a great deal of ones existence, and it strongly influences the ways in which individuals and groups come to understand experience. Importantly, culture is passed along with language (p. 56).
The ungainliness of this lifespan model is evident in the structure of the book, despite its explicit perspective. Most of the chapters are written in relatively rigid sequence of child chapter about disorder X, adult chapter about disorder X followed by a brief “compare and contrast” essay sometimes limited to a page or two in length. While attempting to emphasize the idea of neuropsychological expertise being cradle to grave, the prosody does not match the words. The structure suggests that the genetics, injuries, illnesses, and sociocultural factors that define our practice are complex and that we serve them best when we have the expertise relevant to their specific problem. Consistent with this, the narrower chapters reviewing metabolic and neurodegenerative disorders or leukemia and lymphoma seemed the most successful in integration the content across the pediatric-adult divide.
Donder and Hunters’ book seemed to reflect insecurity about the value of our narrow areas of expertise. Perhaps it is a more humble mission, but this lifespan model may encourage unmerited confidence for many clinicians who have incomplete or incompetent training. Familiarity is not knowledge. Worse, this book tacitly encourages neuropsychologists to step outside of their field altogether; two different chapters included specific medication recommendations (both without support from the literature and poised opposite of the standard of care). To comment about medications without understanding how they work is as sensible as allowing interpretation of standard scores without understanding what an assessment tool measures.
Although psychology began as a subdivision of philosophy, it has become its own discipline because of its adherence to scientific methodology. Science is, at its heart, the antithesis of social construction through this adherence. Neuropsychology operates from an essentialist position: There is something real that we are sampling, however imperfectly. Although there is some degree of freedom to interpret, reality intrudes and renders some opinions more plausible than others (reliability, validity, factor analyses of tests, neuroanatomy, and base rates serve as a professional compass). They also provide the basis for what we can defend and support. We earn our understanding and appreciation of them through education, training, and experience—not a redefinition of nomenclature. The further we drift from that, the further we lose our bearing as a science-based profession and return to academic philosophy. (Please see postscript to this review for additional readings pertinent to the topic of stimulants, appetite suppression and cardiac risk.)