Chapter 1 - The Practice of Neuropsychological Assessment (NA)
• In the 19th century, the idea of controlled observations became generally accepted, thus providing the conceptual tool
with which the first generation of neuroscientists laid out the basic schema of brain-behavior relationships that hold
today.
• In the first half of the 20th century, war-damaged brains gave the chief impetus to the development of clinical
neuropsychology.
• Clinical psychologists and psychologists specializing in personality and social behavior research elaborated the
principles and techniques of educational testing, giving neuropsychology this important assessment dimension.
- Psychology’s other critical contribution to neuropsychological assessment comes primarily from experimental
studies of cognitive functions in both humans and animals.
- In the latter half of the 20th century, many experimental psychologists became aware of the wealth of
information about cognitive functions to be gained from studying brain injured persons, especially those with
localized lesions.
• Now in the 21st century, imaging techniques permit viewing functioning brain structures, further refining
understanding of the neural foundations of behavior.
Examination purposes
• 6 purposes for a neuropsychological examination, each calling for some differences in assessment strategies
1. Diagnosis
● Neuropsychological assessment can be useful for:
○ discriminating between psychiatric and neurological symptoms
○ Identifying a possible neurological disorder in a nonpsychiatric patient
○ helping to distinguish between different neurological conditions
○ providing behavioural data for localizing the site of a lesion or hemisphere side
● NA as a diagnostic tool has diminished while its contributions to patient care and treatment and to understand
behavioural phenomena and brain function have grown. Today, diagnosis and lesion localization are often
achieved through neurological examination and laboratory data →However, neuroimaging does not show the
nature of residual behavioural strengths and accompanying deficits, for this, neuropsychological assessment is
needed.
○ It has been known for decades that despite general similarities in the pattern of brain function sites
(neuroimaging), these patterns will differ more or less between people (NA). Moreover, cognitive
assessment can document mental abilities that are inconsistent with anatomic findings. Thus,
neuropsychological techniques will continue to be an essential part of the neurodiagnostic apparatus.
● Although limited in its applications as a primary diagnostic tool, neuropsychological assessment can aid in
prodromal or early detection and prediction of dementing disorders or outcome.
● Screening is used to identify persons most likely at risk for some specified condition or in need of further
diagnostic study, and where conciseness is required - whether because of the press of patients who may benefit
from neuropsychological assessment or because the patient’s condition may preclude a lengthy assessment.
2. Patient care and planning
● Many patients are referred for detailed information about their cognitive status, behavioural alterations, and
personality characteristics - often with questions about their adjustment to their disabilities - so that they and
the people responsible for their well-being may know how the neurological condition has affected their
behavior.
○ Rational planning usually depends on an understanding of patients’ capabilities and limitations, the
kinds of psychological change they are undergoing, and the impact of these changes on their
experiences of themselves and on their behavior.
● With all the data of a comprehensive neuropsychological examination taken together - the patient’s history,
background, and present situation; the qualitative observations; and the quantitative scores - the examiner
, should have a realistic appreciation of how the patient reacts to deficits and can best compensate for them, and
whether and how retraining could be profitably undertaken.
● Data from successive neuropsychological examinations (repeated testing) repeated at regular intervals can
provide reliable indications of whether the underlying neurological condition is changing, and if so, how rapidly
and in what ways.
○ Repeated testing can also be used to examine whether brain injured candidates for rehabilitation could
learn well enough to warrant cognitive retaining, to evaluate performance inconsistencies, to measure
the effects of surgical procedures, medical treatment, or retraining.
● Neurological impairment may diminish a patient’s capacity for empathy, especially when damage occurs in
prefrontal regions. These misperceptions tend to heighten what mental confusion may already be present as a
result of altered patterns of neural activity.
● The selfdoubt of the brain injured person, often referred to as perplexity, is usually distinguishable from
neurotic selfdoubts about life goals, values, principles, and so on, but it can be just as painful and emotionally
crippling.
○ Distrust of their experiences, particularly their memory and perceptions, is a problem shared by many
brain damaged persons. This self-distrust seems to reflect feelings of strangeness and confusion
accompanying previously familiar habits, thoughts, and sensations that are now experienced differently,
and from newly acquired tendencies to make errors.
○ Careful reporting and explanation of psychological findings can do much to allay the patient’s anxieties
and dispel confusion.
○ “Perplexity, the not knowing for sure if you’re right, is difficult to cope with” - 45 year old teacher
● The family, too, needs to know about the patient’s condition in order to respond appropriately. Family members
need to understand the new, often puzzling, mental changes and what may be their psychosocial repercussions.
Moreover, many brain impaired patients no longer fit easily into family life as irritability, self-centeredness,
impulsivity, or apathy create emotional burdens on family members, generate conflicts between family members
and with the patient, and strain family ties, often beyond endurance.
3. Treatment-1: Treatment planning and remediation
● In the rehabilitation setting, the application of neuropsychological knowledge and neuropsychologically based
treatment techniques to individual patients creates additional assessment demands: Sensitive, broadgauged,
and accurate neuropsychological assessment is necessary for determining the most appropriate treatment for
each rehabilitation candidate with brain dysfunction.
○ In addressing the behavioural and cognitive aspects of patient behavior, these assessments will include
both delineation of problem areas and evaluation of the patient’s strengths and potential for
rehabilitation.
● In programs of any but the shortest duration, repeated assessments will be required to adapt programs and
goals to the patient’s changing needs and competencies.
● Identifying treatment needs - Individualising treatment programs - Keeping abreast of patients’ changing
treatment requirements
4. Treatment-2: Treatment evaluation
● Consumers and referring clinicians need to ask whether a given service promises more than can be delivered, or
whether what is produced in terms of the patient’s behavioural changes has psychological or social value and is
maintained long enough to warrant the costs.
● Neuropsychological evaluation can often best demonstrate the neurobehavioural response - both positive and
negative - to surgical interventions or to brain stimulation. Testing for drug efficacy and side effects also requires
neuropsychological data.
,5. Research
● Neuropsychological assessment has been used to study the organization of brain activity and its translation into
behavior, and to investigate specific brain disorders and behavioral disabilities.
● Research with neuropsychological assessment techniques also involves their development, standardization, and
evaluation.
● Neuropsychological research has also been crucial for understanding normal behavior and brain functions and
the association of cognition with the underlying functional architecture of the brain.
6. Forensic questions
● Neuropsychological assessment undertaken for legal proceedings has become quite commonplace in personal
injury actions in which monetary compensation is sought for claims of bodily injury and loss of function.
● Most questions referred to a neuropsychologist will either ask for a diagnostic opinion (e.g. “Has this person
sustained brain damage as a result of …?”) or a description of the subject’s neuropsychological status (e.g. “Will
treatment help to return her to the workplace?”).
○ Usually the referral for a neuropsychological evaluation will include both questions.
○ Not infrequently the request for compensation may hinge on the neuropsychologist’s report.
● In criminal cases, a neuropsychologist may assess a defendant when there is reason to suspect that brain
dysfunction contributed to the misbehavior or when there is a question about mental capacity to stand trial.
● When dealing with forensic issues the examining neuropsychologist must be alert to the possibility that
claimants in tort actions or defendants in criminal cases may - deliberately or unwittingly - perform below their
optimal level; but the examiner must also remain mindful that for most examinees their dignity is a most prized
attribute that is not readily sold.
The multipurpose examination
• Usually a neuropsychological examination serves more than one purpose.
• Integral to all neuropsychological assessment procedures is an evaluation of the patient’s needs and circumstances
from a psychological perspective that considers quality of life, emotional status, and potential for social integration.
The validity of neuropsychological assessment
• Ecological validity refers to how well the neuropsychological assessment data reflect everyday functioning, or predict
future behavior or behavioral outcomes.
- Questions have been raised about the ecological validity of neuropsychological tests.
What can we expect of neuropsychological assessment in the 21st century?
• In 2004 it was predicted that with their increased efficiency and capacity, assessments by computers would continue to
proliferate. Computerized assessments have not become the major avenue for neuropsychological evaluations, but we
believe we can safely predict that the proportion of assessments using computerized programs - for administration,
scoring, and data storage, compilation, and analysis - will continue its rapid growth.
- However, whether computerization will take over most of the work done by clinical neuropsychologists today is
both doubtful and - for a humanistic profession such as ours - undesirable.
- One type of computerized assessment that is of especial interest is computerized virtual reality assessment
programs with “real-world” characteristics; e.g. learning a path through a realistic-looking park.
- Animal-based cognitive tasks can be adapted with computer and virtual reality technology such that the wealth
of data and hypotheses from animal research can be extrapolated to human studies.
- Computer-based assessment methods also permit neuropsychology to extend into rural settings via
telemedicine in which a neuropsychologist can evaluate the patient from a distance.
• However, the big revolution to come in neuropsychological assessment will likely be multifaceted, dependent in part
on the emergence of what has been termed neuroinformatics and also on the confluence of three factors:
1. Cognitive ontologies
, 2. Collaborative neuropsychological knowledge bases
3. Universally available and standardized assessment methods, largely based on computerized assessments
• Neuropsychological assessment techniques need to be adaptive and integrated with other neurodiagnostic and
assessment methods, so that neuropsychology maintains its unique role while continuing to contribute to the larger
clinical neuroscience, psychological, and medical knowledge base (e.g. neuroimaging methods of analysis become
automated).
- Moreover, tests used for neuropsychological assessments are being adapted for administration during functional
neuroimaging such that, on completion of a combined neuroimaging and neuropsychological assessment session
not only will neuropsychologists have psychometric data on cognitive performance but they will be able to
visualize brain activation patterns related to specific tests and also have a detailed comparison of the brain
morphometry of this patient with a large normative sample.
• One measure of the degree to which neuropsychology has become an accepted and valued partner in both clinical and
research enterprises is its dispersion to cultures other than Western European, and its applications to language groups
other than those for which tests were originally developed. Neuropsychology is facing important challenges for both
greater cross-cultural sensitivity and more language-appropriate tests.
• While real progress has been made over the last few decades in understanding cognitive and other neuropsychological
processes and how to assess them, further knowledge is needed for tests and testing procedures to be sufficiently
organized and standardized that assessments may be reliably reproducible, practically valid, and readily comprehensible.
Yet, the range of disorders and disease processes, the variations and overlaps in their presentations across individuals,
their pharmacologic and other treatment effects, make it unlikely that any “one size fits all” battery can be developed or
should even be contemplated.
- One means of achieving such a goal could be a series of relatively short fixed batteries designed for use with
particular disorders and diseases and specific clusters (e.g. visuomotor dysfunction, short-term memory
disorders). Neuropsychologists would then have at their disposal a set of test modules and perhaps structured
interviews that can be upgraded as knowledge increases and that can be applied in various combinations to
answer particular questions and meet specific patients’ needs.
